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THE    OPERATIONS    OF    SURGERY 


THE    OPERATIONS   OF 
SURGERY 


INTENDED  ESPECIALLY  FOR  THE  USE  OF  THOSE 
RECENTLY   APPOINTED    ON    A   HOSPITAL    STAFF 


THOSE   PREPARING  FOR  THE   HIGHER    EXAMINATIONS 


W.    H.    A.   JACOBSON 

M.CH.    OXON.,    F.R.C.S.,    CONSULTING    SURGEON,    GUY'S    HOSPITAL 
AND 

R.    P.    ROWLANDS 

M.S.    LONDON,    F.R.C.S.,    ASSISTANT    SURGEON    AND    SURGEON    TO    THE    ORTHOP.EDIC 

DEPARTMENT,   GUY'S    HOSPITAL;    JOINT    TEACHER   OF    OPERATIVE 

SURGERY    IN    THE    MEDICAL    SCHOOL 


jfiftb  EMttcn 

WITH   SEVEN   HUNDRED   AND    SEFENTT-SEFEN  ILLUSTRATIONS 


VOL.      II. 


PHILADELPHIA 
P.     BLAKISTON'S     SON     &     CO. 

1012    WALNUT    STREET 
1908 


Printed  in  Great  Britain. 


CONTENTS   OF  VOLUME   II, 


PAKT    IV. 

OPERATIONS    ON    THE    ABDOMEN. 
chap.  i'A,iE 

I.  Ligature  of   Vessels. — External  iliac. — Common   iliac 
Internal  iliac.  —  Gluteal. — -Sciatic.  —  Abdominal  aorta. — 
Abdominal  aneurysm  .....•••  1 — 39 

II.  Operations  ox  Hernia.— ( Operations  for  strangulated  hernia. 

— Radical  cure  of  hernia 4° — 109 

HI.  Colotomy. — Lumbar  or  posterior  colotomy. — Inguinal,  iliac, 
or  anterior  colotomy. — Eight  inguinal  colotomy. — Making 
an  artificial  anus  in  the  ciecum. — Making  an  artificial  anus 
in  the  transverse  colon. — Appendicostomy  ....       no — 148 

IV.  Operations  on  the  Kidney  and  Ureter. — Nephrotomy. — 
Nephrolithotomy.  —  Nephrectomy.  —  Calculous  anuria.  — 
Nephrorraphy  or  nephropexy. — The  surgical  treatment  of 
Bright's  disease. — Operations  on  the  ureter  .         .         •       *49— 259 

V.  Operations  on  the  Intestines. — Acute  intestinal  obstruc- 
tion. —  Appendicitis.  —  Inflammation  of  Meckel's  diverti- 
culum. —  Perforation  of  gastric  ulcer.  —  Perforation  of 
duodenal  ulcer. — Perforation  of  typhoid  ulcer. — Abdominal 
section  in  peritonitis. —  Tubercular  peritonitis. —  Enteros- 
tomy.— Formation  of  an  artificial  anus  in  the  small  and 
large  intestine. — Union  of  divided  or  injured  intestine  by 
suture  or  otherwise. — Modifications  of  circular  enterorraphy. 
— Aids  to  its  performance,  or  means  of  replacing  it. — 
Eesection  of  intestine. — Enterectomy. — Colectomy.— Intes- 
tinal anastomosis.— Short  circuiting. — Lateral  anastomosis 
and  intestinal  occlusion. — Closure  of  fcecal  fistula  or  artificial 
anus. — Enteroplasty     ......••       260     421 

VI.  Operative  Interference  in  Gunshot  and  other  Injuries 

of  the  Abdomen. — Eutture  of  the  Intestine     .        .      422—444 

VII.  Operations  on  the  Stomach.— Gastrostomy. — Gastrotomy. 
—Digital  dilatation  of  the  orifices  of  the  stomach.— Pyloro- 
plasty. —  Gastro-duodenostomy.  —  Pylorectomy.  —  Partial 
gastrectomy.  —  Gastrectomy.—  Gastrojejunostomy.  —  Gas- 
troplication. — Duodenostomy.— Jejunostomy       .         .         •       445— 527 

VIII.  Excision  of  the  Spleen.— Splenopexy        ....      528     533 


vi  CONTENTS    OF    VOLUME   II. 

CHAP.  PAGE 

IX.  Operations  on  the  Liver  and  Biliary  Tracts. — Operations 
for  hydatids.  —  Hepatic  abscess  —  Hepatotomy.  —  Removal 
of  portions  of  the  liver  for  new  growths. — Epiplopexy  for 
cirrhosis  of  liver. — Operations  on  the  biliary  tracts  :  Chole- 
cystostomy. —  Cholecystoi  omy. —  Choledochotomy. —  Chole- 
cystenterostorny. — Cholecystectomy. — Treatment  of  biliary 

fistula 534^  56(J 

X.  Operations  on  the  Pancreas. — The  treatment  of  injuries, 
pancreatitis,  pancreatic  calculi,  pancreatic  cysts,  and  new 
growths 57°~586 

XL  Operations  on  the  Bladder.— Removal  of  growths  of  the 
bladder.— Operative  interference  in  tubercular  disease  of  the 
bladder.  —  Lateral  lithotomy.  —  Supra-pubic  lithotomy.  — 
Median  lithotomy.—  Lithotrity.—  Litholapaxy. —  Perinseal 
lithotrity. — Litholapaxy  in  male  children. — Treatment  of 
stone  in  the  bladder  in  the  female. — Cystotomy. — Ruptured 
bladder. — Puncture  of  the  bladder 587 — 659 

XII.  Operations  for  Diseases  of  the  Prostate.— Adenomatous 
enlargement  or  senile  hypertrophy. — Malignant  disease, 
prostatic  abscess,  prostatic  calculi         .....       660 — 687 

XIII.  Operations  on  the  Urethra  and  Penis.  —  Ruptured 
urethra. — External  urethrotomy. — The  treatment  of  stric- 
ture-retention.— Internal  urethrotomy. — Ectopia  vesicae  and 
epispadias.  —  Hypospadias. —  Epispadias. —  ( 'ircumcision. — 
Amputation  of  the  penis       .......       688 — 732 

XIV.  Operations  on  the  Scrotum  and  Testicle. — Radical  cure 
of  hydrocele. — Varicocele. — Anastomosis  of  the  vas  deferens. 
— Castration. — Orchidopexy         ......       733 — 757 

XV.  Operations  on  the  Anus  and  Rectum. — Eistula. — Haemor- 
rhoids. —  Fissure.  —  Ulcer.  —  Prolapsus.  —  Excision  of  the 
rectum.  —  Imperforate  anus.  ■ —  Atresia  ani  —  Imperfectly 
developed  rectum 758 — 813 

XVI.  Ruptured  Perin.eim 814 — 817 

XVII.  Operations  on  the  Ovary.  --Ovariotomy.— Removal  of  the 

uterine  appendages 818 — 841 

XVIII.  Operations  on  the  Uterus.— Removal  of  the  myomatous 
uterus  by  abdominal   section.  —  Cancer   of  the  uterus.  — 
Removal  of  a  cancerous  uterus  per  vaginam. — Caesarian 
section. — Porro's  operation. — Ectopic  gestation    .         .         .       842—873 
XIX.  Sacro-iliac  Disease. — Arthrectomy 874 


PART     V . 

OPERATIONS    ON    THE    LOWER    EXTREMITY. 

I.  Operations  on  the  Hip- Joint. —Amputation  at  the  hip- 
joint. — Excision  of  the  hip  .......       875 — 903 

II.  Operative  Interference  in  Dislocation  oe  the  Hip     .      904 — 911 


CONTENTS    OF    VOLUME    II.  vii 

CHAP.  PAOB 

111.  Operations  oh  the  Thigh.  —  Ligature  of  the  common 
Femoral. — Suture  of  wounds  of  largo  vessels. — Ligature  of 
the  superficial  femoral  in  Scarpa's  triangle.—  Ligature  of 
the  femoral  in  Hunter's  canal.— Punctured  and  stab-wound 
in  mid-thigh.-  -Amputation  through  the  thigh. — Amputation 
immediately  above  the  knee-joint. — Eemoval  of  exosto-i- 
from  near  the  adductor  tubercle. — Ununited  fracture  of  the 
femur 912— 945 

IT.  Operations  involving  the  Knee-Joint.  —  Amputation 
through  the  knee-joint.— Excision  of  the  knee-joint,— 
Arthrectomy  of  the  knee-joint. —  Wiring  the  patella.— 
Removal  of  loose  cartilages  from  the  knee-joint. — Slipped 

fibro-cartilages 946—977 

V.  Operations  on  the  Popliteal  Space.— Ligature  of  the 

popliteal  artery. — Matas's  operation 978 — 991 

VI.  Operations  on  the  Leg.— Ligature  of  the  posterior  tibial 
artery.— Ligature  of  the  anterior  tibial  artery. — Ligature 
of  the  peroneal  artery.— Amputation  of  the  leg.— Operation 
for  necrosis. — Treatment  of  compound  fractures. — Opera- 
tion for  simple  fracture.— Operations  on  varicose  veins  .  992—1025 
VII.  Operations  on  the  Foot.— Ligature  of  the  dorsalis  pedis.— 
Syme's  amputation.— Koux's  amputation.— Pirogoffs  am- 
putation.— Sub-astragaloid  amputation. — Excision  of  the 
ankle— Erasion  of  the  ankle.— Excision  of  bones  and  joints 
of  the  tarsus.— Excision  of  the  astragalus.— Excision  of  the 
os  calcis  —  More  complete  tarsectomy  for  caries.— Removal 
of  wedge  of  bone  and  other  operations  for  inveterate  talipes. 
— Chopart's  amputation.— Tripier's  amputation.— Amputa- 
tion through  the  metatarso-phalangeal  joints.— Amputation 

of  the  toes 1026-1062 

VIII.  Osteotomy.— Of  the  femur,  for  ankylosis  of  the  hip-joint.— 

For  genu  valgum.-Of  the  tibia 1 063-1072 

IX.  Tenotomy.— Of  the  tendons  about  the  foot.— Syndesmotomy. 

—Of  the  hamstring  tendons.— Of  the  sterno-mastoid  .         .   1073— 1077 
X.  Operations    on    TnE    Nerves.  —  Nerve    suture.  —  Nerve 
stretching • 


PART     VI. 

OPERATIONS    ON    THE    VEETEBEAL    COLUMN. 

Spina  bifida.— Laminectomy  or  partial  resection  of  the   vertebrae  — 

Tapping  the  spinal  theca.— Spinal  anaesthesia     .        .        .        .1086—1104 


INDEX   OF  NAMES "°5 

INDEX   OF   SUBJECTS II27 


PAKT    IV. 

THE    ABDOMEN. 


CHAPTER    I. 
LIGATURE    OF    VESSELS. 

EXTERNAL    ILIAC.      COMMON    ILIAC.      INTERNAL   ILIAC. 
GLUTEAL.      SCIATIC.      ABDOMINAL    AORTA. 

LIGATURE   OP   THE   EXTERNAL  ILIAC   (Figs.  I,  2,  and  3). 

Indications. —  Chiefly  : 

I.  Some  cases  of  aneurysm  of  the  upper  part  of  the  femoral,  or  of  the 
femoral  encroaching  on  the  external  iliac  itself. — Mr.  Holmes  (R.C.S. 
Lect,  Lancet,  1873,  vol.  i.)  shows  that  in  ilio-femoral  aneurysms  it  is 
often  very  difficult  to  say  whether  the  aneurysm  is  or  is  not  limited  to 
the  iliac  or  femoral — i.e.,  whether  it  is  wholly  ahove  or  helow  the  place 
where  the  deep  epigastric  and  circumflex  iliac  come  off,  or  whether  the 
mouths  of  these  vessels  open  out  of  the  sac.  In  the  former  case  the 
aneurysm  would  he  purely  iliac  or  femoral ;  in  the  latter,  ilio-femoral. 
Thus,  ligature  of  this  vessel  is  indicated  where  pressure,  rapid  or 
gradual,  has  failed  to  command  the  circulation,  where  it  is  intolerable, 
where  it  cannot  be  made  use  of  owing  to  the  abundance  of  fat,  from 
failure  of  pulse  and  breathing  under  an  anaesthetic,  or  from  the  height 
at  which  the  aneurysm  involves  the  external  iliac  (it  being  increasingly 
difficult  to  apply  pressure  in  these  cases  without  dangerous  interference 
with  the  peritonaeum  and  its  contents),  where  the  patient  from  chronic 
bronchitis  is  quite  unfit  for  a  prolonged  trial  of  continuous  pressure 
under  an  anaesthetic,  or  in  cases  where  the  increase  of  the  aneurysm  is 
very  rapid. 

Before  deciding  on  relinquishing  the  idea  of  pressure  for  ligature,  the 
surgeon  should  refer  to  a  paper  by  Mr.  Wheelhouse  {Clin.  Soc.  Trans., 
vol.  vii.  p.  57).     This  case  is  one  of  the  most  interesting  in  all  surgery. 

The  patient,  a  publican,  and  syphilitic,  had  previously  been  cured  by  Mr.  Wheelhouse 
of  a  right-sided  popliteal  aneurysm,*  by  means  of  continuous  pressure  for  eight  hours 

*  It  is  very  possible  that  the  strain  thrown  on  the  artery  above  during  the  treatment 
by  pressure  on  the  femoral  was  the  cause  of  the  aneurysm  higher  up.     The  liability  of 
S. VOL.  II.  I 


2  OPERATIONS   o.\    TIIK   ABDOMEN. 

with  a  Porter's  femoral-compressor,  A  few  months  later  be  was  admitted  into  thi 
Leeds  Infirmary  with  a  large  right  iliac  aneurysm,*  reaching  from  Poupart's  Ligament 
to  within  two  inches  o£  the  umbilicu  ,  and  extending  outwards  almost  to  the  spin'-  of 
the  ilium.  The  swelling,  about  the  Bize  of  a  small  cocoa-nut,  was  hard  and  firm  h 
sofl  above;  ii  appeared  to  be  wholly  connected  with  the  external  iliac,  but  to  extend 
above  and  overlie  the  common  iliac.  Pre  are  could  aol  be  made  on  the  latter  vessel 
sufficient  to  stop  the  beating,  as  the  tumour  was  too  much  in  the  way,  bul  it  was  easily 
controlled  by  pressure  on  the  abdominal  aorta.  The  patient  was  kept  under  the  influence 
of  ether  for  five  hours,  Lister's  tourniquet  being  very  slowly  screwed  down  jusl  over  the 
umbilicus.  By  the  end  of  the  time  the  patient  was  black  in  both  limbs,  and  blue  as  fax 
as  the  tourniquet.  This  bad  been  slightly  relaxed  twice.  No  other  ixnpleasani  symptom 
arose  daring  the  whole  time,  a  quarter  of  an  bourwas  taken  in  relaxing  the  pre 
— a  quarter  turn  of  the  bandle  being  made  every  minute.  The  tumour  had  ceased  to 
pulsate,  and  was  firm  and  hard.  Pulsation  gradually  recurred  with  nearly  its  old  force, 
Ihii   was  less  " distensile,"  and  slowly  ceased   altogether,  an   excellent  recovery  b 

Tli;u|(;.-f- 

Iii  ruptured  femoral  aneurysm  the  old  operation  (facilitated  by  the 
application  of  a  tourniquet  above)  would  usually  he  indicated,  hut 
Mr.  Southam  (Brit.  Med.  Journ.,  [883,  vol.  i.  p.  818)  has  briefly 
reported  a  case  in  which  Ik;  tied  the  external  iliac  successfully  in 
a  patient  whose  femoral  aneurysm  suddenly  ruptured  and  became 
diffuse.  The  effused  blood  was  quickly  absorbed,  and  there  was 
never  any  tendency  to  gangrene.  Complete  power  over  the  limb 
was  regained. 

patients  with  one  aneurysm  to  develop  another  may  often  baffle,  the  surgeon.  Mr.  Clutton 
(  Brit,  Med.  ja/if//.,  i88o,  vol.  i.  p,  441)  records  a  case  in  which  a.  femoral  aneurysm  was 
cured  by  the  use  of  Bsmarch's  bandage  applied  up  in  the  tumour,  and  a  Pe'tit's  tourniquei 
adjusted  over  the  brim  of  the  pelvis.  The  first  attempt  lasted  an  hour;  at  the  second 
trial  1  in-  bandage  was  removed  in  an  hum-,  ami  the  tourniquet  continued  for  nine  hours, 
anaesthetics  not  being  given,  The  aneurysm  ceased  to  pulsate  and  began  to  shrink,  bul 
still  fluctuated.  Nine  days  after  leaving  the  hospital,  the  patient  died  suddenly  of  an 
aortic  aneurysm  rupturing  into  the  pericardium. 

f  Dr.  Diver,  <>r  Southsea,  has  put  on  record  a  case  in  which  the  external  iliac  whs  tied 
in  a  case  in  which  n  popliteal  and  an  Inguinal  aneurysm  co-existed  on  Hie  right  side, 
Gangrene  followed,  a  line  or  demarcation  forming  in  the  lower  third  of  the  leg. 
Amputation  through  the  thigh  was  performed,  and  the  patient  recovered.  A  similar 
case  of  double  aneurysm  is  reported  by  Mr.  Eilton  (Med.-Chir.  Trans.,  vol.  Iii.  11.309). 
A  tourniquet  was  first  applied  to  the  righl  common  iliac  for  six  hours  without  effect  on 
the  aneurysms.    A  second  trial  of  pressure  was  made  later  on.  with  a  tourniquei  again  on 

Mi'-  common  iliac  and  one  on  the  femoral  at  Hie  apex  of   Scarpa's  triangle.      In  about  nine 

hours  both  aneurysms  were  cured.    <  Ihloroform  was  used  on  both  occasions. 

j  discs  of  Di'.  Mapother's  and  Mi-.  Ilolden's.  in  which  ilio-femoral  aneurysms  wore 
cured  by  pressure  on  the  common  iliac  and  the  aorta,  will  be  found  recorded  by  Dr. 
Mapoilicr  in  Hie  /h//i.  Med.  Press,  March  29,  1865  ;  and  by  Mr.  Iloldcn  in  86.  Barthol. 

//>>;//.    Iifp.,    vu I.   ii.   p,    m,,,;    ,Si/il-.  /•>',„■.    /,'„'//.    /.V//'.,   1865    0,  pp.  30G,  307.       Ill    Dr.   Mapolher's 

case.  Instrumental  pressure  on  the  righl  common  iliac  (al I  an  inch  below  and  half 

an  inch  in  the  righl  side  of  the  umbilicus),  kepi  up  for  twelve  hours  under  chloroform, 

had  failed.      A  second  attempt,  wilh  a  Si.L'iiorini's  tOUmiquel    OH    the  end  of   (he  abdominal 

aorta,  and  a  Skey's  tourniquei  on  the  femoral  just  as  it  left  the  sac.  pressure  being  Kepi 
up  for  four  hours  and  a  half,  made  the  tumour  solid  and  pulseless.  Two  rigors  followed, 
and  a  carbuncle  fori I  al  thesiteof  the  first  compression.     In  Mr.  Holden's  patienl  the 

aneurysm  was  also  large,  and  double  a<irl  ic  valvular  disease  was  present.      <  'hlorol'orm  was 

given  here  continuously  for  an  hour  and  a  half,  and  then  with  cautious  intermissions, 
owing  to  the  state  of  the  pulse  ami  breathing,  lor  the  rest  of  (he  treatment,  which  lasted 

four  hours. 


IdCATTKK    OK    TIIK    EXTERNAL    ILIAC  3 

2.  Wounds.  A  wound  of  the  external  iliac  is  very  rare.41  Mr. 
Pringle  (Scottish  Mel.  dud  Sun/,  -fount.,  Oct.  1901),  has  successfully 
sutured  a  wound  of  the  external  dine.  The  opening  was  |  inch  long  and 
was  sewn  up  with  catgut,  which  produced  a  kink  in  the  artery,  but  no 
Leakage  took  place,  and  six  months  later  the  man  was  quite  well  and 
able  \o  work.  The  deep  circumflex  iliac  artery  was  tied,  because  it 
orignated  j  of  an  inch  below  the  incision  in  the  artery.  During  the 
operation  bleeding  was  prevented  by  pressure  on  the  abdominal  aorta. 
This  brilliant  result  adds  another  reason  for  opening  the  wound  and 
seeking  the  bleeding  spot  in  all  cases  of  hemorrhage  from  a  wound 
mar  large  vessels.  It  has  been  frequently  tied  for  haemorrhage  from 
parts  below — e.g.,  for  secondary  haemorrhage  after  wounds  of  the 
femoral  high  up,  after  ligature  of  the  femoral,  and  after  amputation  at 
or  near  the  hip.     The  futility  I  of  this  treatment  is  thus  shown  : 

l>r.  Otis  (Med.  and  Sun/.  History  of  the  War  of  the  Rebellion,  pt.  iii.  p.  788)  gives  a 
summary  of  twenty-six  cases  in  which  the  externa]  iliac  was  tied  for  such  cases  as  the 
above.  Of  those,  twenty-three  ended  fatally,  a  mortality  of  88'4  percent.  The  useless- 
ness  of  trusting  to  ligature  of  the  external  iliac  in  such  cases,  instead  of  either  securing 
the  wounded  vessel  itself,  or  trusting  to  well-applied  pressure,  was  Long  before  this 
insisted  on  by  Guthrie. J  This  question  is  alluded  to  again  below,  but  in  proof  of  the 
above  statement  a  case  may  be  mentioned  here,  in  which  haemorrhage  returned  after 
ligature  of  the  external  iliac,  and  was  arrested  by  well-applied  pressure.  The  patient 
had  been  wounded,  January  15,  18G5,  by  a  minie  ball,  entering  at  the  upper  and  inner 
part  of  the  thigh,  and  emerging  near  the  knee.  The  wound  becoming  sloughy,  haemor- 
rhage occurred  (March  jj  and  31),  and  the  external  iliac  was  tied.  April  21,  haemorrhage 
recurred  Erom  the  upper  gunshot  wound,  and  was  successfully  restrained  by  a  horseshoe 
tourniquet,  constantly  kept  on  for  two  weeks,  when  it  was  omitted,  without  any  sub- 
sequent haemorrhage.  The  wounds  were  now  healing  kindly,  when  (May  31)  dysentery 
s.i  in,  carrying  off  the  patient,  June  15,  two  and  a  half  months  after  the  operation  of 
ligature. 

3.  Elephantiasis. — Ligature  of  the  external  iliac  or  femoral  (when  the 
condition  of  the  soft  parts  admits  of  it)  has  been  extolled  by  some 
surgeons  in  the  treatment  of  this  affection. §    A  larger  experience  shows, 


*  The  only  case  with  which  I  am  acquainted  is  one  quoted  by  Mr.  Erichsen  from 
Velpeau  (iVcwtr.  Elini.  de  Mid.  Ojpir.,  t.  i.  p.  175).  in  which  the  above  French  surgeon  was 
suddenly  called  upon  to  tie  the  external  iliac  for  a  knife-wound.  Though  there  had  been 
no  preliminary  dilatation  of  the  collateral  circulation  either  by  pressure  or  by  the  presence 
of  an  aneurysm,  the  result  was  successful. 

t  It  is  fair  to  state  that  Mr.  Bartleet,  of  Birmingham,  published  a  ease  in  which  the 
external  iliac  was  tied  successfully  after  secondary  haemorrhage  from  the  common  femoral. 
the  latter  having  been  tied  for  aneurysm  of  the  femoral  artery.  Previous  to  ligature  of 
the  external  iliac,  "sponge-pressure"  and  pressure  by  means  of  a  Martin's  bandage  were 
tried,  but  no  details  are  given.  It  is  noteworthy  that  the  catgut  ligature  applied  to  the 
femoral  in  this  case  came  away  on  the  seventh  day  (the  first  day  of  the  haemorrhage) 
Unobserved,  and  surrounding  a  small  slough  of  the  artery.      It  had  been  tied  "  tightly.  ' 

I    WoWlds  and  Injuries  oj  the  Arteries.  Lects.  v.  and  vi. 

§  An  apparently  successful  case  is  reported  by  Mr.  Leonard,  of  Bristol.  Measure- 
ments arc  given  nearly  three  years  after  the  operation,  showing  that  the  success  was  then 
maintained,  five  years  later  the  patient  reported  that  "  his  leg  was  much  the  same '  as 
at  the  last  report.  Bandaging  does  not  appear  to  have  been  made  use  of  here.  Prof. 
Buchanan  (Brit.  Med.  Journ.,  Nov.  -*j,  1867  ;  8yd.  So,-.  Hint.  Betr.,  1867  8,  p  300)  reports 
a  ease,  seven  months  after  the  operation,  apparently  cured  by  Ligature  of  the  external 
iliac,  after  failure  of  rest  and  methodical  compression  (this  was  before  the  introduction 
of  Martin's   bandage).     Three   months  later  it  is  candidly  stated   that    the  disease  had 

I — 2 


4  OPERATIONS  ON  THE  ABDOMEN. 

however,  that  when  cases  thus  treated  are  watched,  the  cures  cannot  be 
relied  upon  as  permanent.  Moreover,  too  little  value  has  been  attached, 
in  reported  cures  by  ligature  of  the  main  vessel,  to  the  thorough  rest 
and  elevated  position  entailed  by  tying  the  artery. 

This  operation  should,  I  think,  be  reserved  for  those  cases  (which 
will  be  very  few)  in  which  Martin's  bandages  cannot  be  applied,  owing 
to  cracks,  foul  ulcers,  or  burrowing  sinuses.  Here  the  ligature  may  be 
used  after  explaining  its  risks  to  the  patient,  but  only  as  a  subsidiary 
measure.  The  bandage  will  have  to  be  used  as  well  later,  and  persisted 
in,  during  the  day  at  least,  probably  for  life. 

4.  As  a  distal  operation  in  aneurysm  of  the  common  iliac. — Ligature 
of  the  external  iliac  has  been  so  unsuccessful  here  as  to  call  for  no 
further  comment. 

Surgical  Anatomy. 

Extent. — From  the  lumbo-sacral  articulation  to  a  point  just  internal 
to  the  centre  of  Poupart's  ligament.     Length — 3J  to  4  inches. 

Surface  Marking. — From  a  point  an  inch  below  and  to  the  left  of  the 
umbilicus  to  a  point  just  internal  to  the  centre  of  Poupart's  ligament. 

Relations  : —  In  Front. 

Peritonaeum,  small  intestines. 
Iliac  fascia. 

Lymphatic  glands  and  vessels. 
Genito-crural  nerve  (genital  branch). 

Spermatic  vessels  I      Crossing  artery  near  Poupart's 

Circumflex  iliac  vein  )  ligament. 

Outer  Side.  Inner  Side. 

Psoas  (above).  External  iliac  Iliac  fascia. 

Iliac  fascia.  arteiT-  Vein. 

Behind. 
Iliac  fascia.  Vas  deferens  (dipping 

Vein  (above).  from  internal  ring 

Psoas  (below).  to  pelvis). 

Collateral  Circulation. 

Beep  epigastric  with  Internal  mammary,  lower  in- 

tercostals,  and  lumbar. 

Deep  circumflex  iliac  ,,  Ilio-lumbar,  lumbar,  and  glu- 

teal. 

Gluteal  and  sciatic  ,,  Internal  and  external  circum- 

flex. 

Comes  nervi  ischiadici  ,,  Perforating  branches  of  pro- 

funda. 

Obturator  ,,  Circumflex  arteries  and  epi- 

gastric. 

Internal  pudic  ,,  External  pudic. 

recurred  to  a  considerable  degree.  Dr.  White,  of  Harvard  University  (Inter  nat.  Eneyel. 
of  Surg,,  vol.  ii.  p.  631),  quotes  Wernher  (reference  not  given)  as  having  followed  up 
thirty-two  eases  ;  in  all  there  was  an  immediate  reduction  of  size,  but  the  relief  waa 
permanent  in  three  only.  Dr.  Pinnock,  of  Melbourne  (Lancet.  1879,  vol.  i.  p.  44).  gives 
a  ease  in  which  no  permanent  benefit  followed  on  ligature  of  the  femoral  artery. 


LIGATURE   OF   THE   EXTERNAL    ELTAC.  5 

Operation. — (1)  By  the  lower  and  more  transverse  incision  of  Sir  A. 
Cooper.  (2)  By  the  muscle  slitting  extra-peritonseal  method.  (3)  By 
the  higher  and  more  vertical  incision  of  Abernethy.  The  two  are 
compared  at  p.  8.     (4)  By  the  intra-peritoneeal  method  (p.  22). 

(1)  Incision  of  Sib  A.  Cooper. — This  is  the  method  more  Frequently 
made  use  of.  The  diet  having  been  limited,  and  the  bowels  having 
been  freeby  moved  for  some  days  before  the  operation,  the  parts  shaved, 
and  the  hip  slightly*  flexed,  an  incision  is  made  4  inches  long  (4^  to  5, 
if  there  be  very  much  fat,  or  if  the  parts  are  pushed  up  by  a  contiguous 
aneurysm),  parallel  with  Poupart's  ligament,  and  nearly  an  inch  above 
it,  commencing  just  outside  the  centre  of  the  ligament  and  extending 
outwards  and  upwards  beyond  the  anterior  superior  spine.  t  The 
superficial  fascia  and  fat,  varying  in  amount,  being  divided,  and  the 
superficial  circumflex  iliac  vessels  secured,  the  external  oblique,  both 
fleshy  and  aponeurotic,  is  cut  through,  and  then  the  fleshy  fibres  of 
the  internal  oblique  and  transversalis.  This  is  done  either  by  using 
the  knife  alone,  lighthy  and  carefully,  or  by  taking  up  each  layer  with 
forceps,  nicking  it,  and  slitting  it  up  on  a  director.  If  the  wound  be 
sponged  carefully, %  a  layer  of  cellular  tissue  can  usually  be  seen  between 
the  muscles,  however  thin  they  are.  Any  muscular  branches  should 
be  secured  with  Spencer  Wells's  forceps  as  soon  as  cut;  and  in  pushing 
a  director  beneath  the  muscles  as  little  damage  as  possible  should  be 
done,  owing  to  the  proneness  to  cellulitis  later  on,  and  to  the  proximity, 
in  a  thin  patient,  of  the  peritonaeum.  The  fascia  transversalis,  when 
exposed,  will  be  found  to  vary  a  good  deal  in  thickness  and  in  the 
amount  of  fat  which  it  contains.  It  is  to  be  divided  very  carefully,  § 
and  the  extra-peritonseal  fat,  if  present,  will  next  come  into  view.  First 
one  and  then  two  fingers  being  introduced,  the  peritonaeum  is  to  be 
gently  stripped  up  from  the  iliac  fossa  towards  the  middle  line — i.e., 
upwards  and  inwards  as  far  as  the  inner  border  of  the  psoas.       In 

*  So  that  the  skin  may  not  be  too  much  relaxed  before  being  incised.  Later  on,  to 
relax  the  parts,  the  hips  may  be  more  strongly  flexed. 

t  The  incision  may  have  to  be  made  higher  than  usual,  owing  to  the  upward  extension 
of  the  aneurysm,  to  enable  the  surgeon  to  tie  either  the  upper  part  of  the  external  or  the 
common  iliac.  On  this  point  see  the  remarks  on  the  comparison  of  Cooper's  and  Aber- 
nethy's  operations,  p.  8.  Often  in  these  cases  of  upward  extension  of  the  aneurysm  the 
sac  is  found  to  involve  the  lower  part  of  the  artery,  and  to  have  overlapped  the  upper 
portion. 

%  In  some  cases  where  the  circulation  has  been  much  interfered  with  by  an  aneurj-sm, 
most  copious  hremorrhage,  especially  venous,  has  been  met  with  in  the  earlier  steps  of 
this  operation. 

§  Dr.  Sheen  {Brit.  Med.  Juur/i.,  1882,  vol.  ii.p.  720)  thus'writes  of  the  accident  which 
may  happen  here  :  "  I  made  the  incision  somewhat  too  high,  and,  in  consequence,  opened 
the  peritonaeum,  which  I  mistook  for  transversalis  fascia.  Even  then  I  was  in  a  little 
doubt,  because  some  (omental)  fat  presented  itself,  which  very  much  resembled  the  fat 
seen  in  the  previous  case  (fat  around  the  vessel),  but,  in  pushing  this  up  gently,  a  knuckle 
of  bowel  came  into  view,  which  settled  the  matter."  The  wound  in  the  peritonaeum  was 
sewn  up  with  two  fine  carbolised  sutures,  and  the  case  did  perfectly  well. 

||  Great  care  is  needed  here  if  the  peritonaeum  be  adherent.  This  condition,  when 
present,  is  usually  found  above.  It  is  especially  likely  in  long-standing  cases,  and  where 
the  aneurysm  has  caused  irritative  and  inflammatory  changes.  By  some  it  is  held  that  the 
transversalis  fascia  can  always  be  stripped  up  along  with  the  peritonaeum.  As  this  fascia 
is  thickened  and  attached,  close  to  Poupart's  ligament,  to  form  the  deeper  crural  arch  and 


6  OPERATIONS  ON  THE  ABDOMEN. 

doing  this  care  must  be  taken,  especially  in  the  dead  body,  not  to 
separate  the  iliac  fascia  and  the  vessels  from  their  position  on  the 
.  not  to  tear  this  muscle,  and  not  to  lacerate  the  peritonaeum. 
As  soon  as  the  peritonaeum  has  been  well  raised,  an  assistant  keeps 
this  and  the  upper  lip  of  the  wound  well  out  of  the  way  by  means  of 
broad  retractors.  The  surgeon  then  feels  for  the  pulsation  of  the 
artery  on  the  inner  border  of  the  psoas,  and  carefully  opens  the  layer 
scia  which  ties  the  vessel  to  the  psoas,  and  forms  a  weak  sheath  to 
it.  This  should  be  done  ij  inch  above  Poupart's  ligament,  so  as  to 
lie  well  above  the  origin  of  the  deep  epigastric,  which  usually  comes 
off  £  or  i  inch  above  Poupart's  ligament,  and  the  needle  passed  from 

Fig.  i. 


To  show  the  incisions  for — A.  Ligature  of  the  external  iliac  artery.  B.  Ligature 
of  the  common  iliac  artery.  C.  Ligature  of  the  common  femoral  artery.  1 ».  Stran- 
gulated inguinal  hernia.     E.  Strangulated  femoral  hernia.     (Heath.) 

within  outwards,  carefully  avoiding  the  vein  on  the  inner  side  and  the 
genito-crural  nerve  outside  and  in  front.  In  difficult  cases  the  ligature 
(of  sterilised  silk,  or  kangaroo-tail)  must  mainly  be  passed  by  touch, 
but  a  free  incision,  adequate  use  of  retractors,  and  light  thrown  in  by 
a  large  mirror  will  usually  allow  the  surgeon  to  see  what  he  is  doing. 
The  effect  of  tightening  the  ligature  being  satisfactory,  it  is  cut  short 
and  dropped  in,  the  divided  muscles  are  then  brought  together  with 
buried  catgut  sutures,  and  the  superficial  wound  closed.  The  parts 
must  be  kept  relaxed  by  propping  the  chest  up  slightly  and  flexing  the 
knees  over  a  pillow,  but  too  much  flexion  of  the  groin  is  to  be  depre- 
cated as  causing  a   deep  sulcus  from  which  possible  discharges  may 

front  of  the  femoral  sheath,  it  is  very  doubtful  if  it  can  ever  he  detached  unless  it  be 
divided  or  torn  through.     The  latter  is  very  easy  on  an  aged  corpse. 


LIGATURE   OF   THE    EXTERNAL    ll.l.\<  7 

tpe  with  difficulty.  The  limb  is  evenly  bandaged  from  the  toes 
upwards,  raised,  and  kept  covered  in  cotton-wool,  with  hot  bottles 
placed  in  the  bed.*  In  ens.'  of  threatening  gangrene,  assistants  should 
persevere  in  a  trial  of  friction  of  the  limb  from  below  upwards.    Wh<  re 

th.rc   is  a   history  of  syphilis,  appropriate  remedies  should  he  given 
after  the  operation. 

(2)   After  Blitting  the  external  ohlique  as  described  under  Cooper's 
operation,  the  fibres  of  the  internal  oblique  and  transversalis  muscles 


Anatomy  of  the  iliac  arteries  and  hernia. 

Abdominal  aorta.  10.  External  cutaneous  nerve. 

Spermatic  v.  •  ir.  Epigastric  vessels. 

Inferior  vena  cava.  12.  Iliac  fas 

Ureter.  13.  Spermatic  cord. 

Obliquus  externa-.  14.  Section  of  transversalis. 

Genito-crural  nerve.  15.  External  ab  lominal  ring. 

Obliquus  internum  16.  Section  of  obliquus  interna-. 

Psoas  fascia.  17.  Saphenous  opening. 

Transversalis.  18.  Section  of  obliquus  externum 


may  be  separated,  as  in  McBurney's  operation  for  appendicitis.  The 
wound  can  be  enlarged  if  necessary  by  cutting  into  the  rectus  sheath 
and  drawing  the  muscle  inwards.  By  adopting  this  method  the  risk  of 
ventral  hernia  is  greatly  diminished,  and  the  difficulties  of  the  operation 
are  not  materially  increased,  if  good  retractors  be  used. 

(3)  Incision  of  Abernethy. — In  his  first  operation  this  surgeon 
made  his  incision  in  the  line  of  the  artery  for  about  3  inches,  com- 
mencing nearly  4  inches  above  Poupart's  ligament.  Later  on  he 
modified  his  incision  bv  making  it  less  vertical  and  more  curved,  with 


If  the  patient  be  restless,  as  in  delirium  tremens,  a  long  splint  should  be  applied. 


8  OPERATIONS  ON  THE  ABDOMEN. 

its  convexity  downwards  and  outwards,  and  extending  between  the 
following  points — viz.,  one  about  I  inch  internal  and  I  inch  above  the 
anterior  superior  spine  to  il  inch  above  and  external  to  the  centre  of 
Poupart's  ligament. 

The  respective  advantages  and  disadvantages  of  the  methods  of 
Cooper  and  Abernethy  appear  to  be  the  following :  Cooper's  is  rather 
the  easier,  interfering,  as  it  does,  with  the  peritonaeum  less  and  lower 
down.  It  is  most  suitable  to  those  cases  which  do  not  extend  far,  if  at 
all,  above  Poupart's  ligament.  On  the  other  hand,  where  the  extent  to 
which  the  aneurysm  reaches  upwards  is  not  exactly  known.    Abernetlvy's 


Fig.  3. 


Ligature  of  the  right  external  iliac  artery.  1.  External  oblique  aponeurosis. 
2,  Fleshy  fibres  of  internal  oblique  and  transversalis.  3,  Transversalis  fascia. 
4,  Peritonaeum  (drawn  up  by  the  retractor),  a,  Artery,  v,  Vein.  7;,  Psoas 
muscle.    (Farabeuf.) 


operation,  hitting  off  the  artery,  as  it  does,  higher  up,  or  some  modi- 
fication of  that  given  (p.  16)  for  ligature  of  the  common  iliac,  will  be 
found  preferable. 

Difficulties  and  Possible  Mistakes. 

(1)  Too  short  an  incision.  Here,  as  in  colotomy  and  other  deep 
operations  on  the  abdominal  wall,  every  layer  must  be  cut  to  the  full 
extent  of  the  superficial  ones.  Otherwise  the  operator  will  be  working 
at  the  bottom  of  a  conical,  confined  wound.  (2)  A  wrongly  placed 
incision — i.e.,  one  which,  by  going  too  near  the  middle  line,  opens  the 
internal  abdominal  ring,  or  which,  if  too  low,  may  come  too  near  the 
cord.  (3)  Disturbing  the  planes  of  cellular  tissue  needlessly  or  roughly. 
(4)  Wounding  the  peritonaeum,  owing  to  a  hasty  incision  through  a 
thin  abdominal  wall,  by  rough  use  of  a  director,  especially  if  the  peri- 
tonaeum is  adherent  in  the  neighbourhood  of  the  sac,  or  fused  with  the 
transversalis  fascia.  The  peritonaeum  is  often  difficult  to  distinguish  ; 
it  is  bluish  in  aspect,  but  of  course  not  smooth,  being  covered  with 


LIGATURE    OF   THE    EXTERNAL    ILIAC  9 

cellular  tissue  which  connects  it  to  the  extra-peritonaea]  fat.  ^Strip- 
ping up  the  peritonaeum  roughly  and  too  far.  ((>)  Detaching  the 
artery  from  the  psoas.  17'  Lacerating  the  psoas.  (8)  Tying  or 
injuring  the  vein.  (9)  Including  the  genito-crural  nerve.  (10)  An 
abnormal  position  of  the  artery.  This  may  be  clue  to  an  exaggeration 
of  that  naturally  tortuous  condition  of  the  artery  which  is  especially 
likely  to  be  met  with  in  patients  advanced  in  life.  Another  unusual 
cause  of  displacement  may  be  met  with  in  extravasiited  blood  when  an 
aneurysm  has  given  way. 

sir  W.  Fergusson  briefly  reported  (Brit.  Med.  Journ.,  1S73.  vol.  i.  p.  286)  an  im 
of  this  kind,  in  which  the  sac  gave  way  after  repeated  manipulation. 

Causes  of  Failure  and  Death. 

1.  Gangrene. — In  some  cases,  where  the  limb  does  not  become  gan- 
grenous, the  vitality  is  very  feeble  and  requires  much  attention. 

Thus,  in  Mr.  Rivington's  case  {Clin.  Soc.  Trans.,  vol.  xix.  p.  45),  loss  of  sensation  was 
noticed   on  the  fourth  day,  followed  by  paralysis  of   most  of  the  muscles.       Though 

_:ene  did  not  appear,  and  the  patient  survived  five  and  a  half  months,  the  limb  was 
••  on  the  verge  of  gangrene,"  as  shown  by  sores  appearing  on  the  heel  and  great  toe.* 

2.  Secondary  haemorrhage. — This  is  especially  likely  if  the  wound 
becomes  septic  and  if  silk  is  used.  This  fatal  result  may  be  long 
deferred. 

Thus,  in  Mr.  Kivington's  case  (Joe.  supra  cit.),  the  patient  died  of  secondary  haemor- 
rhage five  and  a  half  months  after  the  operation  ;  the  wound  had  been  found  septic  at 
the  first  dressing  ;  a  catgut  ligature  was  used. 

Early  recurrence  of  pulsation  may  be  ominous  of  secondary  haemor- 
rhage. 

In  a  case  of  Sir  A.  Cooper,  the  haemorrhage  which  proved  fatal  a  fortnight  after  the 
operation  was  found  to  be  due  to  a  large  collateral — viz.,  an  abnormal  obturator  arising 
immediately  above  the  site  of  ligature  (Roux,  ParallUe  <h:  la  Chir.  amglaise  arec  la  Chir. 
*rancai$e,  c)V..  pp.  278,  279). 

3.  Cellulitis.  Septicaemia.  Pyaemia. — Owing  to  the  number  of 
planes  of  cellular  tissue  met  with  here,  any  needless  or  rough  disturb- 
ance of  the  parts,  inadequate  drainage,  or  a  septic  condition  superven- 
ing are  extremely  to  be  deprecated.  The  wound  should  be  opened 
up  at  once  if  any  collection  of  fluid  is  suspected.  4.  Peritonitis. 
5.  Phlebitis  and  secondary  haemorrhage  from  injury  to  the  external 
iliac  vein.  6.  Suppuration  of  the  sac  with  its  attendant  dangers  of 
septic  infection  and  secondary  haemorrhage. f — This  accident  is  far 
from  uncommon  in  cases  of  inguinal  aneurysm  after  ligature.  No 
pains  should  be  spared  to  prevent  its  occurrence  by  taking  every  step 
to  keep  the  wound  strictly  aseptic  from  first  to  last,  and  thus  to  secure 
early  and  sound  healing.     Absolute  rest  should  also  be  enforced  upon 

*  In  one  of  Dr.  Sheen's  cases  already  referred  to,  four  days  after  the  operation  a  large 
patch  of  skin  on  the  outer  side  of  the  thigh  was  noticed  to  be  darkish  in  colour,  and  to  pit 
on  pressure,  though  normal  as  to  sensation.     The  case  did  quite  well. 

t  Very  occasionally  secondary  haemorrhage  may  take  place  to  a  slight  amount,  and 
leave  off  spontaneously.  Thus,  in  one  of  Dr.  Sheen's  cases,  five  weeks  after  the  operation 
•■•  about  an  ounce  of  bright-red  blood  came  from  the  slight  remaining  wound,  and  a  slight 
oozing  again  after  a  few  days,  but  there  was  no  further  haemorrhage."' 


io  OPERATIONS  OX  THE  ABDOMEN. 

the  patient.  If  suppuration  take  place  it  will  usually  be  within  two 
months  of  the  date  of  ligature.  The  symptoms  need  not  be  alluded 
to  here  beyond  pointing  out  that  pulsation  is  one  of  very  grave  omen. 
AN'Ik  11  it  is  evident  that  suppuration,  if  not  established,  is  inevitable, 
the  surgeon  should  so  arrange  his  time  as  to  choose  a  suitable  occa- 
sion, both  as  to  assistance  and  a  good  light,  for  interfering.  Allowing 
the  suppurating  sac  to  open  spontaneously  should  not  be  thought  of, 
not  only  because  of  the  risk  of  haemorrhage,  the  want  of  preparation, 
&c,  but  because  septic  infection  is  now  made  very  probable.  The 
i  »perative  steps  arc  much  the  same  as  in  the  old  operation  for  aneurysm, 
for  which  the  reader  is  referred  to  p.  29.  It  may  be  here  pointed  out 
that  in  this  case  there  is  more  chance  of  the  haemorrhage  taking  the 
form  of  a  general  oozing  from  the  sac,  and  not  that  of  a  gush  or  spirt 
of  blood.  Moreover,  if  the  collateral  circulation  has  been  well  estab- 
lished, there  is  also  the  probability  of  the  sac  being  fed  by  some 
additional  branch,  which,  perhaps,  entering  deep  down,  maybe  a  cause 
of  much  embarrassment.  7.  Recurrence  of  pulsation. — This  is 
especially  likely  to  occur  when  a  catgut  ligature  has  been  used  and 
given  way,  owing  to  its  being  softened  by  suppuration.  Over-free 
collateral  circulation  will  cause  recurrence  of  pulsation  quickly  ;  and 
melting  down  of  soft  coagulum  (this  appearing  to  be  all  that  the  blood 
can  do  in  the  way  of  clotting)  will  bring  about  the  same  cause  of  failure 
later  on.  In  these  cases  the  following  courses  are  open  in  the  matter 
of  the  external  iliac — viz.,  well-adjusted  and  carefully-maintained 
pressure,  and  the  old  operation.  Ligature  of  the  vessel  low7er  down — 
i.e.,  between  the  first  ligature  and  the  aneurysm — and  amputation  are 
not  available  here.*  Two  other  conditions  which  may  supervene  and 
prove  troublesome  should  be  mentioned  here — viz.  :  8.  Formation  of 
a  ventral  hernia. — This  should  be  prevented  as  far  as  possible  by 
ensuring  primary  union,  and  by  the  use  of  deep  chromic-gut  sutures  in 
the  cut  muscles.  Later  on,  if  this  complication  threaten,  an  appro- 
priate belt  should  be  worn.  g.  Coming  away  of  the  ligature  long 
after  the  operation,  through  a  persistent  sinus  or  re-opened  wound. — 
This  may  happen,  even  in  a  wound  kept  sweet  from  first  to  last,  if  a 
silk  ligature  has  not  been  properly  sterilised,  or  has  been  infected  from 
the  fingers  of  the  operator. 


LIGATURE    OP    THE    COMMON    ILIAC    (Figs.   4  and   5). 

Indications. — Very  few  : 

1. — Aneurysms. — Especially  those  inguinal  aneurysms  which  affect 
the  external  iliac  in  its  upper  part,  above  the  origin  of  the  deep 
epigastric,  occupying  the  iliac  fossa  and  lower  part  of  the  abdomen. 
When  such  aneurysms  are  progressing  steadily,  when  they  have  resisted 

*  In  one  case  (Syd.  80c.  Bien.  Itefr.,  1873-4.  p.  220),  after  ligature  of  the  external 
iliac  for  a  femoral  aneurysm  with  catgut,  and  premature  absorption  of  this  on  the  fifth 
day  (the  wound  suppurated  freely,  and  antiseptic  precautions  do  not  appear  to  have 
been  taken),  pulsation  returned,  and  the  swelling  enlarged.  The  patient  was  operated 
upon  again,  and  a  stout  carbolised  hempen  ligature  made  use  of,  one  end  being  left 
long.  Though,  owing  to  the  close  matting  of  parts,  the  peritonaeum  was  wounded  twice, 
and  intestines  and  omentum  protruded,  the  patient  recovered. 


LIGATURE   OF    THE   COMMON    [LI  \<  .  n 

a  trial  of  pressure,  or  are  becoming  diffuse,  and  are  not  thought  amen- 
able to  the  old  operation,  ligature  of  the  common  iliac  is  indicated. 

The  following  remarks  by  one  of  the  chief  living  authorities  on 
aneurysm,  Mr.  Holmes  (R.C.S.  Lectures,  Lancet,  1873,  vol.  i.  p.  297), 
will  aid  the  Burgeon  in  coming  to  a  decision  in  this  most  important 
matter: 

■■  Allowing  that  an  iliac  aneurysm  is  amenable  to  all  three  methods  of  treatment — the 
Hnnterian,  by  ligature  of  the  aorta  or  common  iliac  ;  the  old  operation,  by  laying  open 
the  Bac  and  securing  the  artery  or  arteries  opening  into  and  out  of  it  ;  and  the  method  of 
compression  applied  to  the  aorl  oon  iliac, — I  think  no  one  could  deny  thai 

number  of  cures  by  the  latter  method  bears  a  very  large  proportion  to  the  number  of 
cases  treated,  while  the  cures  by  the  Hunterian  method  are  very  rare,  and  the  other 
method  is  as  yet  pretty  nearly  untried. 

"  But  this  is  far  from  settling  the  question  ;  compression,  doubtless,  often  succeeds, 
but  it  also  often  fails.  It  is  nut  without  its  risks.  It  usually  requires  the  prolonged  use 
of  chloroform,  and  this  cannot  always  be  borne  by  the  patient. 

"The  question  of  applying  the  old  method  in  preference  to  the  Hunterian  in  those 
-  (rare,  it  may  be.  but  which  must  sometimes  be  met  with)  in  which  pressure  has 
failed,  is  one  which  Mr.  Byrne's  brilliant  operations  have  put  in  a  totally  new  light.  And 
I  must  say,  for  my  own  part,  that,  looking  at  the  awful  mortality  which  has  attended  the 
ligature  of  the  common  iliac  for  aneurysm,  and  the  uniform  fatality  of  the  same  operation 
on  the  aorta,  I  think  Mr.  Byrne's  suggestion  ought  to  be  put  to  the  test  of  more  extended 
experience,  although  the  facts  and  reasonings  which  I  have  adduced  will  show  that  I  am 
not  insensible  to  the  risks  which  attend  the  performance  of  the  operation,  to  the  proba- 
bility of  secondary  haemorrhage,  and  to  the  extensive  injury  which  must  be  inflicted  upon 
parts  in  the  immediate  neighbourhood  of  important  organs." 

Mr.  Holmes  then,  in  proof  of  the  great  fatality  of  the  Hunterian  operation  on  the 
common  iliac,  quotes  the  list  collected  by  Dr.  Stephen  Smith  (Amer.  Jburn.  Med. 
July,   i860,  vol.  xl.),  in  which,  out  of   fifteen  cases  in  which  that  vessel  was  tied  for 
aneurysm,  only  three  can  be  reckoned  as  definitely  cured. 

Mr.  Holmes"s  belief  that  subsequent  experience  has  not  been  more  favourable  is 
supported  by  a  table  of  65  cases,  tabulated  by  Dr.  Packard.*  Of  these  65  cases,  no 
fewer  than  51  died,  only  14  recovering,  giving  a  general  mortality  of  7S-46  per  cent.f 

Mr.  Holmes  goes  on  to  discuss  the  old  operation,  and.  in  answer  to  the  objection  that, 
though  the  Hunterian  operation  has  been  attended  with  "  awful  mortality  "  here,  we  are 
not  made  more  secure  by  operating  on  an  artery,  perhaps  not  much  more  than  three 
inches  lower  down,  and  already  involved  in  disease,  writes  :  "  I  reply  that  if  we  grant 
the  artery  where  it  is  involved  in  the  sac  to  be  healthy  enough  to  bear  the  ligature,  many 
advantages  may  be  found  in  the  old  operation  over  that  of  Hunter.  .  .  .  First,  the  clot 
is  removed  and  the  sac  laid  open  :  consequently,  that  softening  of  clot  and  inflammation 
of  a  closed  sac  lying  in  proximity  to  the  peritonaeum,  which  is  so  surely  fatal,  is  obviated. 
Next,  the  ligature  will  probably  be  placed  on  the  external  iliac  instead  of  the  common, 
and  thus  the  chances  of  gangrene  will  be  greatly  diminished,  since  the  internal  iliac  and 
its  branches  are  left  open.  Thirdly,  the  artery  is  tied  at  a  point  where  most  likely  the,' 
peritonaeum  and  viscera  have  been  pushed  away  from  it  by  the  sac,  so  that  there  is 

*  Trans.  Amer.  Surg.  Assoc.,  vol.  i.  p.  234.  Sixty-seven  cases  are  given,  but  the  result 
is  not  stated  in  two. 

t  Grouping  these  cases  into  classes,  after  Dr.  Smith's  example,  in  order  to  obtain 
more  satisfactory  deductions,  Dr.  Packard  concludes  as  follows  : — (i.)  Those  cases  in  which 
the  operation  was  done  for  the  arrest  of  haemorrhage  :  22  cases,  of  which  19  died  and  3 
recovered  ;  mortality,  86-36  per  cent,  (ii.)  Those  in  which  it  was  done  for  the  cure  of 
aneurysm :  35  cases,  of  which  24  died  and  9  recovered,  the  result  not  being  stated  in  2  : 
mortality  in  33  cases,  7272  per  cent,  (iii.)  Those  cases  in  which  tumours  simulating 
aneurysm  led  to  its  performance :  5  cases.  4  of  which  died  and  1  recovered,  (iv.)  Those 
in  which  the  vessel  was  secured  to  prevent  haemorrhage  during  the  removal  of  a  morbid 
growth  :  5  cases,  all  of  which  died. 


12  OPERATIONS  ON  THE  ABDOMEN. 

risk  of  hurtful  interference  with  those  latter  in  the  operation.  And,  lastly,  the  total 
excision  of  the  tumour  precludes  any  such  relapse  as  occurs  sometimes  after  the  Buoterian 
operation. 

•  be  set  the  undoubted  risks  of  secondary  haemorrhage, 
even  in  cases  where  the  immediate  dangers  of  the  operation  have  been  snrmonnted. 
What  this  risk  is  we  have  no  means  of  judging  until  our  experience  of  this  operation 
becomes  greater  ;  but  I  am  under  the  impression  that  .Mr.  Syme  much  underrated  it,  in 
consequence  of  having  operated  chiefly  upon  traumatic  aneurysm.  ' 

Farther  on,  Mr.  Holmes  writes,  while  "  maintaining  that  the  old 
doctrine  on  which  the  superiority  of  Hunter's  operation  is  based  is 
quite  true  in  general,  I  should  have  no  objection  in  the  particular 
instance  of  iliac  aneurysm  to  follow  Mr.  Syme's  practice  ;  at  least, 
until  further  experience  of  it  should  show  that  it  is  wrong:  only  the 
less  dangerous  expedient  of  rapid  compression  of  the  trunk  artery 
under  chloroform,  or  gradual  compression,  with  or  without  chloroform, 
should  first  be  tried." 

The  same  authority,  when,  later  on,  discussing  the  value  of  pressure, 
brings  out  the  following  facts.  That,  while  rapid  compression  under 
chloroform  is  a  mode  of  treatment  by  which  most  gratifying  success 
has  heen  obtained  in  iliac  as  well  as  aortic  aneurysm,  it  exposes  tin- 
patient  to  serious  dangers.  Amongst  these  are  enteritis  and  peritonitis 
from  bruising  of  small  intestine,  mesentery,  nu-^o-colon,  and  sympa- 
thetic;  hematuria;  failure  of  pulse  and  breathing  when  the  pad  is 
screwed  down.  On  account  of  these  very  real  dangers,  which  every 
dexterity  may  not  obviate,  Mr.  Holmes  advocates  a  trial  of  gradual 
compression,  as  safer  though  less  efficient,  and  he  points  out  that  tin- 
relations  of  the  common  iliac  are  less  complicated  than  those  of  the 
aorta,  and  "as  we  get  further  to  one  side,  there  is  more  chance  for  the 
intestines  to  slip  out  of  the  way."  * 

2.  "Wounds. — These  may  be  gunshot  or  bayonet  wounds,  or  knife- 
stabs  of  the  vessel  itself,  or  the  internal  iliac  or  its  branches,  usually 
the  latter.  The  haemorrhage  calling  for  ligature  seems  to  be  usually 
secondary.!  Gunshot  wounds  of  the  common  iliac  have  a  fresh 
interest  now,  owing  to  the  recent  advances  in  surgery  in  the  treatment 
of  gunshot  wounds  of  the  abdomen. 

Dr.  S.  Smithy  gives  two  cases  of  ligature  of  the  common  iliac  for 
wounds : 

One  was   from   a   musket-ball   which    injured   the    \  i;rough   the 

intestines,  and  lodged  in  the  sacrum.  The  operation  was  performed  by  opening  the 
peritonaeal  cavity.  Peritonitis  soon  set  in  ;  secondary  haemorrhage  recurred  repeatedly, 
and  the  case  ended  fatally  on  the  fifteenth  day.  The  other  case  is  of  great  interest,  as  the 
common  and  internal  iliac  were  here  tied  for  severe  haemorrhage  arter  a  stab  in  the  inguinal 
region.     A  large  quantity  of  blood  was  found  in  the  peritonaeal  cavity,  and  the  patient 

*  Mr.  Holmes  draws  attention  also  to  this  most  important  point — i.e.,  that  rapid 
coagulation  in  an  aneurysmal  tumour  cannot  be  regarded  as  in  itself  a  means  of  cure, 
but  only  as  the  commencement  of  a  process  which,  if  not  interrupted,  may  result  in  cure, 
and  that  thus,  while  pulsation  may  diminish  soon  after  a  trial  of  compression,  it  may  not 
absolutely  cease  for  quite  a  month. 

t  It  would  naturally  be  thought  that  haemorrhage  from  a  wound  of  the  common 
iliac  would  be  fatal  before  a  ligature  could  be  applied.     Dr.  01  in  which 

this  vessel  was  wounded  by  a  ball  entering  from  the  buttock  through  the  sacro-iliac 
s%nehondrosis.     Death  took  place  from  haemorrhage  on  the  second  'lay. 

%  Amer.  Jowrn.  Med.  Scin  i860,  vol.  xl.  p.  1  . 


LIGATURE   OF   THE   COMMON    ILIAC.  13 

died  ten  hours  after  the  operation.    At  the  necropsy  it  was  found  that  the  deep  epigastric 
was  the  wounded  vessel. 

Dr.  Otis*  records  four  cases  of  ligature  of  the  common  iliac  during 
the  American  Civil  War  : 

In  one,  a  gunshot  wound,  in  which  the  ball  entered  the  groin  and  came  out  at  the 
buttock,  the  external  iliac  was  tir>t  tied,  the  repeated  haemorrhages  being  believed  to  be 
from  the  profunda  ;  bul  as  the  bleeding  persisted  and  evidently  came  from  the  sciatic,  the 
wound  was  prolonged  and  the  common  iliac  tied.  Both  ligatures  came  away,  and  the 
operation  wound  healed,  but  the  patient  died  about  three  months  later  of  exhaustion, 
associated,  apparently,  with  necrosis  in  the  gluteal  region.  In  the  second  case  the  common 
iliac  was  tied  for  a  gunshot  wound  believed  to  be  of  the  gluteal  artery,  in  which  the 
haemorrhage  was  not  arrested  by  tying  the  internal  iliac.  The  haemorrhage  recurred,  and 
death  took  place  two  days  later.  The  third  case  was  one  of  diffuse  aneurysm  of  the  right 
buttock  and  iliac  fossa  resulting  from  a  bayonet-stab  in  the  former  region.  Death  took 
plaee  four  days  later  from  gangrene  of  the  sac.  The  old  operation  is  considered  by  Dr. 
Otis  to  have  been  preferable  in  this  ease,  but  as  the  necropsy  showed  that  the  anterior 
trunk  of  the  internal  iliac  had  been  wounded,  within  the  sacro-sciatic  notch,  by  the 
bayonet,  it  is  difficult  to  see  how  the  case  could  have  been  treated  save  by  ligature  of  the 
internal  iliac,  either  outside  or  within  the  peritonaeum,  and  then  by  opening  and  filling 
the  aneurysmal  sac  with  aseptic  gauze  or  sponges.  The  fourth  case  was  one  of  aneurysmal 
varix  of  the  femoral  vessels  from  a  punctured  wound  two  inches  below  Poupart's 
ligament.  In  this  case,  owing  to  the  impossibility  of  separating  the  peritonaeum,  this  was 
incised,  and  the  common  iliac  thus  secured.  Peritonitis  proved  fatal  four  days  later. 
Here  ligature  of  the  artery  lower  down,  above  and  below  the  original  seat  of  injury, 
would  have  been  better  treatment. 

3.  For  the  arrest  of  haemorrhage  apart  from  aneurysm. — Such  cases 
may  be  met  with  after  amputation  near  the  hip,  followed  by  secondary 
haemorrhage  from  the  branches  of  the  internal  iliac  in  what  is  usually 
the  posterior  flap. 

Mr.  Liston  (Zond.  Med.  Gaz.,  April  24,  1830)  published  a  case  of  this  kind  in  which, 
after  amputation  below  the  trochanter  minor  for  necrosis  of  the  femur,  haemorrhage 
occurred  from  the  stump  on  the  seventh  day.  As  this  could  not  be  arrested,  the 
common  iliac  was  tied,  but  the  patient  died  twenty-four  hours  later. 

Dr.  Packard  (loc.  supra  cit.,  footnote,  p.  11)  treated  a  somewhat 
similar  case  in  the  same  way,  successfully. 

This  case  is  especially  interesting,  as  the  haemorrhage  occurred  from  branches  of 
the  internal  iliac  after  a  Furneaux  Jordan's  amputation,  a  method  which  has  lately 
come  largely  into  vogue,  and  which  would  usually  be  expected  to  do  away  with  the 
above  risk.f  Haemorrhage  occurred  from  the  stump  on  the  sixth  day,  and,  as  pressure 
failed,  the  common  iliac  was  tied.     The  patient  ultimately  did  well. 

It  will  not,  it  is  hoped,  seem  a  hasty  criticism  on  the  above  if  I  say 
that  in  future  cases  opening  up  the  flaps  and  plugging  with  aseptic 
gauze,  or  the  application,  for  some  days,  of  Spencer  Wells's  forceps, 
aided  b}r  even  pressure  on  the  flaps  and  pressure  on  the  common  or 
external  iliac,  would  be  preferable  to  submitting  the  patient  here  to  the 
severe  and  risky  operation  of  ligature  of  the  common  iliac. 

4.  For  pulsating  tumours  simulating  aneurysm. — As  these  growths 
from  the  iliac  fossa  and  the  walls  of  the  pelvis  have  been  found  to  be 

*  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  pt.  ii.  p.  333. 

f  In  Dr.  Packard's  case  the  Furneaux  Jordan's  amputation  was  performed  probably 
higher  up  than  usual,  owing  to  osteo-myelitis,  after  a  previous  amputation  for  growth,  at 
about  the  middle  of  the  thigh. 


i4  OPERATIONS    ON    THE   ABDOMKX. 

malignant,  it  is  of  the  utmost  importance  to  form  a  correct  diagnosis  in 
these  cases,  and  thus  save  a  patient  who  lias  a  certainly  fatal  disorder 
from  being  submitted  to  an  operation  which  is  most  dangerous,  and 
almost  certain  to  be  useless.*  As  mistakes  have,  however,  been  made 
in  these  cases  by  excellent  surgeons,!  the  chief  points  of  diagnosis,  as 
given  by  Mr.  Holmes,!  may  be  briefly  mentioned  here:  (i)  The  bruit 
is  usually  less  well  marked  ;  (2)  the  pulsation  is  less  heaving  and  less 
expansile  ;  (3)  the  condition  of  the  bone  with  which  the  swelling  is 
connected ;  thus  a  plate  of  bone  may  be  found  in  the  supposed  aneu- 
rysmal sac  ;  the  supposed  aneurysm  may  be  found  both  on  the  gluteal 
and  the  iliac  aspects  of  the  pelvis,  the  bone  being  expanded  by  the 
growth.  (4)  Cancerous  cachexia  may  be  present,  and  perhaps  secondary 
growths  as  well.  To  these  may  be  added  the  valuable  evidence  which 
may  be  given  by  the  X  Hays. 

5.  For  haemorrhage,  not  the  result  of  a  wound. — Ligature  of  the 
common  iliac  has  been  emplo}'ed  in  some  cases  of  this  nature,  usually 
secondary  haemorrhage  after  ligature  of  the  external  iliac,  the  gluteal 
and  sciatic,  or  after  rupture  of  the  external  iliac.  Ligature  of  the  main 
trunk  has  been  so  fatal  here  that  it  should  be  abandoned;  carefully 
applied  pressure,  aided  by  plugging  with  aseptic  gauze,  or  the  old 
operation,  being  certainly  preferable. 

Mr.  Morrant  Baker  has  put  on  record§  a  case  of  great  interest  in  diagnosis,  in  which 
an  abscess  from  sacro-iliac  disease  ulcerated  into  branches  of  the  internal  iliac  artery, 
and  when  opened  gave  rise  to  haemorrhage  calling  for  ligature  of  the  common  iliac. 
A  gardener,  aged  17,  had  felt  pain  a  month  previously  while  digging.  A  tense,  elastic 
swelling,  distinctly  fluctuating,  and  acutely  tender,  occupied  all  the  right  buttock.  It 
was  opened,  and  a  small  stream  of  apparently  arterial  blood  escaped  without  jets.  On 
further  exploration  the  finger  entered  a  large  cavity  between  the  iliac  bone  and  the 
glutei.  The  iliac  fossa  was  full  and  tense,  and  on  examination  per  rectum  a  swelling 
was  found  in  the  right  ischio-rectal  fossa.  On  enlarging  the  gluteal  wound  a  steady 
stream  of  arterial  blood  welled  up  through  the  great  sacro-sciatic  foramen.  This  was 
firmly  plugged,  and  the  common  iliac  tied.  On  removing  the  plug  some  bleeding  still 
occurred,  but  was  easily  arrested.  The  gluteal  wound  became  offensive,  and  this  region, 
together  with  the  upper  part  of  the  thigh,  became  gangrenous,  the  leg  and  foot  remaining 
unaffected.     The  patient  died  forty  hours  after  the  operation. 

At  the  necropsy  the  sacro-iliac  joint  was  open,  with  surrounding  caries.  The  remains 
of  a  large  abscess  were  found,  involving  the  branches  of  the  internal  iliac.  There  was 
no  trace  of  aneurysm. 

6.  Preparatory  to  the  removal  of  caries  of  pelvis. — Where,  after 
amputation  at  the  hip-joint,  pelvic  caries  persists,  leading  steadily  to 
lardaceous  disease,  I  think  an  attempt  should  be  made  to  remove  all 
of  the  innominate  bone  which  is  diseased.  Such  profuse  oozing  follows 
that  the  common  iliac  should  first  be  tied. 

*  In  Guthrie's  case,  a  pulsating  tumour  in  the  right  buttock,  the  size  of  an  adult  head, 
diminished  by  one-half  in  a  month.  Two  months  later  it  again  enlarged,  and  the  patient 
dying  eight  months  after  the  operation,  an  immense  encephaloid  tumour  was  found 
occupying  the  right  iliac  region. 

I  E.g.,  Guthrie  (Loud.  Med.  (in:.,  vol.  ii.  1834);  Stanley  [Med.-Chir.  Trans.,  vol. 
xxviii.)  ;  .Moore  (ibid.,  vol.  x.xxv.). 

I  Syst.oj  Surg.,  vol.  iii.  pp.44,  145.  The  reader  should  also  consult  Mr.  Holmes's 
article,  "  On  Pulsating  Tumours  which  are  not  Aneurysmal,  and  on  Aneurysms  which  are 
not  1'ul-ating  Tumours ''  ( St.  George's  Hosp.  J>'<j>..  vol.  vii.). 

§  St.  Barthul.  IIo-sji.  Hep.,  vol.  viii.  p.  120. 


LIGATURE   OF   THE    COMMON    ILIAC 


ij 


I  adopted  this  coarse  in  a  boy  aged  9,  eleven  years  ago.  The  common  iliac  was  most 
.  tied  by  the  free  anterior  abdominal  incision  given  below,  and  the  pubic  part  of 
the  bone  removed  the  same  day.  A  little  later  I  removed  the  ischium  and  the  acetabu- 
lar portion  of  the  ilium,  leaving  the  upper  half.  Bronchitis  (increased,  I  fear,  by  the 
ether  given  at  the  second  operation)  carried  off  the  child  three  weeks  after  ligature  of 
t he  common  iliac.  The  bleeding  was  >  1  i ;_r  1 1 1  and  easily  arrested,  the  chief  difficulty  mel 
with  here  being  the  detachment  of  the  Bofl  parts  in  the  neighbourhood  of  the  pubes, 
tidier  ischii,  and  sacro-iliac  joint.  The  thickening  of  the  pelvic  fat 
advanced  cases,  shuts  off  the  contents  of  the  pelvis. 

Surgical  Anatomy. — The  common  iliacs,  coming  off  on  the  left  side 
of  the  fourth  lumbar  vertebra,  incline  downwards  and  outwards  to 
divide,  opposite  to  the lumbo-sacral  intervertebral  disc,  into  the  internal 
and  external  iliacs.  The  right  is  rather  the  longer  and  more  oblique 
of  the  two.  Their  length  is  usually  an  inch  and  a  half.  Their  branches 
are  few  and  small — viz.,  to  the  ureter,  psoas  muscles,  glands,  &c.  The 
iliacs  become  increasingly  tortuous  with  age  :  a  point  of  importance  in 
tying  the  vessel  on  an  aged  corpse. 

Line. — One  drawn  from  a  point  1^  inch  below  and  a  little  to  the  left 
of  the  umbilicus  to  the  centre  of  Poupart's  ligament,  the  line  curving 
a  little  outwards,  will  represent  the  course  of  the  artery  with  sufficient 
accuracy. 

Guide. — The  above  line  is  the  only  surface  guide  :  more  deeply  the 
lumbo-sacral  articulation  and  the  psoas  muscles  are  useful  guides, 
especially  in  a  thin  subject.* 

Relations  : —  In  Front. 

Peritonaeum  ;   small  intestine  ;   caecum  and 

appendix,  sometimes. 
Ureter. 
Sympathetic. 


I  HTSIDE. 

Psoas. 
Vena  cava. 
Right  common 
iliac  vein. 


Eight  common 
iliac  artery. 


Inside. 
Left  common  iliac  vein. 


Outside. 
Psoas. 


Behind. 
Right  and  left  common  iliac  veins. 

In  Front. 

Peritonaeum  ;  small  intestine. 

Sympathetic. 

Ureter. 

Superior  hemorrhoidal  artery. 

Left  common 

iliac  artery. 

Beiiino. 
Left  common  iliac  vein. 


*  Attention  has  been  drawn  to  the  need  of  employing  touch,  as  well  as  tight,  in  the 
ligature  of  these  large  trunks  (p.  6). 


i6 


OPERATIONS  ON  THE  ABDOMEN. 


Collateral  Circulation. 
Above. 
Internal  mammary  and 

lower  intercostals 
Lumbar 


-The  chief  vessels  are 


with 


Below. 


Middle  sacral 
Superior  hemorrhoidal 


Deep  epigastric. 
Ilio-lumbar    and    circumflex 

iliac. 
Lateral  sacral. 

Inferior  and  middle  hemor- 
rhoidal. 
In  addition,  the  pubic  arteries  anastomose  behind  the  symphysis. 
Operations  (Figs.  4  and  5). — The  common  iliac  may  be  tied  by  opera- 
tions based  upon  one  of  three  incisions  :   (1)  An  anterior  abdominal, 
by  which  the  vessel  is  approached  more  directly  from  the  front ;  an 
incision  based  upon  those  for  tying  the  external  iliac,  and  made  use  of 
by  Dr.  Mott,  of  New  York,  who  first  tied  this  vessel  for  aneurysm  in 


Common  iliac  artery, 


Fig.  4. 


Ureter 

External  iliac  artery 
External  iliac  vein 
Genito-cmral  nerve 

Ligature  of  the  left  common  iliac  artery.  The  peritonaeum  has  been  drawn 
upwards  and  inwards,  and  the  bifurcation  of  the  common  iliac  artery  exposed. 
(Compare  Fig.  1,  B,  and  Fig.  2.)     (Heath.) 

1827.  (2)  A  posterior  abdominal,  or  loin  incision,  by  which  the  vessel 
is  reached  from  behind  ;  a  method  made  use  of  by  Sir.  P.  Crampton,  of 
Dublin,  in  1828,  and  by  Mr.  Stanley,  at  St.  Bartholomew's,  in  1846 

(Fig.  5). 

(1)  Anterior  Abdominal  Incision. — The  preparatory  treatment  is  here 
the  same  as  that  for  the  external  iliac.  The  parts  being  shaved  and 
cleansed,  a  curved  incision,  5  to  8  inches  long,  according  to  the  amount 
of  fat,  the  development  of  the  body,  and  the  size  of  the  aneurysm,  is 
made,  commencing  just  outside  the  centre  of  Poupart's  ligament  and 
1^  inch  above  it,  then  carried  outwards,  reaching  towards  the  crest  01 
the  ilium,  then  upwards  towards  the  ribs,  and  finally  curving  inwards 
towards  the  umbilicus,  till  sufficiently  free  to  admit  of  the  necessary 
manipulations  for  reaching  the  artery.  The  three  abdominal  muscles 
are  cut  through,  either  on  a  director,  or  with  careful  light  sweeps  ot 
the  knife,  till  the  fascia  transversalis  is  reached  ;  any  vessels  which 
bleed  being  at  once  secured  with  Spencer  Wells's  forceps.  The  fascia 
transversalis,  which  may  generally  be  known  from  the  peritonaeum  by 
the  layer  of  extra-peritoneal  fat  which  usually  intervenes  between  the 


LIGATURE    OF    THE    COMMON     ILIAC 


17 


two,  is  then  picked  up  and  divided  on  a  director,  at  the  lower  pari  of  the 
wound  where  it  is  best  marked.'  Adoption  oi  the  Trendelenberg  posi- 
tion will  facilitate  the  remaining  steps.  The  peritonaeum  is  next  raised 
upwards  and  inwards,  first  one  finger,  and  then  more,  being  insinuated 
towards  the  middle  line  until  the  psoas  is  reached.  On  the  inner  side 
of  this  muscle  the  artery  will  be  found,  the  external  iliac  being  traced 
up  if  needful.  In  order  to  aid  the  surgeon  in  the  difficulties  which 
are  now  met  with,  owing  to  the  artery  lying  at  the  bottom  of  a  very 
deep  wound,  the  abdominal  walls  should  be  relaxed  by  bending  up 
the  thighs,  the  wound  sponged  thoroughly  dry,  and  light  thrown  in 
by  a  reflect  or  or  electric  lamp.  Care  will,  of  course,  have  been  taken 
to  divide  every  layer  from  end  to  end  equally,  and  thus  to  avoid  a 
conical  type  of  wound.  The  position  of  the  vessel  having  been  made 
out,  it  is  to  be  cleaned  with  a  director,  especial  care  being  taken  on 


Fig.  5. 


^Ii^jiuiiijpi 


Cr,-ctr\r 
£ratf» 

Ligature  of  common  iliac  by  a  posterior  incision.     This  would  also  be 

(Bryant.) 


available  for  the  abdominal  aorta. 


the  right  side,  as  here  both  the  common  iliac  veins  lie  behind  the 
artery.  The  needle  should  be  passed  from  within  outwards,  the  ureter 
being  drawn  inwards  and  avoided. 

(2)  Posterior  Incision,  partly  in  Abdomen,  partly  in  Loin, — This 
operation  will  be  best  given  in  the  words  of  Sir  P.  Crampton,t  who 
first  introduced  it : 

"The  first  incision  J  commenced  at  the  anterior  extremity  of  the  last  false  rib, 
proceeding  directly  downwards  to  the  ilium  ;  it  followed  the  line  of  the  crista  ilii, 
keeping  a  very  little  within  its  inner  margin,  until  it  terminated  at  the  superior 
anterior  spinous  process  of  that  bone  ;  the  incision  was  therefore  chiefly  curvilinear, 
the  concavity  looking  towards  the  navel.  The  abdominal  muscles  were  then  divide! 
to  the  extent  of  about  an  inch,  close  to  the  superior  anterior  spinous  process,  down  to 

*  Dr.  Liddell  (Intern.  Kncijcl.  of  Surg.,  vol.  iii.  p.  312)  recommends  that  the  separation 
uf  this  fascia  from  the  peritonaeum  should  be  begun  at  the  upper  part  of  the  wound,  where 
the  adhesion  is  slightest. 

t   Med.-C/tir.  Trans.,  vol.  xvi.  p.  161. 

%  The  patient  would,  of  course,  be  rolled  over  on  to  the  sound  side. 

s. — vol.  ir.  2 


iS  OPERATIONS  ON  THE  ABDOMEN. 

the  peritonaeum  ;  into  this  wound  the  forefinger  of  the  left  hand  was  introduced,  and 
passed  slowly  and  cautiously  along  the  line  of  the  crista  ilii,  separating  the  peri- 
toneum from  the  fascia  iliaca.  A  probe-pointed  bistoury  was  now  passed  along  the 
finger  to  its  extremity,  and  by  raising  the  heel  of  the  knife,  while  its  point  rested 
firmly  at  the  end  of  the  finger  as  on  a  fulcrum,  the  abdominal  muscles  were  separated 
from  their  attachments  to  the  crista  ilii  by  a  single  stroke.  By  repeating  this 
manoeuvre  the  wound  was  prolonged  until  sufficient  room  was  obtained  to  pass  down 
the  hand  between  the  peritonaeum  and  the  fascia  iliaca.  Detaching  the  very  slight 
connections  which  these  parts  have  with  each  other,  I  was  able  to  raise  up  the  peri- 
toneal sac,  with  its  contained  intestines,  on  the  palm  of  my  hand  from  the  psoas 
magnus  and  iliacus  interims  muscles,  and  thus  obtain  a  distinct  view  of  all  the 
important  parts  beneath ;  and  assuredly  a  more  striking  view  has  seldom  been 
presented  to  the  eye  of  the  surgeon.  The  parts  were  unobscured  by  a  single  drop  of 
blood  :  there  lay  the  great  iliac  artery,  nearly  as  large  as  my  finger,  beating  awfully, 
at  the  rate  of  120  in  a  minute,  its  yellowish  white  coat  contrasting  strongly  with  the 
dark  blue  of  the  iliac  vein  which  lay  beside  it,  and  seemed  nearly  double  its  size  ; 
the  ureter  in  its  course  to  the  bladder  lay  like  a  white  tape  across  the  artery,  but 
in  the  process  of  separating  the  peritonaeum  it  was  raised  from  it  with  that  membrane, 
to  which  it  remained  attached.  The  fulness  of  the  iliac  vein  seemed  to  vary  from 
time  to  time,  now  appearing  to  rise  above  the  level  of  the  artery,  and  now  to  subside 
below  it.  Nothing  could  be  more  easy  than  to  pass  a  ligature  round  an  artery  so 
situated.  The  forefinger  of  the  left  hand  was  passed  under  the  artery,  which,  with 
a  little  management,  was  easily  separated  from  the  vein  ;  and  on  the  finger  (which 
served  as  a  guide)  a  common  eyed  probe,  furnished  with  a  ligature  of  moistened 
catgut,  was  passed  under  the  vessel.  A  surgeon's  knot  was  made  in  the  ligature, 
and  the  noose  gradually  closed,  until  Mr.  Colles,  who  held  his  hand  pressed  upon  the 
tumour,  announced  that  all  pulsation  had  ceased.  A  second  knot  was  then  made, 
and  one  end  of  the  ligature  cut  off  short."  Unfortunately,  the  catgut  of  that  day 
became  quickly  dissolved,  pulsation  returned  in  the  tumour  within  fifty  hours  of  the 
operation,  and  on  the  tenth  day  profuse  secondary  haemorrhage  took  place,  death 
following  immediately. 

Comparison  of  the  Two  Methods. — Sir  P.  Crampton  thus  speaks 
of  his  own  and  Dr.  Mott's  operation  :  "  The  operation  of  tying  the 
common  iliac  artery  is  not  only  a  feasible  but  (when  performed  in 
the  manner  described  in  this  paper)  an  exceedingly  easy  operation. 
The  difficulties  which  Dr.  Mott  encountered,  and  which  prolonged  the 
operation  to  nearly  an  hour,*  are  clearly  referable  to  the  circumstance 
of  his  incision  having  been  made  too  low.  This,  in  the  first  place, 
brought  him  in  contact  with  the  aneurysmal  tumour,  from  which  he 
was  obliged,  with  great  labour  and  considerable  risk,  to  detach  the 
peritonaeum  ;  then  he  had  the  whole  mass  of  the  tumour  between  him 
and  the  artery  which  he  was  to  tie  ;  and,  lastly,  he  had  the  intestines 
pressing  down  upon  him  and  producing  such  a  complication  of  diffi- 
culties as  I  believe  few  men  but  himself  could  have  encountered  with 
success." 

Mr.  Skey  (Operative  Surgery,  p.  294)  preferred  the  posterior  incision 
for  these  reasons  :  (i)  It  is  a  part  less  liable  to  consequent  inflammation. 
(2)  The  requisite  separation  of  the  peritonaeum  is  less  extensive.  (3)  The 
artery  is  brought  better  into  view,  the  act  of  passing  the  needle  round 
it  being  made  visible  to  observers  around.  (4)  The  line  of  the  vessel  is 
sufficiently  exposed  to  enable  the  operator  to  select  his  site  of  ligature, 
to  carry  it  either  higher  or  lower,  or  even,  if  necessary,  to  separate  the 
peritonreum  from  the  aorta  itself,  and  to  pass  a  ligature  around  that 

*  Sir  P.  Crampton's  operation  was  completed  in  twenty-two  minutes. 


LIGATURE   OF   THE    INTERNAL    [LIAC.  i«, 

vessel  nt  n  sufficient  distance  from  its  bifurcation.     (5)  The  formation 
of  a  ventral  hernia  is  not  likely  to  occur. 

To  the  above  Mr.  Skey  might  have  added  that  the  posterior  incision 
gives  far  better  drainage  to  the  wound. 

The  difficulties  of  the  operation  and  the  causes  of  failure  and 
of  death  are  much  the  same  as  those  already  given  in  the  account  of 
ligature  of  the  external  iliac  (pp.  8 — 10). 

(3)  Intraperitoneal  Method. — See  p.  22. 

LIGATURE  OF  THE  INTERNAL  ILIAC. 

Indications. — Very  few  and  rare. 

i.  In  some  cases  of  gluteal  and  sciatic  aneurysms. — Mr.  Holmes,  in 
the  course  of  those  lectures  from  which  I  have  already  quoted,  lays 
down  conclusions  which  will  very  greatly  help  the  surgeon  in  deciding 
wdiat  form  of  treatment  is  best  suited  to  these  aneurysms.  They  are 
quoted  below  under  the  heading  of  "  Ligature  of  the  Gluteal  Artery  " 
(p.  26). 

ii.  Hemorrhage. — This  is  most  frequently  met  with  in  military 
surgery  after  gunshot  wounds  of  the  vessel  itself,  but  more  often  of 
one  or  more  of  its  branches  within  the  pelvis,  the  ball  entering  usually 
from  the  front  through  the  inguinal  region  or  behind  through  the 
sacrum. 

Four  such  cases  are  given  by  Dr.  Otis,*  all  being  fatal.  Two  cases,  in  which  this  artery 
was  tied  for  wounds  of  the  sciatic  and  gluteal  respectively,  are  given  by  the  above  writer 
(p.  332)  ;  both  were  fatal  from  haemorrhage. 

Dr.  Liddell,t  who,  as  U.S.A.  Medical  Inspector,  saw  much  of 
military  surgery,  gives  the  following  advice  in  cases  of  punctured 
wounds  of  this  artery  or  its  branches  :  "  The  wound  should  be  explored 
by  introducing  the  finger  into  it  for  the  purpose  of  locating  by  touch 
the  precise  point  whence  the  blood  issues  by  jets  into  the  wound.  If 
the  punctured  artery  is  found  to  be  external  to  the  pelvis,  the  bleeding 
point  should  be  laid  bare  by  enlarging  and  cleansing  the  wound,  and 
the  vessel  secured  by  ligatures  placed  on  each  side  of  the  aperture. 
But  if  it  be  shown,  by  the  occurrence  of  intra-pelvic  extravasation  of 
blood,  or  by  other  signs,  that  the  internal  iliac  artery,  or  some  branch 
thereof,  is  wounded  within  the  pelvis,  it  will  be  impossible  to  reach  and 
tie  the  punctured  artery  in  the  wound.  Under  these  circumstances  it 
sometimes  becomes  very  difficult  to  decide  what  plan  of  treatment 
should  be  adopted.  .  .  .  One  thing,"  Dr.  Liddell  goes  on  to  say, 
"  ought  never  to  be  done,  that  is,  trusting  to  the  use  of  iron  perchloride 
or  persulphate.  \  The  first  thing  to  be  tried,  in  most  cases,  is  com- 
pression. It  should  be  applied  to  the  common  iliac  artery,  and,  at  the 
same  time,  to  the  wound  itself,  if  possible,  with  a  view  to  obtain 
coagulation  of  the  blood  in,  and  obliteration  of,  the  wounded  artery. 
The  very  desperateness  of  these  cases  makes  it  all  the  more  necessary 
to    use    the    compression    faithfully,   intelligently,    and    persistently, 

*  Mod.  and  Surg.  History  of  the  War  of  the  Rebellion,  pt.  ii.  p.  331. 
f  Intern.  Eneijcl.  of  Surg.,  vol.  iii.  p.  125. 
\  See  the  remarks,  vol.  i.  p.  745. 

2 — 2 


20  OPERATIONS  ON  THE  ABDOMEN. 

otherwise  a  traumatic  aneurysm  will  form."  Nowadays  laparotomy 
will  very  likely  be  resorted  to  (p.  22). 

iii.  To  bring  about  atrophy  of  the  enlarged  senile  prostate. 

Dr.  Bier,  first  assistant  to  Prof,  von  Esmarch,  of  Kiel,  w;is  the  first 
to  tie  the  internal  iliacs  for  the  above  purpose  (Wien.  Klin.  Woch., 
No.  32,  Aug.  10,  1893). 

He  did  this  in  three  cases,  in  one  intra-peritomeally  and  in  two  extra-peritonreally. 
The  latter  two  made  good  recoveries.  In  the  first  case  the  way  in  which  the  anaesthetic 
was  taken  caused  so  much  trouble  that,  Trendelenberg's  position  failing,  it  was  found 
needful  to  withdraw  a  large  part  of  the  small  intestine,  in  order  to  reach  the  arteries. 
This  patient  died  of  septic  peritonitis  on  the  third  day. 

Dr.  W.  Meyer  {Ann.  of  Sun/.,  July,  1894)  publishes  a  case  treated  by 
Bier's  method. 

The  patient  was  55,  and  very  stout.  For  six  months  he  had  been  unable  to  pass  any 
urine,  having  to  rely  on  a  catheter  altogether.  The  prostate  was  generally  enlarged  ;  its 
upper  border  could  only  just  be  reached  per  rectum.  The  extra-peritonaea]  method  was 
adopted.  The  left  artery  was  taken  first.  An  incision,  slightly  concave  inwards,  and  five 
inches  long,  was  made  parallel  with  the  upper  third  of  Poupart's  ligament  and  running  up 
towards  the  tip  of  the  eleventh  rib.  The  common  and  internal  iliacs  were  reached  without 
much  trouble.  The  artery  was  tied  with  catgut,  but,  the  vessel  having  been  punctured 
when  the  sheath  was  divided,  two  ligatures  were  applied  on  either  side  of  the  puncture, 
and  the  artery  was  divided  between  them.  The  Ligature  on  the  proximal  end  slipped  off, 
and  further  attempts  to  place  a  ligature  proving  futile,  a  long  pair  of  artery  forceps  was 
placed  on  each  divided  end,  and  left  in  situ,  being  carefully  packed  around  with  gauze. 
The  right  internal  iliac  was  then  tied  with  a  double  catgut  ligature,  but  the  vessel  was  not 
divided.  The  two  forceps  were  removed  on  the  fifth  day,  no  haemorrhage  following.  On 
the  twelfth  day  arterial  haemorrhage  took  place  from  the  track  of  the  forceps  on  the  left 
side.  On  opening  up  the  wound  it  was  found  that  the  bleeding  came  from  an  opening  in 
the  external  iliac,  due  to  the  pressure  of  the  forceps  where  it  crossed  this  vessel.  Pressure 
being  made  on  the  common  iliac,  the  external  was  tied  above  and  below  the  perforation, 
and  then  the  common  iliac  was  tied  also,  silk  being  used  on  this  occasion.  Partial 
gangrene  of  the  foot  followed,  necessitating  an  irregular  amputation  of  its  anterior  part. 
The  influence  of  tying  both  internal  iliacs  in  the  enlarged  prostate  in  this  interesting  case 
was  as  follows  :  Twelve  hours  after  the  operation  the  patient  began  to  pass  his  water 
(twenty  ounces)  in  a  fine  stream  for  the  first  time  for  six  months.  This  improvement 
slowly  increased,  though  it  was  evident  that  there  was  marked  atony  of  the  bladder.  The 
patient  gained  sufficient  power  to  hold  his  water  two,  or  even  three  or  four,  hours,  and 
then  to  pass  ten  or  twelve  ounces  in  a  forcible  stream.  The  residual  urine  remained 
considerable,  ten  ounces  or  more.  The  prostate  became  almost  normal  in  size,  and  the 
length  of  the  urethra  became  reduced  from  23£  to  21i  cm.,  the  length  of  a  normal  urethra 
being  21  cm. 

Dr.  Meyer  also  operated  according  to  this  plan  on  a  man,  aged  63,  with  retention  due  to 
hypertrophy  of  the  prostate.  A  single  silk  ligature  was  easily  placed  around  each  artery 
within  its  sheath,  and  tied.  The  wound  healed  without  reaction.  The  patient  voided  his 
urine  in  a  tine  forcible  stream  several  times  during  the  ight  after  the  operation.  Pietention 
diil  not  again  set  in.  On  the  fifth  day  after  the  operation  the  temperature  became 
subnormal  without  apparent  cause,  and  the  patient  died  comatose  three  days  later.  Only 
a  very  limited  necropsy  was  permitted,  and  there  is  no  account  of  the  state  of  the  kidneys. 
We  have  seen  that  the  two  cases  in  which  Dr.  bier  operated  by  the  extra-peritonaea! 
wd  recovered.  Neither,  before  the  operation,  had  been  able  to  pass  a  drop  of  urine. 
Spontan><uis  power  returned  in  each  case,  and  improved  progressively,  one  of  the  patients 
stating,  fourS*»mths  later,  that  he  could  micturate  as  well  as  ever  before. 

iv.  In  some  oases  of  vascular  pelvic  sarcoma,  and  inoperable  uterine 
tumours  (Baudot  and  Kendirdjy,  Gaz.  des  Hopitaux,  April  I,  1899). 
v.  Also   as   a    prophylactic   against    haemorrhage  in    the   course    of 


LIGATURE   OF   THE    [NTERNAL    ILIAC 


21 


certain  pelvic  operations,  such  as  abdominal  panhysterectomy,  and  in 
abdomino-perinseal  excision  of  the  cancerous  rectum  (Baudot  and 
Kendirdjy,  loc.  supra  cit.). 

Surgical  Anatomy. — A  short  trunk,  about  an  inch  ami  a  half  long, 
of  large  size,  the  internal  iliac,  given  off  opposite  to  tin'  lumbo-sacral 
intervertebral  disc,  dips  downwards  and  backwards  as  fur  as  the  upper 
pari  of  the  sacro-sciatic  notch,  where  it  gives  off  its  anterior  and 
posterior  trunks,  a  ligamentous  cord  also  coming  off  from  the 
bifurcation.  This  cord,  the  remains  <>['  the  obliterated  hypogastric 
artery,  usually  remains  pervious  as  far  as  the  bladder,  as  one  of  the 
vesical  arteries. 

Link. — No  distinct  line  or  guard  can  be  given  for  this  vessel  owing 
to  its  at  once  dipping  into  the  pelvis,  but  it  will  be  worth  while  to 
remember  that  a  line  drawn  with  a  slight  curve  outwards  from  a  point 
about  an  inch  below  and  a  little  to  the  left  of  the  umbilicus,  to  the 
centre  of  Poupart's  ligament,  gives  sufficiently  accurately  the  line  of 
the  common  and  external  iliac  arteries;  the  internal  is  given  off  about 
two  inches  from  the  commencement  of  this  line.* 


Delations  : — 


Outside. 
Right  internal  iliac  vein. 
Obturator  nerve. 


In  Front. 

Ureter. 
Peritonaeum. 
Rectum  (left  side) 

Internal  iliac. 


Inside. 
Pyriformis. 

Sacral  nerves. 


Behind. 
Internal  iliac  vein. 
Sacro-iliac  synchondrosis. 
Lumbo-sacral  cord. 

Collateral  Circulation. 
Sciatic  with 


Superior    branches    of    pro- 
funda. 
Inferior  mesenteric. 
Vessel  of  opposite  side. 
Branches  of  opposite  vessel. 

Sciatic  and  gluteal. 
Middle  sacral. 
Ilio-lumbar  and  gluteal. 


Hemorrhoidal  branches  ,, 

Pubic  branch  of  obturator  ,, 

Branches  of  pudic  ,, 
Circumflex  and  perforating  of 

profunda  ,, 

Lateral  sacral  ,, 

Circumflex  iliac  „ 

Operation. — The  preparatory  treatment  being  the  same  as  in 
ligature  of  the  external  iliac  (p.  5),  the  surgeon  makes  an  incision  much 
as  in  the  case  of  the  common  iliac,  or  else,  in  the  words  of  Dr.  Stevens 
(who  first  tied  the  vessel  successfully  in  1812),  "one  about  five  inches 
long,  parallel  with  the  deep  epigastric  artery,  and  nearly  half  an  inch  on 
the  outer  side  of  it."  The  peritonaeum  having  been  raised  up,  the  hips 
are  well  flexed,  and  the  lips  of  the  wound  retracted  as  widely  as  possible. 
The  finger  now  finds  the  external  iliac,  and  then,  by  tracing  it  up,  the 


*  The  origin  of  the  arteries  will  be  found  nearly  opposite  to  the  centre  of  a  line  drawn 
from  the  anterior  superior  spine  to  the  umbilicus. 


22  OPERATIONS  ON  THE  ABDOMEN. 

internal  iliac  vessel.*  The  cord  of  the  obturator  nerve  must  not  be 
mistaken  for  this. t 

The  artery  is  now  separated,  partly  with  the  finger-nail  and  partly 
with  the  point  of  the  director,  and  the  needle  passed  from  within 
outwards,  avoiding  the  vein  and  psoas  muscle.  The  ureter  usually 
crosses  the  artery  at  its  commencement,  and  will  be  out  of  harm's  way. 
It  will  be  well  to  have  in  readiness  aneurysni-needles  of  different  curves, 
and  an  ordinary  silver  eyed  probe. 

Ligature  of  the  Internal  and  other  Iliacs  by  Abdominal  Section. 
— This  method  has  been  advocated  by  Dr.  Dennis,!  of  New  York,  on 
account  of  the  following  advantages: — (i)  Abdominal  section  in  no 
way  increases  the  dangers  of  the  operation  of  ligature  of  the  internal 
iliac.  (2)  This  method  prevents  a  series  of  accidents  which  have 
occurred  during  the  performance  of  the  operation  of  ligature  of  this 
artery  by  the  older  methods.  Amongst  these  are,  the  division  of  the 
circumflex  and  epigastric  arteries,  wounding  the  vas  deferens,  including 
the  ureter  in  the  ligature,  puncturing  the  iliac  or  circumflex  veins, 
tying  the  genital  branch  of  the  genito-crural,  tearing  the  peritonaeum, 
injury  to  the  sub-peritomeal  connective  tissue,  cellulitis.  (3)  Abdo- 
minal section  enables  the  surgeon  to  apply  the  ligature  at  a  point  of 
election,  and  to  obtain  information  as  to  the  exact  extent  of  the  disease 
in  the  main  arterial  trunk.  (4)  Securing  the  internal  iliac  by  this 
method  takes  much  less  time  than  was  occupied  by  the  older  ones. 

Three  cases  are  given  by  Dr.  Dennis,  two  of  which  occurred  in  his 
own  practice  : 

(1)  A  woman,  aged  60,  presented  pulsatile  tumours  in  buth  gluteal  regions,  the  tumours 
dating  baek  a  year  and  a  half,  and  pain  three  years  back.  Tbe  external  parts  being 
thoroughly  purified,  a  median  incision  was  made  from  tbe  umbilicus  to  the  pubes  ;  the 
small  intestines,  which  would  have  hindered  the  operation,  were  drawn  out  into  warm 
moist  sponges  and  towels,  the  internal  iliacs  of  both  sides  ligatured  with  catgut,  the 
viscera  returned,  the  wound  closed,  and  aseptic  dressings  applied.  The  patient  died,  with 
suppression  of  urine  and  slight  parenchymatous  nephritis,  on  the  third  day.  (2)  A  negro, 
aged  46,  had  a  right  gluteal  aneurysm,  the  trouble  dating  back  seven  months.  By  a 
curved  lateral  incision  the  abdomen  was  opened  ;  owing  to  the  violent  efforts  of  the 
patient,  and  the  difficulty  of  manipulation,  a  few  coils  of  intestine  were  drawn  out,  a 
strong  silk  ligature  applied  to  the  internal  iliac,  the  parts  cleansed,  and  the  wound  closed. 
A  cure  followed.  (3)  A  female,  aged  18,  had  an  aneurysmal  varix  of  the  left  side,  the 
trouble  dating  back  many  years.  Under  careful  antiseptic  treatment  the  abdomen  was 
opened,  the  incision  finally  extending  from  the  symphysis  to  some  distance  above  the 
umbilicus,  the  intestines  drawn  out  sufficiently  to  admit  of  exposure  of  the  vessel,  a  double 
twisted  catgut  ligature  applied  to  the  left  internal  iliac,  the  bowels  returned,  and  the 
wound  treated  as  before.  The  patient  rallied  quickly,  and  the  bowels  were  moved 
normally  on  the  tifth  day  ;  a  slight  acute  albuminuria,  due  to  congestion  of  the  kidney 
from  the  ligature  of  the  main  trunk  of  the  internal  iliac,  appeared  on  the  following  day, 
but  soon  disappeared.  The  aneurysm,  together  with  the  aneurysmal  varix,  was  perfectly 
cured. 

A  few  cases  in  which  the  iliac  arteries  have  been  tied  intra-peri- 
tonaeally  in  this  country  are  on  record.     One  of  the  most  interesting 

*  The  finger  should  be  passed  downwards  and  backwards  towards  the  sacro-iliac 
synchondrosis. 

t  In  cases  of  doubt  the  artery  should  be  compressed  gently  between  the  finger  and 
thumb. 

J  New  York  Med.  News,  Nov.  20,  1886  ;  Annals  of  Surgery,  vol.  v.  Xo.  1,  p.  55.  I  am 
indebted  to  the  latter  periodical  for  the  above  account. 


LIGATURE    OF   THE    [NTERNAL    II, [AC 

of  these  is  fully  recorded  by   Mr.   Making  (Lancet,  vol.   ii.  iSq^    p 

..;,M. 

The  patient,  aged  30,  had  an  inguinal  aneurysm,  aboui  two  inches  in  breadth, 
extending  upwards  about  two-fifths  of  the  distance  between  the  middle  of  Poupart's 
Ligamenl  ami  the  umbilicus,  ami  Eor  about  two  inches  below  the  Ligament.  An  incision 
four  inches  long  was  made  in  the  lefl  Linea  semilunaris;  the  deep  epigastric,  which 
originated  in  the  swelling,  was  tied  between  two  ligatures.  The  Bmall  intestines  were 
held  over  to  the  righl  with  Messrs.  Ballance  ami  Edmunds'  broad  abdominal  retractor; 
the  sigmoid  flexure  was  pushed  upwards,  ami  an  incision  made  through  the  lower  pan 
of  its  mesentery  and  the  peritonaeum  at  the  margin  of  the  pelvis  in  the  course  of  the 
externa]  iliac  The  wound  was  deep,  there  being  about  an  inch  ami  a  half  of  subcu- 
taneous i'at,  and  abundance  of  fat  in  the  sub-peritomeal  tissue,  both  beneath  the  anterior 
abdominal  wall  ami  around  the  vessel.  This,  together  with  some  retching,  rendered 
the  freeing  of  (lie  artery  ami  the  passage  of  the  ligature  a  process  of  some  difficulty. 
The  spermatic  vessels  were  also  exposed  and  swelled  up  considerably  in  the  wound. 
The  artery  was  secured  about  three-quarters  of  an  inch  below  the  bifurcation  of  the 
common  iliac,  and  an  inch  and  a  half  above  the  sac.  Two  threads  of  stout  flossy  sterilised 
silk  were  tied  separately,  but  in  close  apposition,  and  with  sufficient  firmness  to  rupture 
the  internal  and  middle  coats.  The  posterior  peritonaeum  was  sutured  over  the  artery. 
The  patient  left  the  hospital,  with  the  aneurysm  hard,  painless,  and  shrinking,  on  the 
forty-seventh  day. 

The  following  remarks  from  Mr.  Makins,  well  known  not  only  as  a 
surgeon  but  also  as  an  anatomist,  I  quote  verbatim  : 

"The  reason  for  selection  of  the  intra-peritonaeal  method  in  this  case  was  the  high 
position  of  the  aneurysm.  Before  operation  the  pulsation  in  the  iliac  fossa  was  so 
forcible  and  extensive  that  it  seemed  probable  that  it  might  prove  necessary  to  ligature 
the  common  iliac,  and  it  was  thought  that  this  would  be  more  readily  performed  by  the 
intra-peritonaeal  method.  Beyond  this  the  intra-peritonaeal  method  seemed  to  offer  the 
great  advantage  of  not  in  the  least  interfering  with  the  coverings  of  the  sac,  which,  by 
the  ordinary  method,  might  have  been  disturbed  by  the  stripping  of  the  peritonaeum. 
The  experience  gained  by  the  operation  showed  that  the  usual  method  might  have  been 
safely  adopted,  but  this  could  not  be  definitely  determined  beforehand.  An  advantage 
was  gained  in  ready  access  to  the  deep  epigastric  artery,  which,  as  directly  feeding  the 
sac  itself,  needed  ligature,  but,  of  course,  might  readily  have  been  secured  by  an  exten- 
sion of  the  ordinary  wound.  As  to  the  comparative  difficulty  of  the  two  operations  I 
think  there  is  little  to  choose,  and  on  the  whole  the  incision  for  the  extra-peritonaeal 
method  is  perhaps  to  be  preferred  in  the  matter  of  cicatrix  ;  in  the  vertical  incision 
the  advantage  of  suturing  the  fibrous  structures  in  the  linea  semilunaris  is  gained  ;  but, 
on  the  other  hand,  the  resulting  cicatrix  passes  directly  through  from  skin  to  peritonaeum. 
In  the  oblique  incision  the  decussation  of  the  various  muscular  layers  leads  to  a  certain 
intricacy  and  irregularity  in  the  line  of  the  cicatrix  which  may  render  it  the  stronger, 
since  pressure  is  less  readily  brought  to  bear  directly  upon  it.  The  choice  of  the  iliac 
vessels  obtained  is,  I  think,  a  real  advantage,  since  the  incision  needs  neither  extension 
nor  modification  ;  but  in  saying  this  it  should  be  pointed  out  that  this  is  a  much  stronger 
argument  on  the  right  than  on  the  left  side  of  the  body.  Ligature  of  the  right  common 
iliac  artery  by  the  intra-peritonaeal  method  is  probably  the  easiest  of  all  the  operations 
on  the  great  arteries,  since  the  vessel  lies  directly  beneath  the  peritonaeum  of  the  posterior 
abdominal  wall,  uncovered  by  any  structure  of  importance.  On  the  left  side,  on  the  other 
hand,  the  inferior  mesenteric  vessels  as  they  enter  the  sigmoid  mesocolon,  and  pass  down 
to  the  mesorectum,  cover  practically  the  whole  of  the  artery,  and  to  reach  the  common 
iliac  comfortably  and  safely  the  peritonaeum  would  need  to  be  divided  close  to  the  left 
of  the  median  line  of  the  sacrum  and  displaced  outwards.  This  manoeuvre  has  the  dis- 
advantage of  exposing  the  vein  freely,  but  this  would  probably  give  far  less  trouble  than  the 
numerous  mesenteric  vessels  would  when  swollen  by  reason  of  the  loss  of  their  peritoneal 
support.  In  the  case  recorded  above  the  distension  of  the  spermatic  vessels,  when  set  free 
by  the  division  of  the  peritonaeum,  was  much  greater  than  would  have  been  expected."' 


24 


OPERATIONS  ON  THE  ABDOMEN. 


This  most  instructive  case  possesses  the  additional  and  especial 
interest  that  the  patient  developed  a  similar  aneurysm  on  the  right  side 
a  few  months  later  (Lancet,  vol.  ii.  1893,  p.  196). 

On  May  3,  1893,  Mr.  Making  tied  the  right  external  iliac  intra-peritonaeally.  An 
incision,  commencing  an  inch  below  the  level  of  the  umbilicus  and  four  inches  long, 
was  made  in  the  righl  linea  semilunaris.  The  abdomen  being  opened,  the  small 
intestine  was  packed  away  with  two  small  sponges,  and  the  posterior  wall  1 
The  artery  was  then  seen  below  the  termination  of  the  ileum,  crossed  by  the  spermatic 
vessels.  The  aneurysmal  sac  was  aboul  an  inch  and  a  half  in  diameter.  The  peri- 
tonaeum over  the  artery  being  divided,  the  vessel  was  ligatured  with  two  strands  of 
floss  silk,  tied  with  separate  reef-knots,  and  then  the  peritonaeum  sutured  ov«r  the 
artery.  The  patient  was  kept  in  bed  for  two  weeks,  and  went  oui  on  the  thirty-eighth 
day,  having  made  an  excellent  recovery.  A  firm  linear  sear  was  present  in  the  left 
linea  semilunaris,  and  two  small,  hard  Bwellings  marked  the  site  of  the  cured  aneurysms. 
Mr.  Makins  stated  that  he  repeated  the  transperitoneal  method  here,  because  the  first 
had  proved  so  successful,  and  because  the  aneurysm,  though  small,  was  Bituated  entirely 
above  1'oupart's  ligament.  The  operation  on  the  right  side  proved  much  easier  than 
that  on  the  left,  since  the  crossing  of  the  ileum  was  on  a  higher  level  than  was  the  case 
with  the  Bigmoid  mesocolon.  The  artery  also  was  far  more  prominent  on  the  brim  of 
the  pelvis.  The  circulation  was  re-established  much  more  rapidly  and  satisfactorily 
after  the  second  than  after  the  first  operation.  On  the  firsl  occasion  the  limb  was  very 
cold,  and  the  patient  suffered  much  neuralgic  pain  :  on  the  second  the  local  temperature 
fell  little,  if  at  all,  and  the  patient  had  no  pain.  On  the  first  occasion  the  deep  epigas- 
tric was  tied,  a  step  not  taken  on  the  second,  hut  Mr.  Makins  was  inclined  to  think  that 
the  rapid  re-establishment  of  the  circulation  was  rather  dependent  on  the  enlargement 
of  the  branches  of  the  internal  iliac  on  the  opposite  side  resulting  from  the  obstruction 
of  the  first  external  iliac  artery. 

The  two  following  cases,  in  which  abdominal  section  was  resorted 
to  for  ligature  of  the  external  iliac,  show  a  striking  contrast  in  the 
difficulties  which  may  be  met  with  : 

In  Mr.  Mitchell-Banks'  case  {Brit.  Med.  Journ.,  vol.  ii.  1892,  p.  1163),  the  patient, 
aged  62,  had  an  ilio-femoral  aneurysm  as  big  as  a  fist  occupying  the  upper  part  of  the 
right  Scarpa's  triangle,  pushing  its  way  up  beneath  1'oupart's  ligament.  On  September 
20,  1892,  the  abdominal  cavity  was  opened  by  an  incision  about  three  inches  long  in 
the  right  linea  semilunaris.  The  caecum  and  small  intestines  which  came  into  view  were 
held  apart  by  the  hands  of  an  assistant.  The  position  of  the  external  iliac  being  readily 
detected,  the  artery  was  tied  with  catgut,  and  sufficient  pressure  used  to  stop  the 
pulsation  in  the  aneurysm,  and  no  more,  no  attempt  being  made  to  divide  the  internal 
coat.  The  incision  in  the  peritonaeum  immediately  over  the  artery  was  stitched  up  with 
fine  catgut,  so  as  to  make  the  artery  and  ligature  once  more  extra-peritonseal.  The 
patient's  recovery  was  uninterruptedly  successful,  save  for  one  incident.  On  the 
eleventh  day  the  sudden  onset  of  acute  precordial  pain  and  cyanosis,  dyspnoea,  and 
collapse  was  thought  to  point  to  detachment  of  some  bit  of  clot  from  the  neighbour- 
hood of  the  ligature.  These  complications  gradually  disappeared.  For  some  time  the 
aneurysm  contained  fluid  at  one  part,  but  gradually  contracted,  and  the  patient  went 
out  on  the  forty-second  day  after  the  operation. 

Mr.  Banks  states  that  he  made  use  of  the  abdominal  section  here  because  the  aneurysm 
pushed  well  up  beneath  Toupart's  ligament,  and  he  could  not  make  out  with  certainty 
what  was  the  condition  of  the  artery  above  it. 

The  second  case,  under  the  care  of  Mr.  W.  H.  Brown,  of  Leeds,  tells 
a  very  different  story  of  the  difficulties  which  may  attend  ligature  of  the 
external  iliac  by  abdominal  section  : 

The  patient,  a  woman,  aged  48,  was  admitted  into  the  Leeds  General  Infirmary 
with  two  femoral  aneurysms.     The  upper  one,  the  size  of  a  large  cocoa-nut,  occupied  the 


LIGATURE   OF   THE    tNTERNAL    II. [AC  25 

groin,  extending  upwards  above  Poupart'a  Ligament  :  the  Becond,  a  smaller  one, 
occupied  the  middle  third  of  the  same  right  Eemoral  vessel.  The  skin  over  the  upper 
Bwelling  was  dark,  very  thin,  and  threatening  in  give  way.  The  position  of  the  upper 
aneurysm  was  thought  to  preclude  any  of  the  usual  operations,  and  it  was  decided  to  tie 
the  external  iliac  inl  ra-peril  omeally.  by  a  median  incision.  The  abdomen  was  opened 
by  an  incisional  first  four  and  later  six  inches  long,  owing  to  the  great  amount  of  Eat 
in  the  abdominal  wall.  The  omentum  was  also  very  thick,  and  greatly  embarrassed 
manipulation.     It  was  only  after  the  pelvis  bad   been   well  raised  and  emptied  of  the 

small  intestines  (hat  a  view  could  he  obtained  of  the  revel.  Mr.  lirown  states  that  he 
had  the  greatest  difficulty  in  obtaining,  first  of  all,  a  view  of  the  vessel;  secondly,  in 
passing  the  ligature.  So  far  as  the  abdominal  conditions  were  concerned  the  patient 
made  a  u'ood  recovery,  but,  the  foot  aud  leg  becoming  gangrenous,  amputation  of  the 
thigh  became  necessary.  The  patient  sank  about  ten  weeks  after  the  ligature  of  the 
artery. 

Mr.  Wherry  (Lancet,  vol.  ii.  1893,  p.  136)  made  use  of  the  intra-peri- 
tormeal  method  for  ligature  of  the  left  internal  iliac  in  a  case  of  large 
pulsating  sarcoma  of  the  upper,  outer,  and  back  parts  of  the  innominate 
bone.  The  swelling  was  too  large  and  vascular  to  admit  of  its  removal 
safely. 

"An  incision  was  made  from  below  the  umbilicus  to  the  pubes.  There  were  two 
difficulties.  Firstly,  the  vein,  which  was  very  large  and  much  in  the  way,  was  swollen 
by  the  slightest  pressure  of  sponges  or  retractors  upon  the  upper  part.  The  external  or 
common  iliac  would  have  been  much  easier  to  tie  in  this  case.  There  was  some  venous 
bleeding,  which  stopped  after  the  artery  was  tied,  but  the  vein  also  was  tied  by  a  ligature 
just  below  the  first  one  to  make  it  safe.  The  other  difficulty  was  with  the  light.  Large 
reflecting  refractors  were  of  the  greatest  use,  but  an  electric  light  would  have  been  better 
still."  The  patient  made  a  good  recovery.  The  swelling  at  once  shrank  and  ceased  to 
pulsate,  and  the  relief  to  pain  and  other  distressing  symptoms  was  very  great,  but  no 
further  result  is  given. 

Sir  Frederick  Treves  (Operative  Surgery,  vol.  i.  p.  213)  made  use  of  this  method  in 
a  boy,  aged  16,  with  a  vascular  tumour  of  the  buttock,  in  November,  1889.  He  employed 
an  incision  from  the  umbilicus  to  the  pubes,  and  kept  the  intestines  packed  up  and  aside 
with  six  sponges. 

The  following  is  Sir  Frederick  Treves'  opinion  of  the  merits  of  the 
operation  (loc.  supra  cit.,  p.  211),  and  he  is  inclined  to  extend  this 
method  to  the  common  iliac  also  :  "  The  advantages  of  this  method  are 
obvious.  The  vessel  is  easily  and  fully  exposed,  and  the  needle  can  be 
passed  without  risk  to  the  vein  or  ureter.  The  operation  is  simple, 
and  involves  but  little  time.  Its  dangers  are,  comparatively  speaking, 
very  few.  The  ligature  can  be  applied  accurately  at  the  spot  determined 
upon.  The  condition  of  the  artery  and  the  surrounding  parts  can  be 
made  out,  and  a  diagnosis  confirmed  or  modified.  The  great  objection 
that  some  few  years  ago  would  have  been  urged  against  the  procedure — 
the  risk  of  acute  peritonitis — may  be  at  the  present  day  almost 
disregarded." 

Writing  as  I  do  for  those  whose  operative  experience  is  not  to  be 
compared  with  that  of  Sir  Frederick  Treves,  I  hesitate  to  endorse  the 
above  opinion  in  its  entirety.  I  am  of  opinion  that  with  the  above 
incision  the  intestines  will  sometimes  give  great  trouble.  Mr.  Maynard 
{Ind.  Med.  Gazette,  vol.  xxxviii.  No.  7,  July,  1903),  in  tying  the  right 
common  iliac  artery  for  a  diffusing  aneurysm  of  the  external  iliac,  had 
much  trouble  with  the  small  intestines,  the  whole  of  which  had  to  be 
drawn  out   of  the  abdomen  and  wrapped  in  warm   sterilised  towels. 


26  OPERATIONS  ON  THE  ABDOMEN. 

The  operation  then  became  perfectly  simple.  Mr.  Maynard  did  not 
have  the  advantages  of  the  Trendelenberg  position,  and  of  broad  and 
deep  retractors,  both  of  which  are  invaluable.  The  patient  died  on  the 
seventh  day,  the  cause  of  death  remaining  uncertain,  for  no  autopsy  was 
allowed.  Mr.  Currie  (Annals  of  Surgery,  vol.  iv.  1905,  p.  620)  records 
a  successful  case  of  transperitoneal  ligation  of  the  left  external  iliac  for 
aneurysm  of  its  lower  part.  A  median  incision  was  used,  and  the 
artery  was  easily  tied  with  the  aid  of  the  Trendelenberg  position 
and  good  retractors.  A  good  deal  of  handling  and  exposure  will  be 
inevitable,  and  we  all  know  that  where  the  above  are  entailed  septic 
peritonitis  does  still,  in  spite  of  the  advantages  of  modern  surgery, 
tend  to  appear.  Under  favourable  circumstances,  with  modern  skill  in 
abdominal  surgery,  and  the  advantages  of  the  Trendelenberg  position, 
good  intestinal  retractors,  and  reflected  light,  it  is  certain  that  the 
transperitoneal  approach  will  become  more  and  more  popular  for 
the  reasons  so  clearly  indicated  by  Sir  Frederick  Treves  and  Mr. 
Makins  (p.  22).  This  route  is  particularly  suitable  for  ligation  of  the 
internal  and  common  iliacs,  and  for  cases  of  aneurysm  of  the  external 
iliac  when  it  is  not  certain  beforehand  that  a  ligature  can  be  safely 
applied  to  the  external  iliac  extra-peritoneally.  In  these  a  peritoneal 
incision  enables  the  surgeon  to  decide  whether  a  ligature  can  be  placed 
on  the  external  iliac  or  must  be  applied  to  the  common  iliac — a  much 
more  risky  procedure  as  regards  gangrene  of  the  foot  and  leg.  In 
fairness  I  must  add  that  I  have  only  once  tied  either  of  the  iliac 
vessels — the  common  iliac  in  the  case  mentioned  at  p.  15.  The  free 
incision  there  made  use  of  would  have  rendered  the  securing  of  the 
internal  iliac  as  easy  as  it  did  that  of  the  parent  trunk.  In  gunshot 
injuries  or  stabs,  the  intra-peritoneal  method  will,  of  course,  be  made 
use  of.  My  readers  should  refer  to  Mr.  Makins'  opinion  on  the  intra- 
peritoneal method,  quoted  at  p.  22. 

LIGATURE     OF     THE     GLUTEAL     ARTERY. 

Indications. 

1.  Stab.  2.  Aneurysm.  3.  Hemorrhage  after  opening  an  abscess. 
All  are  rare,  especially  the  last. 

1.  Stab. — The  source  of  the  bleeding  from  a  stab  in  the  buttock  may 
be  very  difficult  to  tell  exactly.  The  surgeon  may  be  guided  by  the 
position  of  the  exit  of  the  gluteal  and  sciatic  vessels  (Fig.  6) ;  he  will 
remember  the  outline  of  the  gluteus  maximus,  the  lower  border  of  this 
muscle  forming  the  fold  of  the  buttock,  the  upper  starting  from  the 
crest  about  two  inches  in  front  of  the  posterior  superior  spine,  and 
running  downwards  and  forwards  to  the  greater  trochanter.  Hemor- 
rhage from  a  stab  in  the  upper  part  of  this  muscle  will  probably  come 
from  the  gluteal ;  if  from  the  lower  part,  from  the  gluteal  or  sciatic. 

2.  Aneurysm. — This  affection  is  so  rare  that  it  will  be  sufficient  to 
quote  the  following  conclusions  of  Mr.  Holmes  *  : 

(1)  "  Gluteal  aneurysms,  both  traumatic  and  spontaneous,  are  very 
favourably  circumstanced  for  the  treatment  by  either  rapid  or  gradual 
compression  applied  to  the  aorta  or  common  iliac." 

*  Hunt.  Lect,  Lancet,  11=74,  vo1-  "■  P-  76  '•  ^V^-  °f  Svnrg.,  vol.  iii.  p.  14s- 


LIGATURE   OF   THE   GLUTEAL    A.RTERY.  jy 

Mr.   Holmes  points  out  that  gluteal  aneurysm,  if  not  ruptured,  is 

Usually  of  no  great,  size,  and  docs  not  encroach  upon  the  abdomen,  and 

thus  any  part  of  the  common  iliac  or  aorta  is  accessible  to  pressure. 

(2)  "  If  this  treatment,  with  or  without  anaesthetics,  does  not  succeed 
by  itself,  it  may  be  supplemented  by  coagulating  injection  or  galvano- 
puueture,  while  the  patient  is  narcotised,  and  the  circulation  com- 
manded."    Of  the  two  Mr.  Holmes  prefers  galvano-puncture. 

(3)  "  When  such  treatment  fails,  and  particularly  in  aneurysms  with 
imperfect  or  ruptured  sacs,  where  it  is  not  indicated,  the  internal  iliac 
must  be  tied  when  the  surgeon  thinks  that  he  cannot  find  the  artery 
outside  the  pelvis.  But  when  the  artery  is  accessible,  the  old  operation, 
or  the  operation  of  Anel,  should  be  practised,  according  to  the  size  and 
extent  of  the  tumour." 

In  deciding  whether  the  aneurysm  is  inside  or  outside  the  pelvis,  the 
surgeon  will  see  if  the  pulsation  can  be  commanded  by  pressure  on  the 
artery  above  the  aneurysm,  whether  the  latter  can  be  lifted  from  the 
bone,  and  will  also  make  an  examination  by  vagina  or  rectum. t 

The  old  operation  must  always  be  formidable,  and  while  modern 
tourniquets  may  admit  of  efficient  pressure,  there  is  always  the  risk  of 
fatal  hemorrhage  from  the  artery  having  retracted  into  the  pelvis. 

The  method  of  Anel  does  not  seem  likely  to  be  often  useful.  ( )f 
three  cases,  one  only  has  been  successful. 

(4)  "  The  ligature  of  the  internal  iliac  is  liable  to  failure  in  cases  of 
spontaneous  aneurysm  from  a  diseased  condition  of  the  coats  of  the 
artery,  and  should  always  be  avoided  when  other  means  of  treatment 
are  available." 

This  method  has  proved  fatal  in  about  half  the  cases  operated  on. 
The  varying  length  of  the  artery,  the  proximity  of  the  ligature  in  all 
cases  to  large  branches  and  to  the  sac,  have  all  to  be  remembered. 

Here  also  ligature  of  the  artery  by  laparotomy  will  probably  be 
resorted  to  in  the  future  (p.  22). 

Surgical  Anatomy  of  the  Gluteal  Artery. — A  short,  thick  branch 
from  the  posterior  division  of  the  internal  iliac,  this  leaves  the  pelvis 
above  the  pyriformis,  through  the  sacro-sciatic  notch.  Immediately 
after  its  exit  it  divides  into  a  superficial  and  a  deep  portion.  The 
superficial  is  mainly  distributed  to  the  gluteus  maximus ;  the  deep  lies 
between  the  gluteus  medius  and  minimus,  and  divides  into  two,  the 
upper  branch  running  along  the  origin  of  the  gluteus  minimus,  and  the 
lower  running  obliquely  across  this  muscle  towards  the  trochanter 
major.  The  superior  gluteal  nerve  emerges  just  below  the  artery,  and 
sends  branches  with  the  deeper  portion. 

Line  and  Guide. — "  If  a  line  be  drawn  from  the  posterior  superior 
spine  to  the  great  trochanter,  the  limb  being  slightly  flexed  and  rotated 
inwards,  the  point  of  emergence  of  the  gluteal  artery  from  the  upper 
part  of  the  sciatic  notch  will  correspond  with  the  junction  of  the  upper 
with  the  middle  third  of  this  line"  (MacCormac,  Lig.  of  Arts.,  p.  126, 
Figs.  10,  11). 

Operation  (Fig.  6). — The  patient  being  rolled  two-thirds  over  on  to 

*  Sou  the  remarks  011  the  introduction  of  foreign  bodies  and  galvano-puncture, 
vol.  i.  pp.  814—819. 

t  Au  anaesthetic  being  given,  and  the  hand  passed  here,  if  needful. 


28 


OPERATIONS  ON  THE  ABDOMEN. 


his  lace,  the  part  well  exposed  and  cleansed,  the  limh  hanging- over  the 
edge  of  the  table,  an  incision,  five  inches  long,  is  made  in  a  line 
running  from  the  posterior  superior  spine  to  the  upper  and  inner  part 
of  the  great  trochanter.     The  incision  should  run  almost  parallel  with 


Fig,  6. 


Position  and  direction  of  the  superficial  incisions  which  must  be  made  to  secure 
the  gluteal,  sciatic,  or  pndic  arteries. 

A.  Posterior  superior  iliac  spine.  C.  Tuberosity  of  ischium. 

B.  Great  trochanter.  D.  Anterior  superior  iliac  spine. 

AB.  Uio-trochanteric  line,  divided  into  thirds.  This  line  corresponds  in 
direction  with  the  line  of  the  fibres  of  the  gluteus  maximus.  The  incision  to 
reach  the  gluteal  artery  is  indicate:!  by  the  darker  portion  of  the  line.  Its  centre 
is  at  the  junction  of  the  upper  and  middle  thirds  of  the  ilio-trochanteric  line,  and 
exactly  corresponds  with  the  point  of  emergence  of  the  gluteal  artery  from  the 
great  sciatic  notch. 

AC.  Ilio-ischiatic  line.  The  incision  to  reach  the  sciatic  or  internal  pudic 
arteries  is  indicated  by  the  lower  dark  line.  It  is  also  to  be  made  in  the  direction 
of  the  fibres  of  the  gluteus  maximus.  The  centre  of  the  wound  corresponds 
to  the  junction  of  the  lower  and  middle  thirds  of  the  ilio-ischiatic  line. 
(MacCormac.) 

the  gluteus  maximus.  The  fihres  of  this  muscle  heing  separated, 
between  adjacent  fasciculi,  with  a  director,  a  muscular  branch  should  he 
found  and  traced  down  to  the  exit  of  the  artery.  The  gluteus  maximus 
having  heen  relaxed,  and  the  contiguous  margins  of  the  gluteus  medius 
and  p3rriformis  separated  with  retractors,  the  surgeon,  taking  as  his 
guide  the  ahove  line  and  the  aperture  of  the  great  sacro-sciatic  notch, 


LIGATURE    OF    THE    GLUTEAL    ARTERY.  29 

clears  the  artery  as  high  up  as  possible,  avoiding  the  nerve  and  the 
veins,  ami  dividing  the  adjacent  muscles  if  needful.  The  ligature  should 
be  applied  as  far  within  the  notch  as  possible,  almosl  within  the  pelvis, 
as  the  artery  divides  immediately  after  its  exit. 

Old  Operation. — The  following  is  the  account  of  Prof.  Syme's  case. 
The  man  had  been  stabbed  in  the  buttock  seven  years  before.  The 
aneurysm  measured  nunc  than  ij  inches  in  both  diameters;  this, 
together  with  the  great  thinness  and  laxity  of  the  coverings  being 
opposed  to  coagulation,  led  to  the  adoption  of  the  old  operation. 

"The  patient  having  been  rendered  unconscious  and  placed  on  his  right  side,  I  thrust 
a  bistoury  into  the  tumour,  over  the  situation  of  the  gluteal  artery,  and  introduced  my 
finger  so  as  to  prevent  the  blood  Erom  lowing,  except  by  occasional  gushes  which  showed 

what  would  have  been  the  effect  of  neglecting  this  precaution,  while  I  searched  for  the 
vessel.  Finding  it  impossible  to  accomplish  the  object  in  this  way,  I  enlarged  the  wound 
sufficiently  for  the  introduction  of  my  fingers  in  succession,  until  the  whole  hand  was 

admitted  into  the  cavity,  of  which  the  orifice  was  still  so  small  as  to  embrace  the  wrisl 
with  a  tightness  that  prevented  any  continuous  haemorrhage.  Being  nowr  able  to  explore 
the  state  of  things  satisfactorily,  I  found  that  there  was  a  large  mass  of  dense  fibrinous 
coagulum  firmly  impacted  into  the  sciatic  notch,  and,  not  without  using  considerable 
force,  succeeded  in  disengaging  the  whole  of  this  obstacle  to  reaching  the  artery.  .  .  . 
The  gentleman  who  assisted  me  being  prepared  for  the  next  step  of  the  process,  I  ran  my 
knife  rapidly  through  the  whole  extent  of  the  tumour,  turned  out  all  that  was  within  it, 
and  had  the  bleeding  orifice  instantly  under  subjection  by  the  pressure  of  a  finger. 
Nothing  then  remained  but  to  pass  a  double  thread  under  the  vessel  and  tie  it  on  both  sides 
of  the  aperture."     The  case  did  perfectly  well  *  (Obs.  in  Clin.  Surg.,  p.  1C9). 

If,  in  the  case  of  a  stab,  the  hemorrhage  continues  after  the  ligature 
lias  heen  applied  with  the  ahove  precautions,  and  the  gluteal  has  evi- 
dently been  punctured  within  the  pelvis,  the  internal  iliac  must  be  tied 
after  the  wound  in  the  buttock  has  been  firmly  plugged  with  iodoform 
gauze  wrung  out  of  carbolic  acid  (I  in  20). 

Macewen's  Method  (vol.  i.  p.  814). — A  case  thus  treated  success- 
fully in  the  Edinburgh  Infirmary  by  Mr.  Miller  is  recorded  (Brit.  Med. 
Journ.,  1893,  vol.  i.  p.  1176)  : 

The  patient  here  was  aged  75  on  June  1,  1891.  The  surface  of  the  swelling  having 
been  well  cleansed,  six  long  aseptic  steel  pins  were  introduced  into  the  sac  in  different 
directions,  and  made  to  pass  through  it  until  they  were  felt  to  impinge  against  the 
opposite  wall.  They  were  then  withdrawn  a  little  so  that  their  points  might  scratch  the 
inner  surface  of  the  cavity.  The  pulsations  of  the  swelling  were  sufficiently  powerful 
to  move  the  points  of  the  pins,  and  to  cause  them  to  irritate  the  internal  wall  of  the 
aneurysm.  They  were  left  in  about  half  an  hour,  and  when  withdrawn  the  punctures 
were  covered  with  collodion.  No  anaesthetic  was  given,  nor  did  the  patient  complain  of 
much  pain.  On  June  12  the  above  treatment  was  repeated,  only  four  pins  being  used 
now.  since  two  of  those  used  before  were  found  to  be  too  fine  on  this  occasion,  as  they  bent 
when  force  was  used  to  make  them  perforate  the  now  thickened  wall  of  the  aneurysm. 
On  June  25  no  pulsation  could  be  detected  in  the  aneurysm,  which  had  shrunk  consider- 
ably. At  this  date  a  pulsating  swelling  was  felt  between  the  xipho-sternum  and 
umbilicus.  July  10,  the  gluteal  aneurysm  was  quite  firm  to  the  touch.  The  abdo- 
minal swelling  increased  rapidly.  At  first  it  was  thought  to  be  another  aneurysm,  but 
it  was  later   diagnosed    as   malignant,    the   pulsation    of   the  aorta    being   transmitted 

*  Nowadays  the  application  of  a  Lister's  tourniquet  to  the  abdominal  aorta  would 
facilitate  matters.  Another  successful  case  is  recorded  by  Mr.  J.  Bell,  Prin.  <;/'  Surg., 
vol.  i.  p.  1801. 


3o  OPERATIONS    ON   THE    ABDOMEN. 

through  it.  The  patient  sank  on  August  30.  At  the  necropsy  a  large  soft  sarcoma  was 
found  infiltrating  the  upper  pari  of  the  abdomen.  The  gluteal  aneurysm  was  found 
to  be  quite  firm  and  solid.  It  was  mostly  rilled  with  firm  fibrous  clot,  a  small  part  in 
,the  centre  being  softer. 

LIGATURE   OF  THE   SCIATIC  ARTERY. 

Indications. — Stab.  This  operation  is  so  rarely  required  that  it 
may  be  very  briefly  described  here. 

Surgical  Anatomy. — The  sciatic  artery  emerges,  together  with  the 
sciatic  nerve  and  the  pudic  artery,  from  the  lower  part  of  the  great 
sacro-sciatic  notch  below  the  pyriformis. 

Guide  and  Line. — The  limb  being  rotated  inwards,  a  line  is  drawn 
from  the  posterior  superior  spine  to  the  ischial  tuberosity.  The  exit  of 
the  sciatic  and  pudic  arteries  corresponds  to  the  junction  of  the  middle 
and  lower  thirds  of  this  line. 

Operation  (Fig.  6). — The  sciatic  artery  may  be  found  by  one  of  two 
incisions — (a)  by  a  horizontal  one,  about  five  inches  long,  made  about 
an  inch  and  a  half  below  that  for  the  gluteal  artery,  and,  like  that, 
parallel  with  the  fibres  of  the  gluteus  maximus  ;  (b)  by  one  made 
vertically  in  the  above  given  line.  The  deeper  guides  will  be  the 
margins  of  the  notches,  or  the  great  sciatic  nerve. 

LIGATURE   OF  THE  ABDOMINAL  AORTA. 

Indications. — As  this  most  rare  operation  has  been  fatal  in  every  one 
of  the  cases  in  which  it  has  been  performed  (fifteen,  of  which  only  four 
have  been  done  since  the  introduction  of  antiseptic  surgery),  its  justi- 
fiability has  naturally  been  called  in  question.  On  the  one  hand,  the 
desperate  condition  of  the  patients,  the  advanced  amount  of  disease 
probably  present  in  their  arteries,  hearts,  &c,  the  large  and  rapid  blood- 
current,  the  disturbance  of  very  vital  parts,  and  the  risk  of  peritonitis, 
all  combine  to  render  the  probability  of  success  extremely  small.  On 
the  other  hand,  recent  improvements  in  surgery,  the  introduction  of 
better  ligatures,  the  fact  that  in  these  cases  life  must  speedily  end  if 
nothing  be  done,  and,  perhaps,  the  fact  that  many  of  the  major 
operations  of  surgery  have  been  unsuccessful  at  first,  will  justify 
surgeons  in  again  making  trial  of  this  forlorn  hope,  if  they  feel  certain 
that  otherwise  the  case  is  quite  hopeless.  Since  R.  T.  Morris  {Log. 
infra  cit.)  has  been  able  to  demonstrate  the  possibility  of  making  an  aortic 
aneurysm  "  fill  with  clots  by  the  application  of  a  temporary  ligature  to 
the  aorta,  and  that  circulation  in  the  extremities  can  be  re-established  on 
the  removal  of  the  ligature,"  some  hope  may  be  entertained  of  obtain- 
ing a  success  by  a  modification  of  his  method. 

The  cases  have  mostly  been  those  of  iliac  and  inguinal  aneurysm  in 
which  other  arteries  have  been  tied  without  success.  To  justify  the 
epithet  above  given  of  "  desperate,"  the  first  case,  the  well-known  one 
of  Sir  A.  Cooper  (in  1817),*  may  be  alluded  to. 

Here  the  patient  had  long  suffered  from  an  aneurysm  affecting  the  external  and 
common  iliac  arteries,  leading  to  sloughing  of    the  skin  and  haemorrhage.      Sir  Astley 

*  Prin.  and  Pract.  of  Surg,  (edited  by  Dr.  Lee),  vol.  i.  p.  228. 


LIGATURE    OF    THE    ABDOMINAL    A.ORTA.  ;i 

bavins  failed  in  an  attempl  to  perform  the  old  operation,  owing  to  the  artery  lyin 
deeply,  gave  the   patienl    "the   only    hope   of  safety'1  which    remained  by   tying    the 
aorta. 

As  life  was  here  prolonged  for  forty  hours,  and  as  in  Monteiro's 
case  death  did  not  take  place  till  the  tenth  day,  proof  is  given  of  the 
restoration  of  the  collateral  circulation.* 

Mr.  Mitchell  Banks  records  briefly  (Brit.  Med.  Jowrn.,  1892,  vol.  ii. 
p.  1 164)  the  following  most  interesting  case: 

About  fifteen  years  before,  a  patient  in  a  state  of  exhaustion  came  under  his  care 
with  a  rapidly  increasing  aneurysmal  swelling  occupying  the  left  iliac  region,  and 
reaching  to  the  middle  line  in  front  and  to  the  umbilicus  above.     "  It  was  impossible  to 

Bay  where  ii  sprang  from,  hut,  as  the  man  evidently  had  only  a  short  time  to  live,  it 
was  necessary  to  act  promptly.  I  opened  the  abdomen  in  the  middle  line  (which  was 
thought  rather  an  adventurous  proceeding  in  those  days),  with  the  intention  of  tying  the 
common  iliac,  or  the  aorta  itself,  if  I  got  a  chance.  But  it  was  found  impossible  to  do 
anything.  The  aneurysm  overlapped  the  left  common  iliac  and  the  lower  portion  of  the 
aorta,  so  that  neither  of  them  could  be  reached.  It  was  a  gigantic  thing,  and  had  been 
leaking  for  some  time  at  the  back,  tearing  up  the  tissues  behind  the  peritonaeum  in  all 
directions."     The  patient  sank  a  few  days  later.     No  necropsy  is  mentioned. 

In  addition  to  the  above  cases  in  which  the  aorta  has  been  tied  in  cases  of  aneurysm, 
it  has  been  tied  once  for  haemorrhage  after  a  gunshot  injury  of  the  upper  part  of  the 
thigh,  by  Czerny,  of  Heidelberg.  Haemorrhage  continuing,  the  common  femoral  was  tied, 
together  with  the  superficial  femoral  below  the  profunda.  Bleeding  taking  place  again  in 
six  days,  the  common  iliac  was  tied.  The  haemorrhage  still  persisting,  it  was  thought  that 
the  external  iliac  only  had  been  tied,  and  a  ligature  was  next  placed,  by  mistake,  upon 
the  aorta.  The  patient  lived  twenty-six  hours.  The  same  surgeon  during  a  nephrectomy 
for  a  soft  malignant  growth  of  the  kidney  met  with  such  uncontrollable  haemorrhage 
as  to  compel  him  to  tie  the  aorta,  the  patient  dying  soon  after. 

Surgical  Anatomy. — The  lowest  part  of  the  aorta — viz.,  that 
between  the  bifurcation  and  the  origin  of  the  inferior  mesenteric — is 
that  which  should  be  chosen. t 

The  vessel  may  have  in  front  of  it  the  omentum,  duodenum, 
mesentery,  small  intestines,  and  more  closely  the  aortic  plexus  of  the 
sympathetic,  and  a  layer  of  fascia  of  various  strength.  To  the  right 
side  lies  the  vena  cava,  and  behind  it  are  the  left  lumbar  veins.  The 
bifurcation  is  usually  situated  a  little  to  the  left  side  of  the  umbilicus, 
and  about  three-quarters  of  an  inch  below  it. 

Operation. — This  may  be  performed  (A)  through,  or  (B)  behind, 
the  peritomeum.  The  intra-peritonaeal  method  is  especially  indicated 
when  the  height  at  which  the  ligature  must  be  applied,  or  any  evidence 
of  matting  of  the  structures  of  the  abdominal  wall  (dating  to  inflam- 
mation about  the  aneurysm,  or  to  the  use  of  pressure),  would  probably 
interfere  with  stripping  up  the  peritonaeum. 

*  In  comparing  instances  of  the  restoration  of  the  circulation,  the  one  by  disease  and 
the  other  after  the  surgeon's  ligature,  the  importance  of  the  slow  and  gradual  process  in 
the  one  case  will  not  be  lost  sight  of.  Mr.  Barwell  (Intern.  Encycl.  of  Surg.,  vol.  iii. 
p.  481)  alludes  to  the  experiments  of  Pirogoff  (Waller  and  von  Gnife's  Jowrn.,  Bd.  xxvii. 
S.  122)  and  a  paper  by  Kast  (Zelt.f.  (Mr.,  Bd.  xii.  S.  405)  to  show  that  the  collateral 
circulation  is  established.  Sir  A.  Cooper  (lor.  supra  cif.)  used  to  show  in  his  lectures  an 
injected  specimen  from  a  dog  which  survived  the  operation.  Beyond  this  fact,  however, 
no  comparison  can  be  made  between  the  chance  of  survival  of  healthy  animals  and  that 
of  patients  reduced  to  such  straits  as  to  call  for  this  operation. 

t  This  interval  varies  in  length  from  half  an  inch  to  two  inches. 


32  OPERATIONS  ON  THE  ABDOMEN. 

A.  Through  the  Peritoneum. — The  bowels  having  been  emptied  as 
much  as  possible,  the  skin  cleansed,  the  shoulders  raised,  and  the 
knees  slightly  flexed,  the  surgeon  makes  an  incision  at  leasi  four  inches 
long  in  the  middle  line,  with  its  centre  opposite  to  the  umbilicus,  but 
curving  a  little  to  the  left  here,  sons  to  avoid  the  round  ligament  of  the 
liver  and  the  urachus.  The  linea  alba  being  found  and  divided,  the 
fascia  transversalis  slit  up,  all  haemorrhage  must  be  arrested  before 
opening  the  peritonaeum.*  When  this  structure  has  been  opened  to 
the  whole  extent  of  the  wound,  deep  and  broad  retractors  are 
inserted,  and  the  small  intestine  and  mesentery  drawn  partly  upwards 
and  partly  to  the  sides,  sterile  gauze  being  packed  around,  if  needful, 
to  keep  the  above  structures  out  of  the  way.  The  pulsation  of  the 
vessel  is  now  felt  for,  and  the  deeper  layer  of  peritonaeum  carefully 
scratched  through.  Care  should  be  taken  to  disturb  as  little  as 
possible  the  aortic  plexus  t  during  this  step  and  in  passing  the  needle, 
which  should  be  carried  from  right  to  left. 

The  ligature  used  should  be  one  of  the  flat  tape-like  ones,  of 
kangaroo  tendon  or  sufficiently  stout  silk.  The  passage  of  the  needle 
may  be  attended  with  much  difficulty,  \  not  only  from  the  depth  of  the 
vessel,  and  from  the  presence  of  intestines  if  distended  and  allowed  to 
protrude  into  the  wound,  but  also  from  the  denseness  of  the  cellular 
tissue  surrounding  the  artery. 

B.  Behind  the  Peritoneum  (Fig.  5). — This  method  should  be  tried 
in  any  case  where  the  surgeon  is  unable  to  take  those  precautions  for 
which  intra-peritomeal  surgery  calls.  The  chief  objection  is  the  great 
depth  at  which  the  artery  is  reached  ;  but  it  is  well  worthy  of  notice 
that  in  Monteiro's  case,  which  survived  ten  days,  this  method  was  made 
use  of. 

The  operation  is  performed  on  much  the  same  lines  as  that  already 
given  for  ligature  of  the  common  iliac  (p.  17).  The  incision  should  be 
as  free  as  possible,  from  the  tip  of  the  tenth  rib,  curving  somewhat 
forwards  to  the  anterior  superior  spine.  §  The  muscles  and  trans- 
versalis fascia  being  cut  through,  the  peritonaeum  is  stripped  up  and 
turned  inwards,  several  large  retractors  placed  in  the  wound,  and  the 
ribs  dragged  up  and  outwards.  The  common  iliac  being  found,  this 
vessel  is  traced  up  into  the  aorta  (Fig.  5). 

*  In  Mr.  James's  case  (Me&.-Chir.  Tram.,  vol.  xvi.  p.  10)  a  large  quantity  of  blood 
was  found  post  mortem  in  the  abdominal  cavity.  This  hail  come  either  from  a  vessel  in 
the  parietes,  or  from  one  wounded  in  the  mesentery. 

t  Sir  A.  Cooper  (loc.  supra  /■'//.)  believed  that  his  experiments  on  dogs  proved  that 
inclusion  of  this  plexus,  and  not  the  interruption  of  the  circulation,  was  the  cause  of  the 
paralysis  which  followed  the  experiment.  Jn  Mr.  James's  case,  when  the  ligature  was 
tightened,  the  patient  complained  of  "deadness  in  the  lower  extremities."  This  was  soon 
followed  by  agonising  pain  in  the  same  parts,  only  relieved  by  death  about  three  hours 
after  the  operation. 

I  Thus,  in  Mr.  James's  case  the  aneurysm-needle  broke  at  its  handle,  the  surgeon 
having  "  little  anticipated  occasion  for  so  much  force."  In  one  case  the  sac  gave  way 
during  the  operation. 

§  If  necessary,  a  horizontal  one:  might  be  added,  at  right  angles  to  the  first,  but  the 
rectus  and  the  deep  epigastric  should  on  no  account  be  interfered  with. 


si  EtGICAL   TREATMENT   OF    ABDOMINAL    ANEURYSM.      33 

THE    SURGICAL    TREATMENT     OF    ABDOMINAL 
ANEURYSM. 

1.  Aneurysm  of  the  Abdominal  Aorta. — In  spite  of  recent  advances 
in  treatment,  the  prognosis  of  this  disease  remains  extremely  grave. 
The  late  Dr.  J.  II.  Bryant  (Clinic.  Journ.,  Nov.  25,  1903)  found  that 
the  average  duration  of  life  in  these  cases  is  about  13  months 
from  the  time  that  the  aneurysm  first  becomes  manifest.  He  pointed 
out  that  the  condition  was  correctly  diagnosed  during  life  in  only 
18  of  his  54  cases,  and  also  that  the  opposite  mistake  of  diagnosing 
an  abdominal  aneurysm  which  is  not  present  is  even  much  more 
frequent ;  67  per  cent,  of  the  cases  occur  in  the  neighbourhood  of  the 
coeliac  axis. 

A  few  cases  of  spontaneous  recovery  are  on  record,  and  Osier 
(Lancet,  Oct.  14,  1905)  has  "seen  at  least  two  instances  of  spon- 
taneous healing  in  aneurysm  of  the  abdominal  aorta."  Very  little  is 
to  be  hoped  for  from  medical  treatment. 

Osier  (Lancet,  Oct.  14,  1905)  has  never  seen  a  case  cured  by 
medical  treatment.  The  Tufnell  diet  and  large  doses  of  iodide  of 
potassium  are  disappointing  and  unpleasant ;  the  gelatine  treatment  is 
dangerous,  and  of  but  little  permanent  value. 

Surgical  procedures  may  prolong  life  in  some  cases,  and  shorten  it 
in  others  (vide  infra). 

1.  Compression  above  the  sac  in  the  rare  cases  that  it  is  possible 
to  apply  it  may  be  successful,  as  in  the  case  under  Dr.  Murray,  of 
Newcastle ;  this  patient  remained  well  for  six  years.  This  treat- 
ment can  rarely  be  employed  owing  to  the  high  position  of  the  great 
majority  of  aortic  aneurysms  (vide  supra),  and  it  is  not  free  of 
danger,  the  intestines  and  other  viscera  being  liable  to  serious  injury 
from  compression  against  the  spine. 

The  latter  objections  apply  equally  to  distal  compression. 

2.  Treatment  by  Acupuncture. — This  method  has  been  fully  alluded 
to  at  p.  814,  vol.  i. ;  and  a  brilliantly  successful  case  of  abdominal 
aneurysm  treated  by  Prof.  Macewen  with  needles,  and  the  formation  of 
white  thrombi,  will  be  found  at  p.  816,  vol.  i.  This  patient  was  at 
work  for  over  2\  years  after  the  treatment. 

The  only  safe  method  of  applying  this  and  the  galvano-puncture 
treatment  of  Velpeau  is  after  laparotomy,  the  overlying  viscera  may 
otherwise  be  injured. 

3.  Treatment  by  the  Introduction  of  Wire  (Moore).  —  This 
method  has  been  described  at  p.  813,  vol.  i.  Prof.  Loreta,  of 
Bologna,  has  applied  it  to  one  case  of  abdominal  aneurysm  which 
attracted  much  attention  at  the  time,  but  proved,  as  is  so  common 
in  these  cases,  only  temporarily  successful.  An  account  will  be 
found  (Brit.  Med.  Joum.,  vol.  i.  1885,  pp.  745,  955)>  taken  from  the 
original  paper  (Mem.  Roy.  Acad.  Scien.  Institute  of  Bologna,  Feb.  8, 
1885). 

The  patient  was  a  sailor,  aged  30,  who  had  always  had  good  health,  save  for  syphilis 
five  years  before.  Nearly  two  years  before  his  admission  he  had  felt  something  give  way 
in  the  belly  while  making  violent  efforts.  A  large  aneurysm  occupied  the  epigastric  and 
left  hypochondriac  regions.     An  incision  having  been  made  from  the  ensiform  cartilage 

s—  vol.  n.  3 


34  OPERATIONS  OX  THE  ABDOMEN. 

to  the  umbilicus,  numerous  superficial  adhesions  were  found,  and  carefully  separated,  but 
it  was  found  impossible  thus  to  deal  with  deeper  ones  uniting  the  sac  to  the  stomach, 
spleen,  and  diaphragm.  Hence  it  was  impossible  to  trace  the  aneurysm  to  its  mouth,  nor 
could  it  be  compressed  and  emptied.  It  remained  uncertain,  therefore,  at  the  time, 
whether  the  aorta  or  one  of  its  branches  was  the  vessel  involved.  The  vessel,  which  was 
now  fully  exposed  on  its  right  side,  was  punctured  with  a  fine  trocar,  and  silvered  copper 
wire  passed  in  from  above  downwards  and  to  the  left.  As  soon  as  the  wire  met  resistance 
the  cannula  was  removed,  the  end  of  the  wire  pushed  in,  and  the  puncture  brushed  over 
with  pure  carbolic  acid.  A  little  over  two  yards  had  been  introduced.  The  after-course 
was  one  of  rapid  and  progressive  recovery.  The  man  was  allowed  to  get  up  at  the  end  of 
six  weeks,  the  swelling  having  consolidated,  the  bruit  having  disappeared,  the  pulsation 
being  only  communicated,  and  the  femoral  pulse,  which  had  been  almost  suppressed, 
having  reappeared.  The  patient  died  suddenly,  ninety-two  days  after  the  operation,  from 
rupture  of  the  aorta  immediately  below  the  sac  at  the  angle  of  juncture  between  this  and 
the  aorta.  The  sac,  filled  with  organising  fibrin,  had  shrunk  to  the  size  of  a  walnut. 
The  wire  was  found  unaltered  and  rolled  up  in  a  globular  mass.  Prof.  Loreta  suggested 
that  the  compression  produced  by  the  coagula  in  the  sac  might  have  caused  an  interference 
with  the  blood-supply  to  the  arterial  wall  just  below  the  swelling,  and  so  induced  rupture 
of  an  artery  no  doubt  already  diseased. 

D'Arcy  Power  and  Colt  {Lancet.  Sept.  19,  1903)  reported  a  case  in  which  80  inches  of 
silver  wire  were  introduced  into  an  abdominal  aneurysm  through  an  ingenious  but  rather 
complicated  instrument  invented  by  Mr.  Colt.  Pulsation  diminished  but  did  not  vanish. 
The  patient  died  50  hours  after  the  operation.  A  loop  of  wire  had  passed  into  the  aortic 
arch,  but  most  of  it  was  coiled  up  within  the  sac  amongst  recent  clots  which  filled  the 
sac.  The  whole  operation  lasted  about  half  an  hour,  but  the  actual  introduction  of  the 
wire  only  took  z\  minutes.  The  hole  in  the  sac  was  easily  closed  with  a  few  Lembert 
sutures. 

The  following  advantages  are  claimed  for  the  instrument :  Quickness,  kinking  of  the 
wire  is  avoided,  and  the  risk  of  haemorrhage  is  greatly  diminished. 

Maunsell  (Brit.  Med.  Journ.,  June  18,  1904)  collected  8  cases  of 
abdominal  aneurysm  treated  by  Moore's  method  with  three  cures  of 
the  aneurysm.  It  is  not  stated  how  long  these  cases  were  observed. 
The  cases  that  did  best  were  those  in  which  about  5  or  6  feet  of  wire 
were  used. 

4.  The  Moore-Corradi  Method. — Corradi  (Lo  Sperimentale,  April, 
1879,  p.  445)  introduced  a  modification  of  Moore's  method ;  having 
passed  17  in.  of  wire  into  a  thoracic  aneurysm,  he  then  sent  a  galvanic 
current  through  the  wire.  The  patient  survived  for  13  weeks.  Hunner 
(Bull.  Johns  Hopkins  Ho&p.,  Nov.,  1900)  has  collected  23  cases  of 
thoracic  and  abdominal  aneurysms  treated  by  Corradi's  method,  with 
four  cures,  one  improvement  and  prolongation  of  life,  and  "ten  in 
which  death  was  probably  hastened." 

Maunsell  (loc.  cit.)  collected  8  abdominal  cases,  including  his  own 
interesting  case.     One  of  these  patients  was  cured. 

Maunsell  having  exposed  the  aneurysm  which  was  in  the  coeliac  axis  region,  passed 
six  yards  of  sterilised  fine  silver  wire  through  a  fine  cannula.  The  patient  improved  for  a 
time,  but  died  from  rupture  of  the  aneurysm  into  the  stomach  on  the  45th  day.  Nearly 
all  the  aneurysm  was  filled  with  laminated  and  some  recent  ante-mortem  clot,  amongst 
which  the  wire  was  coiled  ;  the  wire  did  not  project  through  the  perforation. 

The  following  table  from  Professor  Osier's  article  (Lancet,  Oct.  14, 
1905)  is  interesting.  Some  of  these  cases  are  included  in  Maunsell's 
collection  ; — 


SURGICAL  TREATMENT  OF  THE  ABDOMINAL  AORTA.   35 


•■ 

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36 


OPERATIONS  ON  THE  ABDOMEN. 


Fig 


Griffiths  {Lancet,  Aug.  12,  1905)  records  an  interesting  case  in  which  he  passed  about 
6  feet  of  wire  into  an  aortic  aneurysm  placed  just  below  the  diaphragm.  The  patient 
died  from  shock  after  5^  hours.  The  sac  was  filled  with  clot  and  wire  coils.  A  double 
loop  of  the  wire  had  passed  into  the  thoracic  aorta  for  25  inches.  Much  useful  information 
and  valuable  practical  hints  are  derived  from  the  articles  of  Maunsell  (loc.  tit."),  Griffiths, 
and  Stewart,  Phil.  Med.  Journ.,  Nov.  12,  1898. 

The  Operation. — The  aneurysm  having  been  exposed  through  a 
laparotomy  wound,  and  gauze  packing  employed  to  isolate  a  part  of 
the  presenting  surface  of  the  sac,  a  spot  devoid  of  large  blood  vessels 
is  selected,  and  a  purse-string  suture  is  introduced  to  encircle  a  small 
area,  through  which  a  fine  long  trocar  and 
cannula  are  thrust  well  into  the  sac  (vide  Fig. 
7,  A,  B).  The  trocar  is  withdrawn,  and  a  vul- 
canite cannula  (C)  which  fits  the  metal  one 
accurately,  is  now  introduced  for  insulating  pur- 
poses. Sterile  fine  silver  wire  (No.  28)*  is  then 
introduced  through  the  insulating  cannula  ;  if 
the  wire  kink  it  may  be  cut  and  driven  into  the 
sac  by  means  of  the  ramrod  (D)  which  has  a 
cupped  extremity.  From  3-6  feet  of  wire  are 
introduced  according  to  the  size  of  the  aneurysm. 
Most  operators  have  used  too  much  wire.  The 
wire  is  passed  obliquely,  so  that  its  end  may  not 
pass  straight  into  the  aortic  trunk,  but  may  creep 
along  the  wall  of  the  sac  and  coil  within  it. 
A  current  of  15-30  milliampere  is  passed 
through  the  wire  for  about  15  minutes;  60-80 
milliampere  currents  have  been  used,  but  these 
are  apt  to  damage  the  sac  wall,  where  the  wire 
comes  into  contact  with  it,  and  moreover  clotting 
is  just  as  good  with  the  weaker  currents. 

Stewart  recommends  that  the  anode  should 
be  connected  to  the  wire,  and  the  cathode  to  a 
clay  plate  connected  to  the  patient's  back  or 
abdomen.  Both  poles  must  not  be  connected 
with  the  sac,  and  the  cathode  must  not  be 
attached  to  the  wire,  for  gas  is  then  evolved, 
and  a  soft  clot  formed,  which  is  very  different  to 
the  firm  coagulum  formed  round  the  anode. 
The  end  of  the  wire  is  driven  into  the  sac,  and 
the  purse-string  suture  tightened  as  the  cannula} 
are  withdrawn.  The  wound  in  the  abdominal  wall  is  then  sewn  up  in 
the  usual  way.  Some  of  the  dangers  of  the  operation  are  shock,  sepsis, 
circulatory  disturbances  arising  from  sudden  increase  of  the  blood  pres' 
sure,  rupture  of  the  sac,  or  of  the  aorta  near  it ;  this  is  apt  to  occur 
when  the  aneurysm  is  shrinking  after  some  days  or  weeks.     Obstruction 


A,  Metal  trocar  ;  7?,  metal 
cannula  ;  C,  vulcanite 
cannula  ;  D,  ramrod. 
(Griffiths.) 


*  Hunner  (loo.  tit.")  prefers  — M — ,  which  is  finer  and  coils  better  than  silver  wire. 

c  1000  suver 

Silver  gold  or  platinum  may  be  used,  but  not  hard  iron  or  steel,  as  these  snap  or  perforate 

the  sac.     Soft  iron  is  decomposed  too  readily  by  the  current  and  may  lead  to  embolism, 

(Stewart,  loc.  cit.) 


SURGICAL    TREATMENT    OF    AI'.DOMINAL    ANEURYSM.       37 

of  the  aorta  from  pressure  of  the  dotted  aneurysm,  or  projection  of 
the   wire  into  tiie    artery;  paralysis   or  even    gangrene  of   the   lower 

limbs  may  then  occur,  or  interference  with  the  aortic  valves  (Reeve, 
Joints  Hopkins  Bull.,  Nov.,  1900).  Such  dangers  as  are  insepar- 
able from  the  general  anaesthesia  may  be  avoided  in  some  cases  by 
the  use  of  eucaine  and  cocaine.  The  Moore- Corradi  method  is 
certainly  worthy  of  further  trial,  and  is  the  most  hopeful  method  yet 
invented  for  the  treatment  of  the  majority  of  aneurysms  of  the 
abdominal  aorta. 

5.  Ligature  of  the  Abdominal  Aorta  (vide  p.  30). — In  only  a 
few  cases  can  a  ligature  be  placed  on  the  proximal  side  of  the  aneurysm 
(vide  supra,  p.  33).  Of  the  two  recorded  cases  one  died  after  one  day 
and  the  other  on  the  forty-eighth  day. 

6.  Temporary  Ligature  of  the  Aorta. — 'Milton  (Lancet,  1891, 
vol.  i.  p.  85)  suggested  that  temporary  proximal  occlusion  of  the 
abdominal  aorta  might  be  attained  by  means  of  an  elastic  band,  passed 
round  the  artery  and  spine  backwards  through  the  loins,  where  the 
ends  could  be  tightened  at  will. 

Prof.  Keen  (Amer.  Journ.  of  Med.  Sci.,  Sept.  1900),  who  publishes  a 
case  of  ligature  of  the  abdominal  aorta  just  below  the  diaphragm,  the 
patient  surviving  forty-eight  days,  has  devised  an  instrument  by  means 
of  which  temporary  compression  of  the  aorta  may  be  carried  out.  The 
instrument,  which  is  fully  described  and  figured,  consists  of  a  screw 
clamp  in  two  parts,  which  is  applied  directly  to  the  aorta  through  an 
opening  in  the  abdominal  wall. 

Four  experiments  on  dogs  are  described,  the  results  of  which  clearly 
show  the  feasibility  of  the  plan. 

Prof.  Keen  considers  that  the  instrument  might  be  used  either  for  a 
short  interval  under  anaesthesia,  or  might  be  left  in  situ  for  two  or  three 
days,  during  which  pressure  could  be  applied  at  intervals. 

R.  T.  Morris  (Ann.  of  Surg.,  Feb.  1902)  records  a  most  interesting 
and  suggestive  case  of  temporary  distal  ligation  of  the  abdominal  aorta 
by  means  of  a  rubber  catheter  passed  round  the  artery  and  kept  taut 
by  means  of  long  clamp  forceps.  The  elastic  ligature  was  removed 
after  twent}T-seven  hours,  the  aneurysm  having  filled  with  clot.  Soon 
afterwards  pulsation  and  sensation  returned  in  the  lower  extremities. 
The  patient,  however,  died  on  the  third  day  from  septicaemia,  probably 
the  result  of  gangrene  of  portions  of  the  intestine  which  had  been  com- 
pressed by  the  steel  clamp,  but  the  patient  also  suffered  from  a  previous 
pyonephrosis. 

At  the  autopsy  the  aneurysm  was  found  to  be  filled  with  clot,  but 
the  aortic  lumen  was  patent.  At  the  site  of  the  elastic  ligature  the 
internal  coat  was  not  divided. 

This  case  proves  "  that  an  aneurysm  of  the  aorta  can  be  made  to  fill 
with  clots  by  the  application  of  a  temporary  ligature  to  the  aorta,  and 
that  the  circulation  in  the  extremities  may  re-establish  on  the  removal 
of  the  ligature. 

R.  T.  Stratton  (Ann.  of  Surg.,  1903,  vol.  xxxviii.  p.  256),  records 
five  experiments  made  upon  dogs,  and  advocates  the  gradual  closure  of 
large  arteries. 

He  used  waxed  cotton  tape  £  in.  wide,  which  was  passed  round  the  aorta  and  through 
a  gauze-covered  silver  tube,  "  both  ends  o?  the  tape  being  fastened  to  the  axle  of  a  small 


jN  OPERATIONS  ON  THE  ABDOMEN. 

windlass  fixed  to  the  instrument  at  its  outer  extremity.  The  revolving  of  this  tightened 
or  relaxed  the  tape  at  the  will  of  the  operator.  The  wheel  could  be  fixed  at  any  point  by 
means  of  a  hinged  bar  being  pressed  into  small  slots  in  the  margin  of  the  wheel."  A 
Circular  perforated  disk  was  attached  to  the  arterial  end  of  the  silver  tube,  and  the  per- 
forations for  the  tape  were  so  arranged  that  the  margins  of  the  tape  did  not  press  unduly 
on  and  injure  the  pulsating  artery.  The  pressure  was  gradually  increased  and  occlusion 
Completed  after  about  40  hours.  No  unfavourable  symptoms  due  to  the  closure  were 
observed.  Stratton  claims  "  that  these  experiments  are  sufficient  to  demonstrate  the  fact 
that  at  least  in  dogs  a  large  artery  can  be  gradually  constricted  without  undue  violence 
to  its  walls."  Crile  (Ann.  of  Sarg.t  April,  1902)  had  already  proved  that  the  carotid 
arteries  could  be  gently  occluded  for  24—48  hours  by  clamp  pressure  without  noticeable 
damage  to  the  arterial  wall,  and  that  when  the  clamp  was  removed  after  a  number  of 
hours,  the  circulation  was  re-established.  Crile  based  his  conclusions  upon  19  experiments 
on  dogs,  and  iS  operations  on  the  human  being.  In  no  case  did  thrombosis  or  embolism 
occur. 

Stratton  believes  that  the  gradual  occlusion  of  the  abdominal  aorta 
above  an  aneurysm  will  be  found  very  serviceable  in  the  treatment  of  the 
latter ;  he  maintains  that  the  best  results  are  obtained  b}'  the  gradual 
formation  of  laminated  clot  within  the  sac,  and  not  by  the  sudden 
clotting  of  the  contents  en  masse.  Moreover,  the  collateral  circulation 
to  the  abdominal  viscera  and  limbs  will  thus  have  time  to  develop,  and 
the  serious  symptoms  that  follow  sudden  complete  occlusion  of  the 
aorta  will  be  avoided.  Further,  it  is  possible  that  by  this  method 
the  circulation  through  the  aorta  at  the  base  of  the  aneurysm  to  the 
main  arteries  below  may  not  be  abolished  (Morris,  supra  cit.). 

Stratton  relates  a  case  of  aneurysm  of  the  abdominal  aorta  treated  in  the  manner 
described  above  (Jour.  Amer.  Med.  Assoc,  March  10,  1906).  The  constrictor  was  applied 
above  the  sac  and  gradually  tightened.  The  patient  did  well  for  two  days,  but  then 
sensory  and  motor  paralysis  of  the  lower  limbs  developed,  and  death  occurred. 

The  cause  of  death  was  the  inhibition  of  the  functions  of  the  abdominal  viscera,  which 
resulted  from  the  ultimate  complete  closure  of  the  aorta  above  the  coeliac  axis.  The  sac 
was  filled  with  stratified  clot  ;  there  was  no  injury  or  necrosis  of  the  aorta. 

This  method  is  certainly  worthy  of  further  trial. 

Aneurysm  of  the  Iliac  Arteries. — Proximal  ligature  is  the  best  treat- 
ment for  these,  and  the  trans-peritona;al  is  the  safest  route  to  adopt,  for 
this  greatly  reduces  the  risk  of  injuring  the  sac,  and  also  allows  a 
thorough  examination  of  the  vessels  above  the  aneurysm.  The  ligature 
can  then  be  applied  at  any  spot  selected,  and  without  danger  of  including 
important  structures  like  the  ureter. 

This  operation,  however,  should  not  be  lightly  undertaken  without 
the  advantages  of  good  assistance  and  modern  conveniences,  such  as 
the  Trendelenberg  position  and  good  intestinal  retractors  (vide 
pp.  22 — 26,  Mr.  Makin's  and  Mr.  Maynard's  cases). 

Aneurysm  of  the  Hepatic  Artery. — Kehr  (Munch.  Med.  Woch.,  1903, 
p.  1861)  records  a  successful  case  of  ligature  of  the  hepatic  artery  for 
an  aneurysm  of  that  artery  which  had  simulated  gall  stones  at  first  and 
later  ruptured  into  the  cystic  duct  causing  haematemesis. 

Haussons,  in  1897,  collected  22  cases.  In  only  three  of  these  was 
surgical  treatment  attempted,  and  all  the  patients  died. 

Ligation  or  excision  may  be  tried  in  a  similar  case,  and  also  in  the 
ver}r  rare  cases  of  aneurysm  of  the  splenic  and  mesenteric  arteries. 

Aneurysm  of  the  Renal  Artery. — Morris  ("  Diseases  of  the  Kidneys 


SURGICAL   TREATMENT    OF   ABDOMINAL    ANEURYSM.       39 

and  Ureters")  was  only  able  to  collect  the  accounts  of  21  cases  of  this 
rare  condition,  which  is  usually  not  diagnosed  except  during  an 
exploratory  operation  for  supposed  ruptured  kidney  and  perinephritic 
hematoma,  a  new  growth,  or  hydronephrosis.  Practically  all  the  cases 
recorded  have  not  pulsated,  being  diffuse.  The  only  chance  of  saving 
life  is  by  ligature  of  the  renal  artery,  followed  by  nephrectomy  and 
removal  of  the  whole  sac  if  possible. 

An  exploratory  lumbar  incision  having  heen  made,  and  the  aneurysm 
discovered,  the  renal  pedicle  is  secured  either  after  stripping  the 
peritonaeum  forward  when  the  sac  is  small,  or  after  opening  the  peri- 
toneum through  the  linea  semilunaris  and  incising  the  posterior 
peritonaeum  along  the  outer  margin  of  the  colon,  which  is  drawn 
inwards. 

The  sac  may  be  so  adherent  to  the  intestines  or  to  the  diaphragm 
that  it  cannot  be  safely  removed  in  its  entirety. 

Only  four  cases  have  been  treated  by  operation,  and  three  of  these 
recovered,  whereas  all  the  cases  which  were  not  treated  surgically  died. 


CHAPTER  II. 
OPERATIONS  ON  HERNIA.* 

OPERATIONS  FOR  STRANGULATED  HERNIA.— RADICAL 
CURE  OP  HERNIA. 

OPERATIONS  FOR  STRANGULATED  HERNIA. 

It  is  very  important  to  operate  early  and  not  to  waste  valuable  time 
on  taxis.  Thus  Cawardine  (Brit.  Med.  Journ.,  1901,  vol.  ii.  p.  573)  from 
an  analysis  of  183  cases  found  the  mortality  to  be  less  than  2  per  cent, 
in  those  operated  upon  within  12  hours,  more  than  10  per  cent,  when 
12 — 24  hours  had  elapsed  before  operation,  and  that  after  five  days 
had  been  wasted  60  per  cent.  died. 

Chief  Indications  for  Operation  and  Points  to  bear  in  Mind. — -While 
this  is  not  the  place  for  going  into  the  above  fully,  a  few  practical 
remarks  on  those  indications  usually  given  may  be  helpful  to  some  of 
my  readers. 

A.  Local. — i.  A  lump  in  one  of  the  openings,  more  or  less  hard, 
tense,  and  tender,  dull,  partly  or  completely  irreducible,  and  with 
impulse  doubtful  or  absent. 

a.  The  swelling  may  be  small  and  deep-seated,  as  in  a  bubonocele 
near  the  internal  ring,  or  a  femoral  hernia  in  a  fat  patient. 

b.  Two  hernise  may  be  present,  both  irreducible.  The  surgeon 
should  operate  on  the  one  which  is  the  more  tense  and  has  the  less 
impulse,  and  the  one  which  has  the  more  recently  descended.  If  this 
fail  to  give  relief,  either  the  opposite  swelling  must  be  explored  or 
abdominal  section  performed  in  the  middle  line.  This  step  will  prob- 
abl}T  allow  of  the  opposite  hernia  being  reduced  from  within,  and  also 
of  any  other  possible  seats  of  strangulation  being  explored — viz.,  the 
inner  aspects  of  the  deeper  rings. 

c.  As  to  the  impulse,  it  is  worth  while  to  observe  carefully  the  point 
where  this  ceases.  This,  probably,  is  over  the  site  of  stricture,  and 
should  be  about  the  centre  of  the  incision. 

On  this  most  important  point,  of  impulse,  Sir  W.  H.  Bennett  speaks 
as  follows  :  In  a  case  of  strangulated  omental  inguinal  hernia  with 
commencing  gangrene  of  the  omentum,  there  yet  was  no  interference 
with  the  action  of  the  bowels,  constipation  and  vomiting  were  alike 
entirely  absent,  but  the  symptom  which  conclusively  called  for  opera- 
tion was  the  entire  absence  of  real  hernial  impulse.     The  following 

*  The  different  forms  of  hernia,  those  which  present  on  the  thigh  as  well  as  the 
inguinal  and  umbilical  varieties,  will  be  considered  here  for  the  sake  of  convenience,  and 
because  they  are  all  abdominal  in  origin. 


STRANGULATED    FEMOtiAL    HKK.MA.  4i 

renmrks  on  the  detection  of  impulse  are  worthy  of  the  most  careful 
attention  :  "  The  impulse  in  ordinary  non-strangulated  hernia,  whether 
the  contents  of  the  Bac  be  omentum  or  bowel,  is  expansile  in  character, 
that  is  to  say,  the  tumour,  when  the  patient  coughs  or  strains,  not  only 
rises  under  the  hand,  hut  expands  in  size.  In  hernial  tumours  con- 
taining bowel  this  sudden  increase  in  the  hulk  is  principally  due  to 
the  additional  quantity  of  gas,  &c,  which  is  suddenly  driven  into  the 
herniated  portion  of  gut  by  the  aet  of  coughing  or  straining.  In 
omental  hernias  the  expansion  is  partly  due  to  the  sudden  turgescence 
in  the  omental  vessels,  and  partly  to  the  increase  of  tension  in  the  sac 
due  to  the  cough.  Naturally,  therefore,  the  amount  of  expansion  is 
relatively  greater  in  hernia?  containing  bowel  than  in  those  composed  of 

omentum In  strangulated  hernia  it  is  important  to  understand 

that  absence  of  impulse  does  not  necessarily  mean  immobility  during 
coughing,  for  a  hernia,  even  if  tightly  strangulated,  will  often  move 
freely  under  the  hand,  especially  if  it  he  omental.  This  movement  is, 
however,  rather  of  the  nature  of  a  jinn])  or  jerk,  and  is  never  expansile. 
There  is  no  question  which  has  a  more  practical  bearing  upon  the  treat- 
ment of  strangulated  hernia  than  the  expansile  character  of  this  impulse. 
It  may  be  safely  held  as  a  surgical  dictum,  that  every  case  of  hernia  in 
which  any  change  has  taken  place  in  the  condition  of  the  tumour,  such  as 
increase  of  size  or  tension,  whilst  expansile  impulse  is  absent,  should  be 
regarded  as  strangulated." 

d.  Sir  J.  Paget  (Clin.  Lett.,  p.  108)  thus  wrote  of  the  hardness  of  a 
hernia: — "In  large  hernia?  the  hardness  may  chiefly  be  felt  at  and  near 
the  neck  and  mouth  of  the  sac,  especially  in  inguinal  herniae,  and  you 
must  take  care  not  to  be  deceived  by  a  sac  which  is  soft  and  flaccid 
everywhere  except  at  its  mouth,  for  there  maybe  strangulated  intestine 
in  the  mouth  of  the  sac  though  the  rest  contain  only  soft  omentum  or 
fluid  not  sufficient  to  distend  it ;  nay,  you  must  not  let  even  a  wholly 
soft  condition  of  the  hernia,  or  an  open  external  ring,  weigh  down 
against  the  well-marked  symptoms  of  strangulation,  for  the  piece  of 
intestine  at  the  mouth  of  the  sac  may  be  too  small  to  give  a  sensation 
of  hardness,  or  the  whole  hernia  may  be  omental." 

B.  General — The  SympAoms  of  Intestinal  Obstruction. — i.  Consti- 
pation becoming  absolute,  even  as  to  flatus. — It  is  well  known  that 
small  scybalous  motions  may  be  forced  out  by  the  straining  of  a 
patient  with  a  strangulated  hernia,  anxious  to  get  his  bowels  to  act. 
Further,  and  in  intestinal  obstruction  generally,  the  bubbling  away  of 
an  enema  may  simulate  the  passage  of  flatus.  In  those  rare  cases 
where,  other  evidence  of  strangulation  being  present,  the  bowels  con- 
tinue to  act  at  intervals,  it  is  probable  that  the  constriction  of  the 
bowel  is  not  complete,  and  leaves  a  channel  along  the  mesenteric 
border  (Richter's  partial  enterocele).  In  such  cases  which  have  been 
left  long,  owing  to  the  absence  of  constipation  and  perhaps  the  slight- 
ness  of  the  vomiting,  the  surgeon  must  examine  the  bowel  very  care- 
fully before  he  returns  it.  Constriction,  though  only  partial,  may  have 
here  caused,  from  its  long  duration,  thinning  or  ulceration  of  the 
intestine  at  one  spot,  and  fecal  extravasation  may  take  place  as  soon 
as  the  bowel  is  returned.  If  there  is  any  reason  for  doubt  in  these 
cases  the  stricture  should  be  thoroughly  divided  and  the  bowel  left 
in  situ. 


42  OPERATIONS  ON  THE  ABDOMEN. 

Constipation  may  be  absent  in  cases  of  strangulation  of  the  omentum 
alone,  or  of  an  appendix  epiploica  or  of  the  ovary. 

ii.  Vomiting.* — Especially  if  (a)  this  is  changing  from  the  early 
rejection  of  stomach  contents  or  bile  to  freculent  fluid  ;  (b)  even  if  it  is 
repeated  only  at  long  intervals,  and  all  other  signs  are  absent  or  little 
marked  ;  (c)  it  must  be  remembered  that  vomiting  may  be  stopped  by 
drugs,  strangulation  persisting,  or  the  intestines  may  be  empty.  There 
is  often  a  deceptive  lull  in  this  symptom  after  two  or  three  days,  the 
vomiting  recommencing  again  later. 

iii.  Shock  more  or  less  severe,  according  to  the  suddenness  of  the 
onset  and  the  severity  of  the  strangulation. 

iv.  Colicky  pains  occurring  at  short  intervals,  usually  terminating 
in  vomiting.  These  pains  are  usually  referred  to  the  umbilical  region, 
and  are  due  to  the  powerful  but  futile  peristalsis  of  the  obstructed 
small  intestine.     They  are  very  characteristic  of  intestinal  obstruction. 

v.  The  sunken  sallow  features  and  anxious  countenance  and  the 
scanty  high  coloured  urine  from  intestinal  obstruction. 

vi.  Tympanites  and  other  evidence  of  peritonitis. 

These  will  not,  of  course,  debar  the  surgeon  from  operating,  but  they 
will  lead  him  to  warn  the  friends  that  relief  will  probably  come  too  late. 

STRANGULATED    FEMORAL    HERNIA   (Fig.  7a). 

The  stomach  may  be  washed  out  in  some  cases  just  before  the 
operation  to  minimise  the  dangers  incident  to  the  vomiting  of  foul 
material  during  the  induction  of  anaesthesia  and  to  lessen  the  vomiting 
after  the  operation. 

In  bad  cases  a  hypodermic  injection  of  strychnine  may  be  given  just 
before  or  during  the  operation.  Subcutaneous  infusion  of  a  pint  or  more 
of  saline  or  saccharine  solution  is  also  of  great  benefit,  and  can  be  per- 
formed while  preparations  are  being  made  for  the  operation.  In  less 
severe  cases  a  rectal  injection  of  h  pint  of  saline  solution  may  be  given. 

Operation.! — The  parts  being  shaved  and  thoroughly  cleansed,  a 
little  iodoform  rubbed  in  around  the  genitals,  the  limbs  being  kept 
warm  with  blankets  and  a  hot  bottle  or  two  if  the  patient's  vitality  is 
low,  and  the  knee  flexed  slightly  over  a  pillow,  an  incision  two  and 
a  half  to  three  inches  long  is  made  vertically  on  the  inner  side  of  the 
swelling.  Some  small  branches  of  the  superficial  external  pudic  occa- 
sionally require  torsion  or  ligature.  The  cribriform  fascia  and  the 
fascia  propria  (femoral  sheath  and  septum  crurale)   are  next  divided 

*  Sir  J.  Paget  (loe.  swpra  cit.,  p.  112)  says  :  "  If  I  were  asked  which  of  the  signs  of 
strangulation  I  would  most  rely  on  as  commanding  the  operation,  I  should  certainly  say 
the  vomiting."  Later  on  (p.  114)  he  urges  that  the  practitioner  should  not  wait  for  any 
characteristic  mode  of  vomiting,  nor  be  misled  by  the  absence  of  any  particular  fluid,  nor 
even  by  the  absence  of  all  vomiting,  nor  under-estimating  the  importance  of  occasional 
vomiting  as  a  signal  for  operation. 

t  While  general  anaesthesia  will  be  preferred  in  most  cases  from  the  more  certain  loss 
of  sensibility  and  the  relaxation  of  the  parts,  a  case  related  by  Dr.  Mason  (Brit.  Med. 
Journ.,  vol.  i.  p.  834)  shows  how  valuable  cocaine  may  be  as  a  local  anaesthetic.  B  Eucaine 
is,  however,  far  safer  and  more  effectual  than  cocaine,  and  if  the  following  mixture  recom- 
mended by  Mr.  Barker  be  employed,  there  need  be  no  fear  of  any  subsequent  sloughing  of 
the  skin  from  the  effects  of  eucaine  :  B  Eucain.  gr.  iii. ;  sod.  chlor.  gr.  xii  ;  ^  adrenalin 
chlor.  sol.  uj  x.  :  water  to  5  iiiss. 


STB  \\<;i  l.\TKl>    FEMORAL    HERNIA. 


43 


in  the  same  vertical  line,  with  or  without  a  director,*  according  to 
their  thickness  and  the  experience  of  the  operator,  all  the  incisions 
made  going  quite  up  to  and  above  the  top  of  the  swelling,  so  as  to  lie 
over  tlie  scat  of  strangulation,  usually  Gimbernat's  ligament. 

The  varieties  here  are  best  given  in  Sir  James  Paget's  words  (loc. 
supra  cit.f  p.  132)  :  "  In  some  instances,  as  you  trace  up  the  neck  of 
the  sac,  you  find  it  tightly  banded  across  by  a  layer  of  fibrous  tissue 
called  Key's  ligament — a  layer  traceable  as  a  falciform  edge  of  the 
fascia  lata,  where  that  fascia,  bounding  the  upper  part  of  the  saphenous 
opening,  is  connected  with  the  crural  arch,  and  is  thence  continued  to 
Gimbernat's  ligament.  Sometimes  a  fair  division  of  this  layer  of  fibres 
up  to  the  edge  of  the  crural  arch  is  sufficient  to  render  the  hernia 
reducible.  .  .  .  But  in  more  cases  this  is  not  sufficient,  and  you  may 
feel  the  stricture  formed  by  bands  of  fibres  which  encircle  the  neck  of 
the  sac,  and  which  must  be  divided,  band  by  band  and  layer  by  layer,  till 
none  can  be  felt.  These 
fibres  are  part  of  the  deep 
crural  arch.  Very  rarel}r, 
however,  even  the  division 
of  these  is  not  sufficient, 
for  the  stricture  is  formed 
by  thickening  of  the  mouth 
of  the  sac  itself.  This 
condition,  which  is  a  com- 
mon cause  of  stricture  in 
inguinal  hernia,  is  very  UerHT 
rare  in  femoral  ;  but  it 
certainly  does  occur."  t 

Opening  the  Sac.  — 
The  sac  must  always  be 
opened,  because  of  the 
(1)  great  importance  of 
examining  the  bowel ;  (2)  the  dangers  of  opening  the  sac  are  very 
small  with  due  precautions  nowadays,  and  the  dangers  of  reducing 
the  hernia  without  opening  the  sac  are  immeasurably  greater ;  (3)  it 
renders  an  attempt  at  radical  cure  possible,  and  this  should  be  done 
in  all  patients  who  are  not  in  extremis. 

In  this  and  in  the  former  case  much  difficulty  is  occasionally  met 
with  in  deciding  as  to  whether  the  sac  is  reached  or  no.  The  causes 
of  difficulty  here  are  mainly — (1)  An  altered  condition  of  the  soft  parts 
from  the  pressure  of  a  truss,  or  from  long  strangulation ;  (2)  from 
meeting  with  fluid  outside  the  sac;  (3)  from  the  extreme  thinness  of  the 
patient,  which  leads  to  the  sac  being  reached  unexpectedly ;  (4)  from 
the  opposite  condition,  much  fat  being  met  with  in  several  of  the  deep 
layers,  making  it  uncertain  which  is  the  extra-peritonasal  layer,  the  fat 

*  The  operator  can  also  manage  very  well  with  scissors,  keen-edged  but  blunt-pointed, 
first  nicking  each  layer,  and  then  separating  it  from  the  next  with  the  closed  points. 

t  In  trying  to  divide  points  of  stricture  outside  the  sac,  attention  should  be  paid  to  the 
following  :— 00  First  reaching  the  sac  itself,  if  possible,  by  a  careful  division  of  all  the 
overlying  structures  in  the  vertical  incision  carried  well  upwards  ;  (2)  carefully  drawing 
down  the  sac,  so  as  to  expose  any  fibres  constricting  its  neck  ;  (3)  gently  insinuating  the 
point  of  the  director  under  any  bands  met  with. 


Site  of  incision  for  strangulated  femoral  hernia. 


44  OPERATIONS  ON  THE  ABDOMEN. 

in  these  cases  being  often  soft,  and  readily  breaking  down  under 
examination  ;  (5)  an  apparently  puzzling  number  of  layers — this  con- 
dition is  usually  due  to  "  hair-splitting  "  over-carefulness  on  the  part 
of  the  operator,  at  other  times  it  is  brought  about  by  a  much  thickened 
fascia  propria  separated  into  imperfect  layers  b}'  its  softened  condition 
or  inflammatory  matting;  (6)  by  the  absence  of  a  sac* 

Aids  in  Recognising  the  Sac  in  Cases  of  Difficulty. — Several  of  those 
ordinarily  given  (Erichsen,  loc.  supra  cit.) — e.g.,  "  its  rounded  and  tense 
appearance,  its  filamentous  character,  and  the  arborescent  appearance 
of  vessels  on  its  surface  " — are,  I  think,  quite  fallacious.  So,  too,  with 
regard  to  the  escape  of  fluid  from  the  sac,  for  this  is  often  dry  in  femoral 
hernise,  and  occasionally  fluid  is  met  with  before  the  sac  is  reached.  A 
smooth  lining  characteristic  of  its  inner  surface  is  more  reliable,  but 
the  inner  surface  of  the  fascia  propria  is  sometimes  remarkably  smooth. 
The  hernial  sac  is  denser  than  any  of  its  covering,  and  of  a  bluish- 
white  colour.  Moreover,  the  omentum  differs  from  the  extra-peritonaeal 
fat  in  having  much  larger  and  characteristic  veins.  Two  points  remain 
which  will  help  to  solve  the  doubt — (a)  To  draw  gently  down  the  doubtful 
structure,  whether  sac  or  bowel,  and  to  examine  whether  it  is  con- 
tinuous above  and  below  with  the  structures  of  the  abdomen  and  thigh, 
like  the  other  coverings  of  the  hernia,  or  whether  it  has  a  distinct  neck 
to  be  traced  into  the  abdominal  cavity  ;  (b)  To  see  if  the  point  of  a 
Key's  director  can  be  insinuated  along  this  last  doubtful  layer  into,  and 
moved  within,  the  peritonaeal  cavity  or  no.  In  a  very  few  cases  the 
surgeon,  if  still  in  doubt,  incises  carefully  the  suspected  layer,  and 
tries  if  he  can  pass  in  a  probe  and  move  it  from  side  to  side ;  if  this 
can  be  done,  he  is  still  outside  the  bowel,  not  between  the  peritonseal 
and  muscular  coats  of  intestine.  The  difficulties  here  are  however  so 
great  that  several  operators  have  reduced  a  femoral  hernia  en  masse 
during  the  operation  of  herniotomy,  and  others  have  only  been  enabled 
to  prevent  this  catastrophe  by  great  care.  (See  "  Reduction  en  Masse," 
Guy's  Hosp.  Rep.,  vol.  lvi.) 

The  sac  being  carefully  nicked  with  the  scalpel-blade  held  horizontally 
at  a  spot  where  it  can  best  be  pinched  up  with  dissecting-forceps — a 
matter  of  much  difficulty  at  times,  owing  to  its  tenseness — is  slit  up  on  a 
director,  and  its  contents  examined.  If  omentum  first  present  itself, 
this  is  drawn  to  one  side  and  unravelled,  and  intestine  sought  for.  This 
usually  takes  the  form  of  a  small,  very  tense  knuckle,  of  varying  colour 
and  condition.  If  it  will  facilitate  the  manipulations  needful  for 
reduction,  the  omentum  may  be  first  dealt  with.  (1)  If  this  be  volumin- 
ous and  altered  in  structure,  it  should  be  tied ,  +  bit  by  bit,  with  reliable 
chromic  gut  or  silk,  and  then  cut  away,  the  scissors  being  applied  so 
close  to  the  ligatures  as  to  leave  holding-room,  but  no  excess  to  mortify 
or  slough.  After  the  return  of  the  intestine,  the  stump  is  also  replaced 
within  the  abdomen.     (2)   If  the   omentum  be  small  in  amount  and 

*  A  sac  is  said  to  be  absent  in  some  cases  of  hernia  of  the  caecum,  and  where  the  patient 
has  been  operated  on  before.  This,  however,  was  not  the  case  in  three  hernias  containing 
the  caecum,  and  in  two  which  had  been  operated  on  before,  that  have  come  under  my  care. 

f  For  security's  sake  the  ligatures  should  be  made  to  interlock.  If  haemorrhage  occur 
from  the  omentum  after  it  has  been  replaced,  the  surgeon  must  remember  that  returned 
omentum  generally  escapes  far  from  the  wound.  It  will  thus  be  usually  needful  to 
extend  the  wound  upwards  along  the  linea  semilunaris. 


STRANcl rLATED    FEMORAL    HERNIA. 


45 


Fig.  8. 


Cutting  edge 


recently  descended,  it  may  be  merely  returned.  (3)  In  a  few  rare  rnsrs 
when  the  omentum  is  intimately  adherent  to  the  sac,  and  the  patient's 
condition  does  not  admit  of  delay,  the  omentum  must  be  left  in  situ. 
As,  however,  this  course  very  much  interferes  with  the  satisfactory 
wearing  of  a  truss,  and  as  it  is  likely  to  lead  to  a  fresh  descent  of  bowel, 
it  should  never  be  followed  if  it  can  be  avoided. 

Reduction  of  the  Intestine. — As  soon  as  this  is  exposed,  the  surgeon 
examines  with  the  little  finger,  or  a  Key's  director,  the  tightness  of 
Gimberimt's  ligament.  In  a  few  cases  reduction  may  be  at  once  effected 
by  gentle  pressure  backwards  on  the  bowel  with  the  tip  of  the  little 
finger.  Hut  in  the  large  majority  the  above  site  of  stricture  will  need 
division — a  point  requiring  much  carefulness  for  fear  of  injuring  the 
intestine  or  important  surrounding  structures.  If  the  degree  of  tightness 
of  the  parts  admit  of  it,  there  is  no  director  so  safe  and  satisfactory 
as  the  index  or  little  finger  of  the  left  hand  passed  up  to  the  stricture, 
the  hernia-knife  being  introduced  along  the  pulp  of  the  finger  (Fig.  8). 
But  there  is  rarely 
room  for  this,  and  a 
Key's  director!  must 
usually  take  the  place 
of  the  finger.  The  tip 
of  this  instrument 
being  insinuated  into 
the  peritonseal  cavity 
just  under  Gimber- 
nat's  ligament,  the 
hernia-knife  J  is  in- 
troduced obliquely 
or  fiat-wise  upon  it, 
its  end  slipped  under 
and  beyond  the  ligament,  its  edge  turned  towards  the  constricting 
fibres,  and  a  few  of  these  gently  cut  through  in  an  upward  and  inward 
direction.  In  doing  this  it  is  well  for  the  surgeon  to  draw  down  the 
edges  of  the  cut  sac  close  to  its  neck,  and  to  ask  an  assistant  to  hold 
these,  thus  facilitating  the  passage  of  the  director  and  the  knife  by 
preventing  the  sac  falling  into  folds  before  them.  Occasionally,  also, 
a  knuckle  of  intestine  persistently  coils  over  the  edge  of  the  director. 
This  is  best  met  by  patience,  by  drawing  it  out  of  the  way  by  the 
carbolised  finger-tip  of  an  assistant,  or  by  pressing  it  down  with  the 
handle  of  a  pair  of  dissecting-forceps. 

The  direction  and  the  extent  to  which  the  stricture  must  be  cut  are 
matters  of  much  importance.  The  upward  and  inward  line  is  the  only 
path  of  safety.     Directly  outwards  lies  the  femoral  vein  ;  by   cutting 


(Fergusson.) 


*  The  cutting  blade  of  the  knife  shown  here  is  needlessly  long  and  unguarded. 

t  This  director  is  broad,  so  as  to  prevent  any  intestine  curling  over  and  reaching  the 
knife  ;  blunt-pointed,  go  as  not  to  damage  the  contents  of  the  peritonaeal  cavity  ;  finally, 
its  groove  does  not  run  quite  up  to  the  end,  so  that  the  knife-point  shall  be  stopped  before 
it  comes  in  contact  with  the  important  parts. 

X  A  curved  one  will  be  found  most  useful.  The  cutting  blade  is  usually  too  broad 
and  the  tip  too  massive.  On  the  other  hand,  a  worn-down  blade  has  been  known  to  break 
while  dividing  a  tense  Gimbernat's  ligament.  The  intestine  may  thus  be  wounded,  or  the 
fragment  of  the  knife  escape  into  the  peritonaea!  cavity, 


46  OPERATIONS  ON  THE  ABDOMEN. 

upwards,  the  spermatic  cord,  and,  if  upwards  and  outwards,  the  epi- 
gastric artery,  would  he  endangered ;  behind  are  the  peritonaeum  and 
pubes.  The  incision  upwards  and  inwards  must  be  of  the  nature  of  a 
nick  ;  otherwise,  owing  to  the  imperfect  healing  of  the  fibrous  structure, 
the  ring  will  be  left  large  and  gaping,  thus  facilitating  the  re-descent  of 
the  hernia,  producing  much  difficulty  in  fitting  trusses,  and  causing 
certain  discomfort  and  probable  peril  to  the  patient,  especially  if  she 
belong  to  the  poorer,  hospital  class. 

Giinbernat's  ligament  having  been  carefully  and  sufficiently  nicked, 
the  bowel  is  replaced  either  by  gentle  squeezing  between  the  finger 
and  thumb,  so  as  to  empty  it  of  its  contents,  or  with  the  pressure  of 
the  little  finger ;  the  sac  being  now  kept  stretched  with  forceps  so 
that  no  folds  interfere  with  the  return  of  the  bowel.  If  pressure  on 
one  part  of  the  intestine  fail,  it  must  be  tried  at  another  point. 
After  the  reduction  of  the  intestine  the  tip  of  the  little  finger  should 
be  introduced  through  the  crural  canal  into  the  peritonseal  cavity  to 
ascertain  that  the  gut  is  absolutely  safe  ;  a  little  sterilised  iodoform  is 
then  dusted  on  to  the  stumps  of  omentum,  and  these  too  returned,  if 
this  has  not  been  done. 

If  the  patient's  condition  and  age  admit  of  it,  and  if  the  adhesions 
are  not  too  firm,  the  sac  should  next  be  taken  away  by  carefully 
separating  it  with  the  finger  or  a  director  from  its  attachments.  It 
should  then  be  pulled  well  forwards,  an  aseptic  finger  introduced  up 
to  its  neck,  this  part  next  ligatured  with  stout  silk  as  high  up  as 
possible,  the  finger  then  withdrawn,  and  the  sac  cut  away  half  an  inch 
below  the  ligature.  Unless  the  condition  of  the  patient  is  grave,  or 
the  tissues  have  been  infected  from  foul  contents  of  the  sac,  the  femoral 
ring  should  be  closed  in  one  of  the  ways  described  at  p.  92.  The 
superficial  wound  should  be  sewn  up,  except  at  one  spot  where  a 
cigarette  drain  can  be  inserted.  The  dressings  must  be  applied  with 
sufficient  care  to  keep  the  wound  secure  from  obviously  close  sources 
of  contamination.  It  is  well  to  place  a  separate  pad  of  carbolised  tow 
or  salicylic  wool  over  the  anus  and  genitals,  and  to  draw  the  water  off 
before  the  patient  leaves  the  table.  The  thigh  should  not  be  kept  too 
much  flexed,  otherwise  the  escape  of  discharge  from  the  drainage-tube 
will  be  interfered  with. 

The  account  of  an  ordinary  operation  having  been  given,  it  remains 
to  consider  certain  complications.     These  are  chiefly  : 

I.  Adhesions  of  Bowel  to  the  Sac  or  Omentum. — The  treatment  of 
this  uncommon  complication  must  vary  with  (a)  the  character  and 
position  of  the  adhesions,  (/?)  the  condition  of  the  intestines,  and 
(y)  the  state  of  the  patient.  Owing  to  the  difficulty  of  fitting  on  a 
truss  if  any  of  the  hernia  is  left  unreduced,  every  attempt  should  be 
made  to  free  the  contents  by  separating  the  adhesions  with  the  point 
of  a  steel  director,  or  a  blunt-pointed  bistoury.  When  near  the 
neck  they  must  always  be  divided,  sufficiently  nicked,  or  stretched. 
No  intestine  and  omentum  still  adherent  to  each  other  should  ever  be 
returned.  A  few  cases  remain  in  which  adhesions  should  be  left 
alone.  When  gangrene  is  threatening,  but  the  operator  is  too  short- 
handed  to  face  resection  of  the  affected  intestine,  the  presence  of  adhe- 
sions, especially  about  the  neck  of  the  sac,  is  the  chief  safeguard  against 
extravasation  into  the  peritonaea!  cavity.   In  some  cases  of  large  hernia, 


STRANGULATED  FEMORAL  HERNIA.         47 

if  the  patient  be  much  collapsed,  so  long  as  any  recently  descended 
loop  is  returned,  any  long-adherent  intestine  may  be  left.  And  in 
other  cases  of  collapse  from  delay  of  the  operation,  where  there  is  much 
difficulty  in  returning  a  loop  of  intestine,  especially  if  this  be  not  in 
good  condition,  it  may  he  left,  after  the  stricture  has  been  sufficiently 
divided. 

It  occasionally  happens  in  these  cases  of  deeply  congested  bowel, 
especially  in  inguinal  hernia,  that  after  an  otherwise  successful  herni- 
otomy the  patient  passes  profuse  and  bloody  stools.  This  condition 
may  prove  fatal.  In  one  or  two  cases  of  this  kind  which  have  come 
under  my  notice  the  operator  was,  most  unfairly,  blamed  for  having 
incised  the  bowel. 

Mr.  Rough  (Lancet,  Oct.  n,  1884)  records  a  case  in  which  a  patient  died  in  collapse 
two  hours  alter  the  reduction  of  a  very  large  scrotal  hernia.  The  pelvic  cavity  was  full 
of  blood-stained  serum;  ten  feet  of  intestine  were  found  dark  purple  in  colour,  but 
uninjured.     On  laying  the  gnt  open  about  a  pint  and  a  half  of  blood  escaped. 

2.  Tightly  Constricted  or  Gangrenous  Intestine. — In  spite  of  all  that 
has  been  taught  about  the  importance  of  early  operations,  cases  do  still 
occur  in  which  returning  the  bowel  is  doubtful  or  out  of  the  question. 
Nothing  is  more  difficult  than  to  decide  upon  the  treatment  of  the 
intestine  in  doubtful  cases.  A  prompt  decision  must  be  made  after  a 
careful  examination  of  the  intestine,  mesentery  and  contents  of  the  sac, 
and  the  general  condition  of  the   patient  will   influence  the  decision. 

(a)  The  Intestine.  In  some  cases  of  doubt,  as  long  as  the  stricture  is 
sufficiently  divided  and  the  intestine  placed  only  just  within  the  crural 
ring  (the  wound  being  left  open  and  the  sac  not  ligatured),  the  interior 
of  the  abdomen  is  the  best  place  for  the  intestine.  And  this  is  true  of 
congested  intestine,  however  deeply  loaded  with  blood  only,  as  long  as 
there  is  some  shade  of  red  present.  But  on  these  points  nothing  will 
surpass  the  advice  of  Sir  J.  Paget  (loc.  supra  cit.,  p.  138)  :  "  You  are  to 
judge  chiefly  from  the  colour  and  the  tenacity.  Use  your  eyes  and  your 
ringers  ;  sometimes  your  nose ;  very  seldom  }rour  ears,  for  what  you 
may  be  told  about  time  of  strangulation,  sensations,  and  the  rest  is 
as  likel}'  to  mislead  you  as  to  guide  aright.  As  to  colour  ....  I  am 
disposed  to  say  that  you  may  return  intestine  of  an}^  colour  short  of 
black,  if  its  texture  be  good  ;  if  it  feel  tense,  elastic,  well  filled  out, 
and  resilient,  not  collapsed  or  sticky  ;  and  the  more  the  surface  of  the 
intestine  shines  and  glistens,  the  more  sure  you  may  be  of  this  rule. 
When  a  piece  of  intestine  is  thoroughly  black,  I  believe  you  had  better 
not  return  it,  unless  you  can  be  sure  that  the  blackness  is  wholly  from 
extravasated  blood.  It  may  not  yet  be  dead,  but  it  is  not  likely  to 
recover  ;  and,  even  if  it  should  not  die  after  being  returned,  there  will 
be  the  great  risk  of  its  remaining  unfit  to  propel  its  contents,  and 
helping  to  bring  on  death  by  what  appears  very  frequent — distension 
and  paralysis  of  the  canal  above  it.  But,  indeed,  utter  blackness  of 
strangulated  intestine  commonly  tells  of  gangrene  already  ;  and  of  this 
you  may  be  sure  if  the  black  textures  are  lustreless,  soft,  flaccid  or 
viscid,  sticking  to  the  fingers,  or  looking  villous.  Intestine  in  this 
state  should  never  be  returned.  Colours  about  which  there  can  be  as 
little  doubt,  for  signs  of  gangrene,  are  white,  grey,  and  green,  all  dull, 
lustreless,  in  blotches  or  complete  over  the  whole  protruded  intestine. 
....  Then  as  to  the  texture  of  the  intestine  :  it  should  be,  for  safety 


48  OPERATIONS  ON  THE  ABDOMEN. 

of  return,  thin- walled,  firm,  tense,  and  elastic,  preserving  its  cylindrical 
form,  smooth,  slippery,  and  glossy.  The  further  the  intestine  deviates 
from  these  characters,  the  more  it  loses  its  gloss  and  looks  villous,  the 
more  it  feels  sticky  and  is  collapsed  and  out  of  the  cylinder  form,  the 
softer  and  more  yielding,  the  more  pulpy,  or  like  wet  leather  or  soaked 
paper,  the  less  it  is  fit  for  return."  It  is  very  important  to  notice 
whether  the  hlood  returns  quickly  or  sluggishly  to  a  portion  of  the 
loop  of  bowel  which  has  been  rendered  anaemic  by  the  pressure 
of  the  finger.  It  should  always  be  remembered  that  although 
the  bowel  may  not  be  actually  gangrenous,  it  may  slough  or  perforate 
soon  after  its  reduction,  and  that  in  many  more  cases,  without  any 
perforation,  the  intestinal  wall  may  be  so  severely  damaged  as  to  allow 
the  escape  of  the  virulent  germs  within  it  into  the  peritonseal  cavity 
inducing  rapidly  fatal  peritonitis.  A  number  of  patients  also  die  from 
paralytic  distension,  and  a  few  from  enteritis,  or  profuse  haemorrhage 
from  the  bowel.  The  dangerous  condition  of  the  distended  bowel  above 
the  obstruction  is  too  apt  to  be  forgotten  ;  it  is  often  in  a  condition  of 
infiltrating  septic  inflammation,  and  its  contents  are  highly  poisonous, 
and  owing  to  paralytic  distension  drainage  is  rarely  successful  in 
removing  this  toxic  accumulation. 

A  consideration  of  the  following  table  inclines  us  to  agree  with 
Mr.  Barker's  statement  that  more  than  one  half  of  the  deaths  after 
herniotomy  are  due  to  the  reduction  of  too  severely  damaged  bowel. 

Table. — Causes  of  Death  in  cases  Dtikg  after  Operation 
for  Strangulation. 

(From  a  paper  by  Mr.  Barker,  Lancet,  May  30,  1903.) 

Sepsis       2 

Sloughing            ...         ...         ...         ...         ...  12 

Peritonitis           ...         ...         ...         ...         ...  43 

Collapse ...         ...         ...         ...  17 

Asthenia ...         14 

Lung  Troubles ...         ...  16 

Heart  failure       ...         ...         ...         ...         ...         ...         ...  2 

Haemorrhage       1 

Obstruction         ...         ...         ...  3 

Anaesthetic          ...         ...         ...         ...  2 

Lung  embolism  ...         ...         ...         ...         ...         2 

114 
Unascertained    13 

Total 127 

(/;)  If  the  mesentery  is  greatly  thickened  and  firm  from  inflammatory 
oedema  or  interstitial  haemorrhage,  if  its  veins  are  thrombosed,  and  its 
arteries  cannot  be  felt  to  pulsate,  then  it  is  clear  that  the  loop  of  bowel 
ought  not  to  be  returned  into  the  abdomen. 

(c)  The  nature  of  the  fluid  in  the  sac  is  also  of  importance,  for  if  it 
be  fovuand  sanious,  it  indicates  that  the  condition  of  the  loop  of  bowel 
is  so  bad  as  to  allow  infection  through  the  damaged  walls ;  and  the  risk 
of  peritonitis  incurred  by  returning  such  intestine  is  great.  Moreover, 
some  of  the  septic  fluid  may  trickle  into  and  infect  the  peritonaeum. 

In  other  long-standing  cases  of  femoral  hernia  the  chief  stress  of  the 


STRANGULATED    FEMORAL    HERNIA.  40 

constriction  is  shown,  not  on  a  dying  loop  of  intestine,  but  in  ulcera- 
tion, partial  or  nearly  ring-like,  at  the  neck  of  the  sac,  under  the  sharp 
edge  of  Gimbernat'a  ligament.  Where  this  condition,  owing  to  the 
duration  of  the  case,  is  Buspected,  the  intestine  should  be  very  gently 
drawn  down,  and  carefully  examined;  if  only  a  grey  or  white  line  be 
found,  this  may  be  inverted  by  means  of  a  Lembert  suture  and  fortified 
by  a  mesenteric  flap,  and  the  bowel  which  is  otherwise  recoverable 
may  be  returned.  If  the  mischief  is  more  severe  and  approaching 
perforation,  resection  is  the  safest  plan. 

When  it  has  been  decided  that  the  bowel  cannot  be  reduced  without 
undue  risk,  the  surgeon  has  to  decide  between  (a)  the  formation  of 
an  artificial  anus  and  (b)  resection.  Wherever  possible,  i.e.,  in  cases 
where  tlic  condition  of  the  patient,  and  the  r.rprricnce,  and  help  ready  to 
the  surgeon's  hand,  admit  of  his  talcing  this  step,  the  gangrenous  intestine 
should  always  be  resected. 

(a)  In  a  few  cases  where  the  above  conditions  arc  absent,  the  surgeon 
must  rest  content  with  opening  the  intestine,  leaving  it  in  situ,  and 
draining  the  distended  bowel  above.  The  quickest  way  will  be  to  draw 
the  whole  loop  that  is  damaged  outside  the  peritoneal  sac,  and  keep  it 
in  place  by  a  sterilised  bougie  or  glass  rod  of  appropriate  size,  as  in 
inguinal  eolotomy  (q.v.). 

It  has  been  much  disputed  whether,  in  these  cases,  when  the  intes- 
tine is  unfit  to  be  returned,  it  is  safe  or  needful  to  divide  the  stricture 
in  addition  to  laying  open  the  intestine.  On  the  one  hand,  M.  Dupuy- 
tren,  Sir  A.  Cooper,  Mr.  Key,  and  Sir  J.  E.  Erichsen  have  advocated 
this  step  being  taken  ;  on  the  other,  Mr.  Travel's  and  Sir  W.  Lawrence 
were  against  it.  The  following  words  of  a  very  brilliant  writer*  will 
probably  convince  most  that  this  'step  is  not  only  injurious  but  un- 
needed  :  "  The  only  result  of  this  is  that  the  protecting  barrier,  which 
divides  the  still  aseptic  peritoneal  cavity  from  the  putrid  sac,  is 
broken  down,  and  putridity  spreads  upwards  into  the  abdomen  and 
kills  the  patient  by  rapid  septicemic  poisoning.  Why  break  down 
this  valuable  wall '?  If  it  is  argued  that,  unless  the  stricture  is  divided, 
the  contents  of  the  bowel  cannot  escape,  then  the  reply  is  that  expe- 
rience proves  this  to  be  utterly  untrue.  In  a  very  short  time  both 
flatus  and  feces  find  their  way  out.  As  everyone  knows,  the  nipping 
of  the  gut  is  not  produced  by  a  sudden  narrowing  of  the  hernial  aper- 
ture, but  by  a  swelling  of  the  loop  of  gut When  the  gut  is  slit 

up,  its  contents  are  set  free,  and  its  inflammatory  juices  escape,  with 
the  result  that  its  swelling  goes  down,  and  room  enough  is  soon  per- 
mitted for  wind  and  feces  to  pass,  more  particularly  as  the  feces  are 
invariably  quite  liquid."  A  rubber  tube  may  be  passed  along  the 
lumen  of  the  gangrenous  loop  to  the  interior  of  the  distended  bowel 
above  the  constriction  and  fixed  in  position  by  means  of  a  purse-string 
suture  passing  through  the  edges  of  the  intestinal  wound  and  one  side 
of  the  tube,  which  should  be  long  enough  to  drain  to  a  rubber  bag  at 
the  side  of  the  patient.  It  is  unfortunately  true  that,  although  the  tube 
may  be  passed  well  into  the  distended  bowel  within  the  abdomen,  very 
little  of  the  pints  of  putrescent  fluid  drains  away  in  the  worst  cases  owing 

*  Sir  W.  Banks,  Clinical  Xotes  on  Two  Yeirs'  Surgical  Work  in  the  Liverpool  Royal 
Infirmary,  p.  96. 

S. — VOL.  II.  4 


50 


OPERATIONS  ON  THE  ABDOMEN. 


to  paralysis  of  the  intestine.  Few  cases  which  are  so  desperate  as  to  be 
suitable  for  the  formation  of  an  artificial  anus  ultimately  recover.  In  a 
series  of  406  cases  of  strangulated  hernia  at  University  College  Hospital 
(Barker,  loc.  supra  cit.),  only  two  out  of  twenty  recovered  after  this 
procedure.  The  reasons  for  this  high  mortality  are  chiefly  the 
desperate  general  condition  of  the  patient  at  the  time  of  the  operation, 
which  is  followed  by  shock,  septic  peritonitis  from  the  condition  of  the 
distended  bowel  within  the  abdomen,  suppuration  and  sloughing  in  the 
wound,  and,  lastly,  the  mortality  of  a  secondary  resection  is  high  in 
these  cases.  Shock  can  be  minimised  by  doing  the  primary  operation 
under  eucaine  anaesthesia  as  recommended  above. 

(b)  Resection. — The  present  high  mortality  of  strangulated  hernia 
will  be  very  considerably  lowered  by  the  adoption  of  primary  resection 
in  suitable  cases  under  favourable  circumstances.  The  extension  of 
its  use  to  those  doubtful  cases  in  which  damaged  bowel  is  too  often 
returned  will  diminish  the  mortality  of  this  class,  for  the  general 
condition  of  the  patient  is  usually  good  enough  to  enable  him  to  bear 
the  shock  of  a  rapid  resection  performed  by  a  skilful  surgeon. 

It  is  important  to  remember  that  resections  are  rarely  wide  enough  ; 
it  is  of  little  use  to  resect  the  strangulated  loop  without  also  removing 
the  distended  paralysed  bowel  above  the  obstruction.  Mr.  Barker 
(April  27,  1901,  and  loc.  supra  cit.)  has  laid  great  stress  on  the 
removal  of  enough  of  this  inflamed  and  damaged  bowel ;  up  to  six 
feet  of  small  intestine  may  be  removed,  if  necessary,  without  materially 
increasing  the  shock  of  the  resection  and  without  interfering  seriously 
with  subsequent  nutrition.  Between  1899  and  May,  1903,  Mr.  Barker 
performed  seven  extensive  enterectomies  for  strangulated  hernia  with 
only  two  deaths,  one  of  these  dying  from  the  pressure  of  an  old  fibrous 
band  on  the  bowel  after  its  return  into  the  abdomen,  and  another  from 
peritonitis,  which  was  probably  due  to  infection  from  a  suppurating 
hernial  sac,  which  was  not  drained  externally.  Hofmeister  (Beit.  Z.  Klin. 
Bel.  xxviii.  H.  3)  also  publishes  twenty-five  primary  resections  with 
a  mortality  of  40  per  cent. 

It  is  perhaps  needless  to  say  that  these  extensive  resections  can 
only  be  undertaken  by  surgeons  skilled  in  intestinal  surgery  and  on 
patients  whose  general  condition  is  fairly  good.  For  those  patients 
presenting  themselves  when  in  extremis  the  formation  of  an  artificial 
anus  under  local  anaesthesia  still  remains  the  most  suitable  treatment. 

Mr.  Barker  states  that  the  marked  diminution  in  the  mortality  of 
herniotomies  at  University  College  Hospital  during  the  four  years 
1899 — 1903,  was  due  almost  entirely  to  the  successful  extensive  resec- 
tions performed  in  suitable  cases.  During  these  years  the  mortality 
was  reduced  from  about  25 — 30  per  cent,  to  18  per  cent. 

The  operation  of  resection  will  be  described  later  (Chapter  V.). 
3.  Wound  of  Intestine. — This  may  be  due  to  (a)  carelessly  incising 
thin,  soft  parts ;  (b)  great  difficulty  in  making  out  the  sac  and  the 
intestine  in  a  fat  patient,  with  the  parts  matted,  especially  if  the  light 
is  bad  ;  (c)  to  the  intestine  being  allowed  to  curl  over  the  edge  of  the 
director  while  the  stricture  is  being  divided,  or  to  this  being  cut  with 
careless  freedom,  or,  lastly,  to  a  loop  lying  out  of  sight  just  above  the 
constriction,  and  to  the  hernia-knife  coming  in  contact  with  this.  Any 
bubbling  of  flatus  or  escape  of  faeces  must  lead  to  a  careful  search  for 


STKANCULATKl)    FEMORAL    HERNIA.  51 

the  wound.  The  operation  wound  being  freely  enlarged,  the  wound 
in  the  intestine  found,  temporarily  closed  with  a  Spencer  Wells's 
forceps,  and  drawn  quite  out  of  the  abdomen,  the  intestines  around 
are  carefully  cleansed  and  packed  out  of  the  way,  and  protected  with 
tampons  of  iodoform  gauze  or  flat  sponges.  When  the  wound  in  the 
intestine  is  small,  it  may  usually  be  inverted  and  closed  by  means  of  a 
purse-string  suture  of  fine  silk  which  nicks  up  only  the  serous  and 
some  of  the  muscular  coat.  If  the  opening  be  larger,  it  should  be 
closed  by  Lembert's  suture  (see  Suture  of  the  Intestine).  Whichever 
method  is  used,  the  injured  part  should  be  replaced  just  within  the 
peritomeal  cavity,  and  in  a  severe  case  the  sac  should  not  be  taken 
away  or  the  wound  closed. 

4.  Wound  of  Obturator  Artery. — The  position  of  this  vessel  when  it 
rises  by  a  common  trunk  with  the  deep  epigastric  instead  of  from  the 
internal  iliac,  which  occurs  in  two  out  of  every  seven  (Gray),  may  bear 
a  very  important  relation  to  the  crural  ring.  In  most  cases  when  thus 
arising  abnormally,  the  artery  descends  to  the  obturator  foramen  close 
to  the  external  iliac  vein,  and  therefore  on  the  outer  side  of  the  crural 
ring  and  out  of  harm's  way.  In  a  small  minority  of  cases  the  artery 
in  its  passage  downwards  curves  along  the  margin  of  Gimbernat's  liga- 
ment, and  may  now  be  easily  wounded. 

The  treatment  is  mainly  preventive — i.e.,  by  making  the  smallest 
possible  nick  that  will  be  sufficient  into  any  point  of  stricture,  such  as 
Gimbernat's  ligament,  a  point  the  importance  of  which  has  already 
been  alluded  to  (p.  46),  and  by  using  a  hernia-knife  that  is  not  over- 
sharp.  If  the  artery  has  probably  been  wounded,  the  following  points 
are  of  interest: — (1)  The  haemorrhage  may  not  at  once  follow  the 
wound.  It  may  not  make  its  appearance  till  the  bowel  is  all  reduced, 
or  even  until  a  quarter  of  an  hour  after  the  wound  has  been  stitched 
up.  In  one  case,  that  of  Dupuytren,  no  haemorrhage  occurred,  and  the 
division  of  the  artery  was  discovered  for  the  first  time  at  the  necropsy 
three  weeks  after  the  operation.  (2)  It  ma}'  occur  when  the  sac  has 
not  been  opened.  (3)  As  is  shown  by  Dupuytren's  case,  it  is  not  neces- 
sarily a  fatal  accident.  (4)  Very  various  means  have  served  to  arrest 
the  haemorrhage,  (a)  Pressure,  as  in  the  cases  of  Sir  W.  Law?rence, 
Mr.  Hey,  and  Mr.  Barker.*  This  means  was  successful  in  two  out  of 
the  three  cases  in  which  it  has  been  employed.  It  should  only  be 
resorted  to  when  the  patient's  condition  does  not  admit  of  the  wound 
being  enlarged,  and  the  bleeding  points  found  and  dealt  with  by  ligature 
or  forci-pressure.  When  pressure  has  to  be  trusted  to,  it  should  be 
efficiently  employed  by  means  of  tampons  of  iodoform  gauze  wrung  out 
of  carbolic  acid  lotion  (1  in  20)  and  secured  on  silk.  (/?)  Ligature  of 
the  vessel,  usually  the  proximal  end.  Of  five  cases  given  by  Mr.  Barker, 
this  was  successful  in  four ;  it  is  only  stated  in  one  that  the  distal  end 
was  also  secured.  The  ligature  had  been  applied  in  some  cases  by  con- 
tinuing the  wound  upwards;  in  others  b}r  making  an  incision  parallel 
with  Poupart's  ligament,  as  if  for  tying  the  external  iliac.  This  step 
should  always  be  taken  when  the  patient's  condition  is  satisfactory.! 

*  Clin.  Soe.  Trans.,  vol.  xi.  p.  180.  This  paper  will  well  repay  perusal.  Most  of  the 
above  information  is  taken  from  it. 

f  Mr.  Hulke  {Lancet,  1SS5.  vol.  i.  p.  74C).  by  freely  opening  up  the  wound  and  using 

4—2 


52  OPERATIONS  ON  THE  ABDOMEN. 

In  two  of  Sir  W.  Lawrence's  eases  the  fainting  of  the  patient  appears  to 
have  decided  the  cessation  of  haemorrhage.  Both  of  these  recovered. 
(y)  In  the  event  of  ligature  being  really  impossible,  it  might  be  worth 
while,  before  taking  other  steps,  to  try  the  application  of  a  pair  of 
Spencer  Wells's  forceps.  These  should  be  left  in  situ  for  three  or  four 
days,  and  would  favour  drainage. 

Causes  of  Hernia  not  doing  well  after  the  Operation  (vide  Table  on 
p.  48). — Most  of  the  bad  results  are  due  to  one  or  both  of  the  following 
causes : — 

(a)  The  reduction  into  the  abdomen  of  bowel  in  a  severely  damaged 
state. 

(b)  The  operation  is  still  frequently  too  long  delayed. 

(1)  Peritonitis,  indicated  by  general  abdominal  tenderness,  rigidity, 
tympanites  and  vomiting.  (2)  Collapse  from  exhaustion.  (3)  Lung 
complications  such  as  bronchitis,  septic  pneumonia,  pulmonary  embolism. 
(4)  Sepsis,  suppuration  in  the  wound,  erysipelas,  sloughing  of  the  bowel 
or  wound,  septicaemia.  (5)  Enteritis  and  haemorrhage  from  the  bowel. 
The  eight  following  are  the  causes  of  intestinal  obstruction  after 
operations  for  hernia  :  (6)  The  descent  and  re-strangulation  of  the 
bowel.  (7)  So  much  damage  to  the  intestine  that  it  lies  paralysed  in 
the  peritonaeal  cavity.*  (8)  Cicatricial  stricture  of  the  intestine. 
(9)  Fixing  of  the  bowel,  after  its  reduction,  by  adhesions  to  the 
abdominal  wall.t  (10)  Formation  of  a  band  out  of  the  above  adhe- 
sions. (11)  Fixing  of  the  two  ends  of  a  loop  of  intestine  by  adhesions. 
(12)  Formation  of  an  omental  band  in  the  neighbourhood  of  one  of 
the  hernial  orifices,  a  band  so  formed  causing  obstruction  later  (Brit. 
Med.  Joum.,  1879,  v°l-  "■  V-  491)-  (T3)  A  very  rare  condition.  The 
sac  may  be  multilocular ;  when  the  intestine  is  reduced  it  may  be 
returned  into  one  of  these  cavities  instead  of  within  the  abdomen. 
Mr.  Bellamy  has  published  such  a  case  (Lancet,  1886,  vol.  ii.  i>.  433). 
A  good  illustration  of  this  is  given  in  Mr.  Holmes's  Surgery,  p.  698, 
Fig.  322 ;  the  patient  here  died  eight  days  after  an  operation  for 
strangulated  hernia.  (14)  Reduction  en  masse  at  the  operation. 
This  is  especially  dangerous  in  femoral  hernia. 

STRANGULATED    INGUINAL    HERNIA    (Fig.   9). 

Operation. — In  considering  this  it  will  not  be  needful  to  go  again 
into  detail,  as  in  the  case  of  Strangulated  Femoral  Hernia ;  the  chief 
points  of  difference  and  those  of  importance  will  be  considered 
carefully. 

The  parts  being  shaved  and  cleansed,  and  the  thigh  a  little  flexed, 
an  incision  four  inches  long  at  first  is  made  in  the  long  axis  of  the 

large  retractors,  found  a  comparatively  large  atheromatous  artery  spouting  freely.  From 
its  position  this  was  a  large  communicating  artery  between  the  deep  epigastric  and 
obturator,  lying  just  behind  Gimbernat's  ligament.  Both  ends  were  secured  with  very 
great  difficulty.     The  patient  did  well. 

*  I  have  recorded  (Brit.  Med.  Joum.,  1879,  vol.  ii.  p.  491)  an  instance  of  this  in  which, 
ten  days  after  an  operation  for  intestinal  obstruction  by  bands,  death  took  place  from  the 
intestine  never  having  recovered  itself. 

f  This  and  the  ne*t  three  are  "riven  by  Sir  Frederick  Treves,  Lancet,  1884,  vol.  i.  p.  1022. 


STRAN01TLATK1)    IN(ilJINAL    HERNIA.  53 

tumour,  with  its  centre  (in  an  ordinary  scrotal  case*)  over  the  external 
abdominal  ring.  The  pressure-forceps  may  be  left  on  the  external 
pudics  (both  superior  and  inferior),  these  vessels  being  finally  closed  by 
the  sutures  which  unite  the  wound.  As  the  Layers  are  divided,  the 
knife  being  kept  strictly  in  the  same  line  throughout,  some  arching 
fibres  of  the  inter-columnar  fascia  may  be  seen  above,  but  the  first 
layer  usually  recognised  is  the  cremasteric  fascia,  often  much  thickened. 
After  this  the  transversalis  fascia,  also  much  thickened  and  vascular- 
looking,  is  slit  up,  and  any  extra-peritonaeal  fat  overlying  the  greyish- 
blue  sac  looked  for.  The  surgeon  now  sees  if  he  can  find  any 
constricting  fibres  outside  the  sac,  and  slits  them  up  on  a  director. 
The  sac  must  always  be  opened  with  the  precautions  already  given 
(p.  44),  the  contents  are  thoroughly  examined,  omentum  got  rid  of  if 
this  step  will  give  more  room,  and  the  site  of  stricture!  found  with  the 
finger  or  tip  of  the  director.  It  is  next  divided  with  the  hernia-knife 
manipulated  under  it  in  a  direction  straight  upwards,  so  as  to  lie 
parallel  with  the  deep  epigastric,  whichever  side  of  the  hernia  this 
vessel  occupies.!  During  this  stage  the  steps  given  at  p.  45  must 
be  taken  to  avoid  any  injury  to  the  intestine.  The  constricting  point 
being  divided  and  dilated,  the  next  step  is  reduction  of  the  intestine. 
This,  in  bulky  inguinal  hernia?,  is  often  a  matter  of  difficulty  and  time. 
The  chief  causes  of  difficulty  here  are — (1)  A  large  amount  of 
intestine,  one  or  two  coils  of  small  and  some  large  intestine  being  not 
very  uncommon.  (2)  The  distension  of  these  with  flatus,  &c.  (3)  In- 
sufficient division  of  the  stricture  ;  or  there  may  be  a  point  of  stricture 
higher  up  than  the  one  divided,  and  overlooked.  (4)  During  attempts 
at  reduction  one  bit  of  intestine  may  get  jammed  across  the  ring 
instead  of  slipping  up  along  it,  and  against  this  the  rest  of  the  con- 
tents are  fruitlessly  pressed.  (5)  Folds  of  the  sac  may  in  much  the 
same  way  block  the  opening. 

Aids  in  Difficult  Cases. — First,  that  part  which  lies  nearest  the  ring 
should  be  taken — e.g.,  mesentery  before  intestine.  After  each  part  is 
got  up,  pressure  should  be  made  on  it  for  a  few  seconds  before  another 
is  taken  in  hand.  If  the  surgeon  find,  after  a  while,  that  he  is  making 
no  progress  with  one  end  of  a  coil,  he  should  take  in  hand  the  other 

*  In  a  strangulated  bubonocele  the  centre  of  the  incision  should  lie  over  the  internal 
abdominal  ring,  and  in  the  deeper  part  of  the  incision  the  deep  epigastric  must  be  felt  for, 
and  avoided. 

f  The  site  of  the  stricture  in  inguinal  hernia  varies.  In  both  varieties,  in  old  cases 
of  long  duration,  it  is  usually  situated  in  the  neck  of  the  sac  itself,  owing  to  contraction 
and  thickening  of  this  and  the  extra-peritonasal  tissue.  In  other  cases  of  oblique  hernia 
the  stricture  is  found  in  the  infundibuliform  fascia  at  the  internal  ring,  just  below  the 
edge  of  the  internal  oblique  in  the  canal,  or  at  the  external  ring.  In  a  direct  hernia  the 
constricting  point,  if  not  in  the  sac,  is  probably  caused  by  the  fibres  of  the  conjoined 
tendon.  In  many  cases  the  parts  are  so  approximated  and  altered  that  in  the  short  time 
given  for  an  operation  it  is  not  so  easy  to  tell  exactly  in  what  tissues  lie  the  strangulation, 
as  to  relieve  it.  Finally,  in  many  cases  of  young  subjects  and  acute  strangulation, 
muscular  spasm — e.g.,  of  the  internal  oblique — must  be  borne  in  mind. 

%  Of  course,  if  the  surgeon  is  certain  that  he  is  dealing  with  an  oblique  hernia,  he 
may  cut  outwards,  and,  in  the  case  of  a  direct  hernia,  inwards,  so  as  to  avoid  the  deep 
epigastric.  In  all  cases  the  cut  should  be  of  the  nature  of  a  nick  dividing  only  those 
fibres  which  actually  constrict,  any  additional  dilatation  being  usually  now  effected  by 
the  tip  of  the  director  or  finger, 


54 


OPERATIONS  OX  THK  ABDOMEN. 


end,  or  another  coil  altogether  if  more  than  one  be  present.  Much  of 
the  difficulty  met  with  in  the  reduction  of  the  intestine  is  due  to  the 
surgeon  not  first  unravelling  the  coil  or  coils,  not  duly  tracing  up  the 
intestine  to  the  ring  so  as  to  make  out  the  relations  of  the  two,  and,  above 
all,  to  his  not  making  up  his  mind  which  end  of  the  coil  it  is  exactly 
which  he  intends  to  begin  reducing.  During  the  manipulations  the 
thigh  should  be  flexed  and  rotated  a  little  inwards,  and  the  cut  edges  of 
the  sac  drawn  tense  with  forceps,  so  as  to  prevent  any  folding  or  push- 
ing up  of  this  before  the  intestine.  If  the  intestines  nre  much  distended, 
attempts  should  be  made  to  return  some  of  their  contents  first  into  the 
abdominal  cavity.  If,  after  gentle  squeezing  with  the  finger  and  thumb, 
and  careful  pressure  upwards  on  each  successive  bit  of  intestine,  it 
all  appears  to  be  returned,  the  little  finger  must  be  passed  into  the 
abdominal  cavity  to  make  certain  that  no  knuckle  remains  in  the  canal 
or  internal  ring. 

Cases  will  occasionally  be  met  with,  where,  owing  to  the  low  condition 


Fig.  9. 


Incision 


The  site  of  the  incision  for  strangulated  inguinal  hernia. 

of  the  patient,  the  large  amount  of  intestine  down,  its  great  distension, 
its  altered  condition,  still  red  and  only  congested,  but  softened,  with  the 
peritonsBal  coat  shaggy  rather  than  lustrous,  and  tending  to  tear  easily, 
it  is  clear  that  reduction  will  not  be  effected  by  manipulation  only.  If 
the  distension  is  due  to  flatus,  an  oblique  puncture  may  safel}'  be  made 
with  a  very  fine  hydrocele  trocar,  the  perforation  being  inverted  and 
closed  by  means  of  a  purse-string  suture,  which  is  introduced  before  the 
fine  trocar  is  used,  and  which  is  tightened  as  the  latter  is  withdrawn. 
Where  fluid  faecal  matter  is  present  the  above  step  is  dangerous. 
Where  the  intestine  is  much  congested  and  softened,  though  not  yet 
gangrenous,  or  where  the  surgeon  has  not  skilled  assistance  and  all  the 
aids  of  modern  surgery  ready  to  his  hand,  he  had  better  leave  the  intes- 
tine in  the  sac  after  a  free  division  of  the  stricture.*     This  method,  while 


*  This  will  all  gradually  and  slowly  return  into  the  peritona?al  cavity.  On  this  point 
the  following  case  by  South  (Chelius's  Surgery \  vol.  ii.  p.  40)  is  of  interest  : — "  I  know  by 
experience  that  if  strangulation  be  relieved,  it  is  of  little  consequence  liow  much  intestine 
be  down.  In  reference  to  this  point,  I  recdlect  the  largest  scrotal  rupture  on  which  I 
have  operated,  and  in  which,  before  the  division  of  the  stricture,  then-  was  at  leas*'  half 


STRANG1  LATED    [NG1  l\  \L    BERNIA.  55 

under  the  above  conditions  the  Bafer,  prevents,  of  course,  any  attempt 
nt  relieving  the  patient,  at  one  operation,  by  a  radical  cure.  For  a 
consideration  of  the  points  which  may  aid  in  deciding  on  the  treatment 
of  bowel  in  a  doubtful  condition,  or  in  a  gangrenous  state,  the  reader 
is  referred  to  p.  47. 

During  any  prolonged  manipulation  of  the  intestines  these  should  he 
kepi  covered  as  much  as  possible  by  iodoform  or  plain  sterile  gauze 
wrung  out  of  hot  normal  saline  solution.  It  is  wise  also  that  the  patient 
should  be  well  under  the  anaesthetic  now,  and  breathing  quietly.  If 
vomiting  occur,  the  surgeon  must  wait,  keeping  up  pressure  on  what  he 
has  reduced.  When  the  intestine  is  all  reduced,  any  ligatured  stumps 
of  omentum  are  returned,  and,  if  the  condition  of  the  patient  admit  of 
it,  the  sac  is  detached,  one  of  the  methods  of  radical  cure  given  at 
pp.  72  to  92  made  use  of,  the  precautions  as  to  the  cord  and  other 
points  given  at  p.  73  being  carefully  followed. 

In  this,  the  wound  should  he  carefully  sponged  with  mercury 
perchloride  solution  (1  in  4000),  and  left  exposed  as  little  as  possible, 
especially  the  parts  near  the  opening  into  the  peritonaeum. 

In  providing  drainage  after  an  operation  on  a  large  inguinal  hernia, 
where  the  parts  have  been  much  handled  either  before  or  during  the 
operation,  it  is  well  worth  while  to  bring  the  lower  end  of  a  drainage- 
tube  out  at  the  lower  part  of  the  freshly  sterilised  scrotum,  by  means 
of  a  counter-puncture  there,  thus  ensuring  efficient  escape  of  the 
discharges,  and  syringing  out  of  the  wound  if  needful. 

After  thus  considering  the  chief  points  in  the  operation,  it  remains  to 
draw  attention  to  some  special  points  connected,  with  inguinal  hernia. 

I.  Varieties. — In  addition  to  the  oblique  and  direct  varieties,  both  of 
which  are  acquired,  there  are  some  others  of  much  practical  importance 
— e.g.,  (a)  Congenital  hernia  into  the  funicular  process  of  peritonaeum. 
Here  the  tubular  process  of  peritonaeum  is  divided  into  a  shut  vaginal 
sac  below  and  an  open  funicular  process  above.  Into  the  latter  the 
contents  descend,  but  are  not  iu  absolute  contact  with  the  testis. 
(b)  Congenital  hernia  into  the  tunica  vaginalis ;  the  tubular  process  of 
the  peritonaeum  is  open  from  the  abdomen  to  the  fundus  scroti,  and  the 
contents  lie  in  contact  with  the  testis.  A  careful  study  of  the  herniae  of 
infants  and  children  proves  that  this  variety  is  very  much  rarer  than  the 
first  variety,  (c)  Hour-glass  contraction  of  the  sac.  Here  the  tubular 
process  is  open  as  in  (b),  but  an  attempt  at  closure  has  brought  about 
a  constriction  which  may  be  at  the  external  abdominal  ring  or  lower 
down  in  the  scrotum.  If  the  contents  pass  through  this  constriction, 
and  get  low  enough,  they  will  be  in  actual  contact  with  the  testis. 
{d)  Encysted  hernia  of  the  tunica  vaginalis.  Here  the  funicular  process 
is  closed  at  its  upper  extremity — i.e.,  at  either  ring  or  in  the  canal — 


a  raid  of  bowel  down,  filled  with  air ;  and,  after  the  stricture  had  been  cut  through,  at 
least  as  much  more  thrust  through,  so  that  I  almost  despaired  of  getting  any  back  ;  yet, 
after  a  time,  I  returned  the  whole.  To  my  vexation,  however,  next  morning  I  found  that 
my  patient  had  got  out  of  bed  to  relieve  himself  on  the  chamber-pot,  and,  as  might  be 
expected,  the  bowel  had  descended,  and  iu  such  quantity  that  the  scrotum  was  at  least 
as  big  as  a  quart  pot.  and  the  vermicular  motion  of  the  intestine  was  distinctly  seen 
through  the  stretched  skin.  Nothing  further  was  done  than  to  keep  the  tumour  raised  to 
the  level  of  the  abdominal  ring,  and  by  degrees  it  returned,  and  the  patient  never  had  an 
untoward  symptom.*' 


56  OPERATIONS  ON  THE  ABDOMEN. 

and  open  below  to  the  testicle.  The  hernial  protrusion  as  it  comes 
down  either  ruptures  this  septum  (when  of  sudden  descent),  or 
gradually  inverts  it,  or  comes  down  behind  it.  These  cases  are  rare, 
but  may  be  puzzling  when  the}'  occur,  as  the  operator  has  more  than 
one  layer  of  peritonaeum  to  incise  before  reaching  the  contents. 
(e)  Interstitial  hernia,  in  which  the  sac,  and  often  the  testicle,  lie 
between  the  internal  and  external  oblique  muscles.  The  writer 
recently  operated  on  an  infant,  in  which  the  condition  was  bilateral, 
there  were  no  external  rings ;  the  cords  were  long  enough  for  easy 
placement  of  the  testis  within  the  scrotum. 

That  the  above  varieties  have  an  importance  beyond  that  of  anatomical 
puzzles  is  shown  by  the  fact  that  in  (a),  (c)  and  (d)  strangulation  may 
be  very  acute  and  urgent.  Again,  though  the  defect  is  a  congenital  one, 
the  hernia  does  not,  in  many  cases,  make  its  appearance  till  the  patient 
has,  in  early  adult  life,  been  subjected  to  some  sudden  strain.  Finally, 
in  these  cases  any  prolongation  of  the  taxis  will  be  not  only  futile,  but 
actually  dangerous,  owing  to  the  tightness  of  the  strangulation  and  the 
facility  with  which,  from  the  delicacy  of  its  adhesions,  the  sac  may  be 
separated  or  burst. 

II.  Reduction  en  Masse,  and  Allied  Conditions. — These  have  been 
chiefly  met  with  in  inguinal  hernia?  owing  to  the  loose  connections 
of  the  sac  and,  sometimes,  to  the  force  used  in  attempts  at  reducing 
large  specimens.  Strangulation  may  persist  after  (a)  displacement,  or 
(b)  rupture  of  the  sac.  In  the  former,  the  sac,  still  strangling  its 
contents  at  its  neck,  is  displaced  bodily  between  the  peritonaeum, 
usual]}',  and  extra-peritonaeal  fascia.  In  the  latter  the  sac  is  rent, 
usually  close  to  its  neck  and  at  its  posterior  aspect,  and  some  of  its 
contents  are  thrust  through  into  the  extra-peritonaeal  connective  tissue. 
The  chief  evidence  of  these  accidents  is :  though  the  swelling  has 
disappeared,  perhaps  completely,  this  has  taken  place  without  the 
characteristic  jerk  or  gurgle.  On  close  examination,  though  the  bulk 
of  the  hernia  is  gone,  some  swelling,  often  tender,  is  usually  to  be  made 
out,  deep  down,  in  the  neighbourhood  of  the  internal  ring.  Above  all, 
the  symptoms  persist,  perhaps  in  an  intensified  form. 

The  treatment  is  immediate  exploration  of  the  inguinal  canal  and  the 
internal  ring.  If  the  cord  is  exposed,  the  whole  sac  has  probably  been 
detached.  If  any  of  the  sac  is  left  above,  a  rent  in  it  should  be  sought 
for.  Supposing  the  index  finger,  passed  through  the  internal  ring,  fail 
to  find  any  swelling,  aided  by  pressure  from  above,  a  vertical  incision 
must  be  added  to  the  upper  end  of  the  oblique  one,  and  the  neighbourhood 
of  the  internal  ring  explored.* 

III.  Retained  Testis  simulating  Hernia. — Such  a  testis,  when  inflamed, 
or  twisted  on  its  mesorchium,  which  is  often  long  enough  to  allow  this, 
may  closely  simulate  strangulated  hernia.  A  testis,  perhaps,  has  never 
descended  ;  a  truss  has  been  worn  and  laid  aside.  The  patient  presents 
himself  with  a  tender  swelling  in  one  groin,  with  indistinct  impulse. 
The  abdomen  is  tense  and  full,  constipation  is  present,  and  perhaps 
vomiting  of  bilious  fluid.  Such  a  swelling  should  be  explored  and  the 
testis  removed,  as  it  is  certain,  later  on,  to  cause  serious  trouble,  even 

*  As  this  will  probably  involve  abdominal  section,  the  steps  given  later  should  be 
referred  to, 


STRANGULATED    UMBILICAL    HKIINIA.  57 

if  the  present  urgent  symptoms  subside  with  palliative  treatment. 
In  other  cases  a  retained  testis  may  draw  down  an  adherent  loop  of 
intestine  which  may  become  actually  strangled.* 


STRANGULATED     UMBILICAL     HERNIA. 

Two  distinct  forms  of  strangulated  hernia  will  be  met  with  here.  One, 
more  rare,  is  of  small  size,  with  a  single  knuckle  of  intestine  acutely 
strangled  in  the  navel-cicatrix.  The  other,  the  more  common,  is  often 
huge,  its  contents  mixed,  intestine  both  large  and  small,  and  omentum. 
Such  hernias  soon  become,  in  part  at  least,  irreducible  ;  when  in  this 
condition,  any  unwise  meal  may  readily  bring  about  obstruction,  a 
condition  requiring  much  care  to  tell  from  strangulation,  f  In  other 
cases  a  large  irreducible  hernia  may  easily  become  strangulated  from 
the  descent  of  some  additional  loop  of  bowel.  The  adequate  fitting 
of  a  truss  is  often  a  matter  of  much  difficulty  here,  owing  to  the  large 
size  of  the  abdomen,  the  presence  of  adherent  omentum,  and,  frequently, 
of  an  habitual  cough. 

Practical  Points  before  Operation. — (a)  The  sac  usually  communicates 
directly  with  the  general  peritonseal  cavity  by  a  large  opening.  (/?)  The 
contents  are  not  only  mixed,  but  of  long  standing,  and  often  adherent. 
(7)  The  patients  are  often  advanced  in  life,  obese,  flabby,  and  not 
infrequently  the  subjects  of  chronic  bronchitis.  (8)  The  coverings  are 
ill  nourished  and  slough  easily. 

Operation.— In  view  of  the  delicacy  of  the  skin  and  the  intertrigo 
which  is  often  present,  the  cleansing  must  be  thorough  but  gentle.  An 
anaesthetic  having  been  administered,  a  curved  transverse  incision  two 
to  three  inches  long  is  made  across  the  lower  J  aspect  of  the  neck  of  the 
swelling,  the  hernia  being  pushed  upwards  to  facilitate  this.§  The  cover- 
ings are  much  thicker  and  more  easily  distinguished  here  than  over  the 
fundus  of  the  hernia,  where  it  is  easy  to  injure  the  contents.     Moreover 

*  For  fuller  information  on  these  matters  I  would  refer  my  readers  to  The  Diseases  of 
the  Male  Organs  of  Generation,  chapter  ii.  p.  72. 

f  Amongst  the  most  important  points  will  be  the  voniting,  whether  early  in  onset, 
constant,  and  showing  signs  of  becoming  fasculent,  and  the  constipation,  whether 
absolute,  even  to  the  passage  of  flatus.  In  doubtful  cases  the  rule  should  be  to  operate. 
"  The  risk  of  operating  on  a  hernia  which  is  inflamed  and  not  easily  reducible  is  very 
small  in  comparison  with  the  risk  of  leaving  one  which  is  inflamed  and  strangulated  ; 
and  even  if  you  can  find  reasons  for  waiting  it  must  be  with  the  most  constant  oversight, 
for  an  inflamed  and  irreducible  hernia  may  at  any  time  become  strangulated,  and  will 
certainly  do  so  if  not  relieved  by  rest  and  other  appropriate  treatment "  (Sir  J.  Paget, 
lor,  supra  rit..  p.  106). 

%  The  lower  part  is  her;  recommended  because,  in  Mr.  Wood's  words  (Intern.  Eacycl. 
of  Surg.,  vol.  v.  p.  1165),  "the  point  of  strangulation  in  an  adult  umbilical  hernia  is 
most  frequently  at  the  lower  part  of  the  neck  of  the  sac,  where  the  action  of  gravity,  the 
dragging  weight  of  the  contents,  and  the  superincumbent  fat,  together  with  the  pressure 
and  weight  of  the  dress  or  an  abdominal  belt,  combine  to  press  downwards  upon  the  sharp 
edge  of  the  abdominal  opening.  It  is  here  that  adhesions  and  ulceration  of  the  bowel  are 
most  frequently  found,  and  here  the  surgeon  must  search  for  the  constriction  in  cases  of 
strangulation."     An  incision  here  also  gives  better  drainage. 

§  If  the  surgeon  intends  to  attempt  a  radical  cure,  and  if  the  skin  is  diseased,  much 
thickened  with  old  abrasions,  lie  should  remove  tin's  area  by  two  elliptical  incisions. 


58  OPERATIONS  ON  THE  ABDOMEN. 

the  contents  are  rarely  adherent  at  the  very  neck  of  the  rupture.  Search 
should  be  made  for  any  constricting  bands  of  fibres  outside  the  sac. 
The  sac  must  be  opened,  with  the  knife  held  horizontally,  and  slit  up, 
care  being  taken  now  and  throughout  the  operation,  in  cases  of  large 
hernia?,  that  protrusion  of  intestine  be  prevented  by  the  means  given  a 
little  later.  The  contents  having  been  examined,  any  intestine  is  gently 
displaced  upwards,  while  the  surgeon  turns  the  curved  surface  of  a 
Key's  director  over  the  lower  edge  of  the  opening,  and,  guiding  the 
hernia  knife  on  this,  divides  the  constricting  edge  downwards.  If 
sufficient  space  is  not  given,  the  downward  nick  may  be  repeated,  or 
the  director  turned  against  the  lateral  or  upper  aspects  of  the  ring,  and 
fibres  here  also  divided. 

Adhesions  of  the  contents  of  the  sac  are  not  infrequently  met  with. 
If  they  are  veiy  close  and  dense,  and  if  the  condition  of  the  patient  is 
unsatisfactory,  and  if  the  surgeon  be  short-handed,  he  should  be  content 
with  a  free  division  at  one  or  two  places  of  the  constricting  ring,  and 
with  reducing  any  portion  of  intestine  that  has  clearly  only  recently 
come  down,  and  leave  the  rest  undisturbed. 

A  complication  of  large  umbilical  hernias  is  thus  well  described  by 
Mr.  Wood  (loc.  supra  cit.,  p.  1168)  : 

"  In  corpulent  persons,  in  whom  the  operation  has  been  delayed  until 
peritonitis  has  begun,  the  operator  has  frequently  to  contend  with  a  rush 
of  bowels  out  of  the  abdomen.  This  should  be  restrained  by  receiving 
them  in  warm  towels*  wet  with  carbolic  lotion,  and  applying  pressure 
by  the  hands  of  assistants.  If  it  can  be  managed,  all  the  operative 
proceedings  within  the  sac  should  be  done  before  such  a  rush  occurs  ; 
but  if  a  cough,  or  vomiting,  or  anaesthetic  difficulty  occurs  at  this 
juncture,  this  is  sometimes  impossible,  and  the  surgeon  is  compelled  to 
do  the  best  he  can.  In  such  cases  the  operation  becomes  a  formidable 
one  indeed,  and  is  comparable  only  to  laparotomy  under  conditions  of 
distension  of  the  intestines.  The  bowels  and  omentum  should  alwa}rs, 
if  possible,  be  kept  in  the  warm  wet  towels,  and  not  indiscriminately 
handled  by  the  assistants,  whose  arms  should  be  bared  and  well  purified 
with  carbolised  lotion.  The  intestines  should  always  be  returned  before 
the  omentum,  which  should,  if  possible,  be  spread  outt  over  them  before 
the  stitches  are  applied." 

All  the  intestine  and  the  remains  of  the  omentum,  carefully  ligatured, 
having  been  returned  if  possible,  the  surgeon  now,  if  the  patient's  con- 
dition admits  of  it,  removes  the  redundant  sac  and  skin  by  joining  the 
ends  of  the  first  incision  by  another  one  passing  across  the  upper  aspect 
of  the  neck  of  the  rupture.  The  opening  into  the  abdominal  cavity  is 
closed  in  the  following  manner  : — The  sac  is  carefully  separated  all 
round  till  its  neck  is  cleared,  the  redundant  part  is  cut  away,  and  the 
peritonreum  closed  by  means  of  a  continuous  suture  of  fine  silk.  The 
operation  is  completed  by  rapidly  performing  one  of  the  operations  for 
radical  cure  which  are  described  on  p.  101.    Mayo's  operation  is  simple, 

*  Large  squares  of  iodoform  gauze  wrung  out  of  hot  sterile  salt  solution  are  to  be 
preferred. 

f  Mr.  Wood  prefers  leaving  the  edge  of  the  omentum  so  arranged  as  to  become 
adherent  to  the  lower  margin  of  the  hernial  opening,  so  as  to  prevent,  if  possible,  any- 
future  protrusion,  to  tying  it  and  cutting  it  short. 


STRANGULATED    oMTURATOR   HERNIA.  59 

and  probably  for  the  best.  In  some  cases  the  edges  of  the  recti  may  be 
quickly  exposed  and  sewn  together  without  much  difficulty.  Attempts 
to  draw  the  edges  of  the  fibrous  ring  together  without  the  aid  of  flaps 
are  to  be  condemned,  because  the  sutures  are  very  apt  to  tear  out 
even  during  the  operation,  and  much  more  so  during  the  vomiting  that 
follows  the  operation.*  The  writer  remembers  two  cases  in  which 
re-strangulation  occurred  from  this  cause. 

It  will  be  seen  from  the  above  account  that  two  methods  may  be 
pursued  in  the  reduction  of  a  strangulated  umbilical  hernia:  (1)  If  the 
surgeon  be  short  handed  and  the  hernia  very  large  or  the  patient's 
general  condition  grave,  the  ring  is  freely  divided  at  one  or  two  points, 
but  the  contents  disturbed  as  little  as  possible,  any  recently-descended 
intestine  being  returned,  but  thickened  omentum  and  adherent  intes- 
tine (especially  large)  being  left  undisturbed.  (2)  Free  opening  of  the 
sac,  examination  and  separation  of  its  contents,  return  of  all  intestine, 
and  of  omentum  after  ligature  and  excision  of  some  of  the  latter. 

While  the  second  of  these  courses  has  the  great  advantage  of  leaving 
the  patient  permanently  in  a  more  satisfactory  condition,  as  it  admits  of 
a  radical  cure,  the  surgeon  can  only  rightly  decide  between  this  and 
the  first  course  by  a  careful  consideration  of  each  case.  The  following 
points  may  aid  in  judiciously  selecting  either  operation  : — (1)  The  size, 
long  standing,  previous  attacks  of  incarceration  and  obstruction  of  the 
hernia,  all  these  tending  to  bring  about  adhesions  and  alterations  in 
the  parts.  (2)  The  condition  of  the  patient — viz.,  the  degree  of  flabby 
fatness,  chronic  bronchitis,  probable  renal  and  hepatic  disease,  amount 
of  depression  by  vomiting  and  pain.  (3)  The  presence  of  the  skilled 
help  so  essential  in  these  cases.  (4)  The  way  in  which  the  anaesthetic 
is  taken.  (5)  The  amount  of  experience  of  the  operator.  Thus  a 
hospital  surgeon,  frequently  operating  and  with  all  instruments  and 
assistance  at  hand,  may  readily  incline  to  one  course,  while  the  other 
may  as  wisely  be  followed  by  a  surgeon  who  has  to  operate  under  very 
different  circumstances. t  For  a  consideration  of  the  treatment  of 
damaged  intestine,  ride  p.  47. 

STRANGULATED   OBTURATOR  HERNIA. 

This  form  of  hernia  lias  occurred  too  frequently  to  be  entirely  passed 
over.  It  may  be  so  readily  and  fatally  overlooked  that  a  few  words  on 
its  diagnosis  will  not  be  out  of  place. 

(1)  Position  of  the  swelling.  This  appears  in  the  thigh  below  the 
horizontal  ramus   of  the   pubes,   behind   and  just  inside  the  femoral 

*  Mr.  Barker  {Brit.  Med.  Jburn.,  1885,  T°l-  '*■  P-  hoi)  advises  the  use  of  a  double  row 
of  sutures — the  first,  to  unite  the  edges  of  the  ring  ;  the  second,  to  give  extra  strength 
to  the  sear,  are  passed  through  the  anterior  layer  of  the  sheath  of  the  rectus  on  each 
side,  at  about  one-third  of  an  inch  from  the  edge  of  the  ring.  On  these  being  brought 
together,  a  considerable  fold  of  fibrous  tissue  is  inverted  and  brought  into  contact  in  the 
middle  line,  over  the  first  row  which  closed  the  ring. 

t  Mr.  Clement  Lucas  {Clin.  Sue.  Trans.,  vol.  xix.  p.  5)  advocated  more  radical 
measures,  such  as  excision  of  the  sac  and  redundant  skin,  with  suture  of  the  ring,  in  all 
cases  of  umbilical  hernia.  Two  successful  cases  are  recorded,  both  excellent  instances  of 
this  treatment,  and  one  of  especial  interest,  as  the  patient  had  been  previously  thrice 
tapped  for  ascites,  and  the  operation  allowed  three  pints  and  a  half  of  fluid  to  escape. 


60  OPERATIONS  ON  THE  ABDOMEN. 

vessels,  behind  the  pectineus,  and  outside  the  adductor  longus.  (2)  On 
careful  comparison  of  the  outline  of  Scarpa's  triangles,  a  slight  fulness 
is  found  in  one  as  compared  with  the  hollow  in  the  other.  (3)  Pain 
along  the  course  of  the  obturator  nerve,  down  the  inner  side  of  the 
thigh,  knee,  and  leg.  (4)  Persistence  of  symptoms  of  strangulation, 
the  other  rings  being  empty  or  occupied  by  reducible  hernia.  (5)  A 
vaginal  or  rectal  examination.  In  making  these  examinations  in  cases 
of  intestinal  obstruction,  care  should  always  be  taken  to  examine  the 
pelvic  aspect  of  the  obturator  foramen. 

Operation. — Two  different  ones  present  themselves  :  (i.)  by  cutting 
down  on  the  sac,  as  in  other  hernias  ;  (ii.)  by  abdominal  section, 
and  withdrawing  the  loop  from  within. 

(i.)  The  parts  having  been  duly  cleansed  and  slightly  relaxed,  an 
incision  is  made  parallel  to  and  just  inside  the  femoral  vein.*  The 
saphenous  opening  being  probably  exposed  in  part,  the  fascia  over  the 
pectineus  and  the  fibres  of  this  muscle  having  been  divided  transversely 
for  one  and  a  half  or  two  inches,  the  obturator  muscle  covered  by  its 
fascia  and  some  fatty  cellular  tissue  is  next  defined,  and  the  hernial  sac 
probably  now  comes  into  view,  either  between  the  muscle  and  the 
pubes,  or  between  the  fibres  of  the  muscle.  The  sac  must  be  opened, 
and  if  any  constriction  has  to  be  divided,  the  knife  should  be  turned 
either  upwards  or  downwards,  the  latter  being  the  easier  if  any  con- 
stricting fibres  intervene  between  the  sac  and  the  bone.  As  the 
obturator  vessels  lie  usually  on  one  side  or  the  other,  a  lateral  incision 
must  be  avoided. 

Care  must  be  taken  to  keep  the  femoral  vessels  drawn  outward  with 
a  retractor,  while  any  branches  of  the  obturator  or  anterior  crural  nerve 
are  drawn  aside  with  a  blunt  hook,  the  same  precaution  being  taken 
with  the  saphena  vein. 

When  by  the  passage  of  the  little  finger  into  the  abdomen  it  is 
certain  that  the  intestine  is  reduced,  if  the  condition  of  the  patient 
admits  of  it,  the  sac  is  separated  and  ligatured  close  to  the  thyroid 
foramen  and  removed.  Drainage  must  be  provided  with  aseptic 
horsehair  or  a  fine  tube. 

(ii.)  The  operation  of  abdominal  section  will,  perhaps,  be  more 
frequently  performed  in  the  future. 

An  obturator  hernia  was  thus  reduced  by  Mr.  Hilton  in  a  case  which  simulated 
intestinal  obstruction.  Some  empty  intestine  being  found  and  traced  downward.-:,  led 
to  the  detection  of  an  obturator  hernia,  which  was  reduced  by  gentle  traction  aided  by 
firm  pressure  made  deeply  in  the  thigh.  The  patient,  who  was  not  operated  on  till  the 
eleventh  day,  died  of  rapid  peritonitis. 

Sir  J.  E.  Erichsen  briefly  mentions  a  case  operated  on  by  this  means  in  1884  by  Mr. 
Godlee.  The  hernia  was  reduced  without  difficulty,  but  the  patient,  who  was  much 
collapsed  at  the  time,  died  in  about  twenty-four  hours. 

Question  of  the  advisability  of  reducing  Strangulated  Hernia  by 
Abdominal  Section. 

This  question  having  arisen  here  may  be  dealt  with  once  for  all. 

*  Mr.  Birkett  (loc.  x//j>n/  cit.,  p.  830)  says  the  incision  "  may  commence  a  little  above 
Poupart's  ligament,  at  a  point  midway  between  the  spine  of  the  pubes  and  the  spot  where 
the  femoral  artery  passes  over  the  ramus  of  that  bone," 


STRANGULATED    OBTURATOR    HERNIA.  61 

Cases  will  occur  from  time  to  time,  such  as  Mr.  Hilton's  (loc.  supra  cit.), 
in  which,  evidence  of  acute  intestinal  strangulation  existing  and  no 
hernia  being  detected  externally,  on  the  abdomen  being  opened  the 
cause  will  be  found  to  be  apiece  of  a  small  intestine  nipped  in  part  of 
its  circumference,  probably  in  either  one  of  the  femoral  or  obturator 
rings.  Still  more  rarely,  a  surgeon  may  find  such  difficulty  in  reducing 
an  obturator  hernia  from  without,  that  he  feels  himself  driven  to 
resort  to  abdominal  section.  More  frequently  he  may  find  the  bowel 
gangrenous  in  an  obturator  hernia.  It  is  to  be  remembered  that  the 
rupture  is  often  a  partial  enterocele  with  dubious  symptoms  which  have 
delayed  treatment.  If  the  patient's  condition  be  fairly  good,  resection 
is  then  indicated,  and  can  only  be  performed  through  a  laparotomy 
wound.  An  incision  should  be  made  through  the  corresponding  rectus 
low  down,  the  Trendelenberg  position  adopted,  and  the  limbs  of  the 
loop  of  bowel  which  are  within  the  pelvis  clamped  with  Doyen's  intes- 
tinal forceps.  The  constriction  should  then  be  divided  in  a  downward 
direction,  and  the  strangulated  intestine  withdrawn  into  the  pelvis  and 
then  out  of  the  abdomen,  where  it  can  be  thoroughly  examined  and 
resected  if  necessary.  Should  the  sac  be  suppurating  it  can  be  drained 
through  a  wound  in  the  thigh.  Some  years  ago  it  was  suggested  that  it 
should  be  the  rule  to  reduce  hernia?  generally,  and  to  perform  the  radical 
cure  by  abdominal  section.  Thus  at  the  meeting  of  the  British  Medical 
Association  in  1891  (Brit.  Med.  Journ.,  Sept.  26,  189 1),  this  question 
was  discussed,  the  late  Mr.  Lawson  Tait  introducing  the  subject.  As 
might  be  expected,  the  proposal  to  abandon  the  old  operation  and 
treatment  by  median  abdominal  section  met  with  no  support 
from  those  surgeons  who  know  anything  of  operations  for  strangu- 
lated hernia  in  hospital  practice,  especially  in  males.  Save  in  the 
rarest  cases,  such  as  those  belonging  to  the  category  I  have  men- 
tioned, such  a  step  is  to  be  condemned  in  the  strongest  terms,  for 
the  following  reasons :  (1)  Operations  for  relief  of  strangulated  hernia 
must  sometimes  be  performed  by  general  practitioners.  The  old  and 
well-established  operation  is  one,  per  se,  of  but  slight  severity,  and  one 
that  usually  can  be  kept  extra-peritonasal  by  an  operator  of  ordinary 
skill  and  of  average  anatomical  knowledge.  Those  who  would  substi- 
tute abdominal  section  forget  that,  however  safe  they  may  consider 
themselves,  with  their  especial  experience,  to  be  in  preventing  peritonitis 
— a  very  different  standpoint  from  that  of  a  general  practitioner — 
neither  they  nor  anyone  else  can  prevent  the  shock  which  goes  with 
intra-peritonseal  operations,  a  complication  which  is  certainly  to  be 
avoided  in  patients  exhausted  by  a  strangulated  hernia.  (2)  The 
reduction  of  the  intestine  which  is  spoken  of  as  so  easy  after  abdominal 
section  by  those  who  advocate  this  method,  is  liable  to  be  prevented  by 
adhesions  to  the  sac,  &c. ;  when  such  exist — and  no  one  can  foretell  this 
point — the  sac  must  be  explored  in  the  usual  way.  (3)  There  is  a  very 
grave  risk  that  the  intestine  is  tightly  nipped,  and  often  may  give  way 
when  pulled  upon  through  a  median  incision.  Those  who  advocate 
abdominal  section  will  say  that  the  resulting  extravasation  can  be  met 
by  flushing,  &c.  It  will  be  well  for  all  such  to  remember  the  following 
advice,  tersely  put  by  Sir  W.  Bennett  (Clin.  Lect.  on  Hernia,  p.  122)  : 
"  Let  it  be  noted  that  it  is  generally  far  more  easy  to  soil  the  peritonaeum 
than  to  cleanse  it."     The  same  surgeon  points  out  (ibidem,  p.  121)  that 


62  OPERATIONS  ON  THE  ABDOMEN. 

the  fluid  found  in  the  sac  of  herniae,  when  strangulation  has  long  existed, 
is  sometimes  dark  and  ill-smelling,  though  no  lesion  may  be  apparent 
in  the  gut  itself.  By  an  ordinary  herniotomy  such  fluid  is  thoroughly 
drained  away  from  the  peritonaeal  cavity,  and  any  such  intestine  is 
cleansed  before  it  is  put  back,  or  otherwise  appropriately  dealt  with. 

(4)  All  operating  surgeons  are  agreed  that,  whenever  the  condition  of 
the  patient  admits  of  it,  an  operation  for  strangulated  hernia  should  be 
completed  by  giving  the  patient  at  least  a  chance  of  radical  cure.  I 
am  distinctly  of  opinion  that  no  intra-peritonseal  operation  yet  described 
will  secure  radical  results  in  inguinal  herniae.  (5)  Those  who  think 
they  are  improving  matters  by  substituting  abdominal  section  for  the 
old-established  herniotomy,  object  to  the  latter  on  account  of  its  ten- 
dency to  weaken  the  abdominal  wall  by  the  incision  made  to  reach  and 
relieve  the  constriction.  Such  advocates  forget  the  criticism  pithily 
put  forward  during  the  above  discussion  by  Mr.  Keetley,  that  treatment 
of  herniae  by  abdominal  section  created  two  potential  hernial  apertures 
where  there  was  originally  but  one. 

RADICAL  CURE  OF  HERNIA. 

Before  describing  the  different  methods,  the  following  points  claim 
attention  ;  and  while  the  improvements  of  modern  surgeiy  have  estab- 
lished radical  cure  on  a  sound  scientific  basis,  many  questions  remain 
still  undecided.  The  chief  of  these  are :  (1)  the  mortality  of  the 
operation.  (2)  The  use  of  the  terms  "  radical  cure  "  and  "  permanency 
of  the  cure."  (3)  The  earliest  age  at  which  the  operation  is  advisable 
in  children.     (4)  The  advisability  or  need  of  wearing  a  truss  afterwards. 

(5)  The  best  material  for  suture.     (6)  The  best  form  of  operation. 

(1)  The  Mortality  of  the  Operation. — The  following  statistics  show 
what  modern  surgery  and  experienced  hands  can  do.  Drs.  Bull  and 
Coley  (Ann.  of  Surg.,  vol.  xxviii.,  1898,  p.  604)  have  compiled  a  list 
of  8594  cases,  under  the  care,  be  it  noted,  of  well-known  operators, 
with  seventy-eight  deaths,  giving  the  very  low  mortality  rate  of 
•9  per  cent.  The  same  writers  in  a  later  publication  (Ann.  of  Surg., 
June,  1903)  publish  an  analysis  of  1095  of  their  own  cases,  with  a 
mortality  of  only  two — less  than  '2  per  cent.  One  of  these  died  of 
ether  pneumonia.  Since  these  deaths  Coley  has  performed  500  radical 
cures  without  a  death.  These  authors  also  quote  the  mortality  at 
Carle's  Clinic  in  Borne  as  only  two  in  1400  operations  ;  and  at  the 
Johns  Hopkins  Hospital,  where  an  extensive  operation  is  employed,  at 
one  in  459.  Bull  and  Coley  (Med.  Bee,  March  18,  1905)  publish  a 
mortality  of  only  '3  per  cent,  in  1500  radical  cures  in  children,  mostly 
over  four  years  of  age. 

(2)  The  Value  of  the  Term  "  Radical  Cure,"  and  the  Permanence 
of  the  Cure  after  Operation. — Some  years  ago  Mr.  Macready,  surgeon 
to  the  City  of  London  Truss  Society,  wrote  the  following  weight}7  words 
on  what  he  called  the  unsatisfactory  nature  of  the  evidence  as  to 
efficacy  of  the  radical  cure  (A  Treatise  on  Ruptures,  p.  234)  :  "  The 
evidence  brought  forward  by  one  surgeon  after  another  in  favour  of 
these  operations  is  always  of  the  same  character.  A  number  of  cases 
are  given  in  which  the  operation  has  been  performed,  and  in  which 
the    result  has  been  watched  for  periods  varying  usually  from  a  few 


KAIMCAL    CURE    OF    HERNIA. 


63 


months  to  four  or  five  years.  Very  few  c;ises  are  under  observation  so 
long  as  five  years;  for  the  patient  changes  his  residence  or  declines 
to  show  himself.     M.  Terrier  <>n  one  occasion  wrote  to  twenty-live  old 

patients,  and  received  only  two  replies.  It  must  not  be  supposed  that  a 
patient  is  cured  because  he  does  not  come  for  inspection.  The  relapsed 
cases  at  the  Truss  Society  have  almost  all  been  asked  if  they  have  visited 
the  operator  to  show  him  the  result.  In  the  great  majority  of  cases  they 
prefer  not  to  go  back,  and  very  often,  alas  !  express  themselves  as  if  a 

Fig.  10. 


-  6 


Dissection  of  inguinal  canal. 

1,  External  oblique  turned  down.     2,  Internal  oblique.     3,  Transversalis. 

4,  Conjoined  tendon.     5,  Rectus  abdominis  with  its  sheath  opened. 

6,  Triangular  fascia.     7,  (.'remaster.     (Heath.) 

deception  had  been  practised  upon  them.  It  is  much  to  be  regretted 
that  patients  should  feel  this  reluctance  to  face  the  operator  again,  for 
in  consequence  the  surgeon  is  apt  to  form  too  favourable  an  opinion  of 
the  efficacy  of  his  plan.  Sometimes  a  patient,  after  remaining  cured  for 
a  number  of  years,  passes  from  under  observation  and  again  becomes 

ruptured All    that    we    can    say  of  the  operations,  involving 

complete  removal  of  the  sac,  is  that  they  all  give  immunity  to  a  certain 
number  for  a  certain  time." 

Since  Macready  wrote  these  melancholy  words,  things  have  changed 
and    improved    greatly;  but    some    of   his    warnings    are    still    to    be 


.64  OPERATIONS  ON  THE  ABDOMEN. 

remembered.     Surgeons  are   still  too    apt   to   claim    their   results  as 
radical  cures  after  a  few  months  or  a  year. 

In  recent  years  we  have  learnt  more  distinctly  the  principles  on 
which  this  operation  is  to  be  conducted.  Two  or  three  methods  have 
now  been  employed  on  such  a  large  scale,  and  with  such  excellent 
results,  that  it  seems  probable  that  a  permanent  cure  can  be  promised 
in  a  large  number  of  favourable  cases.  This  qualified  statement 
requires  explanation.  By  a  "  permanent  cure,"  I  mean  a  cure  which 
will  last  a  lifetime.  By  "  favourable  cases,"  I  mean  children,  young 
subjects,  hernise  of  moderate  size,  where  the  rings  and  canal  are  still 
present  and  not  stretched  and  converted  into  one  large  direct  gap  into 
which  the  tips  of  two  or  three  fingers  can  be  easily  placed  ;  cases 
where  the  patients  operated  on  have  sense  enough  to  give  the  newly 
repaired  structures  sufficient  rest  for  their  consolidation,  and  where,  if 
they  must  follow  employment  or  exercise  that  involves  much  straining, 
they  will  give  the  parts  the  support  of  a  truss  of  light  pressure  or  a 
belt*  (ride  infra).  If  this  is  not  done  we  shall  see,  if  cases  are  carefully 
followed  up  and  candidly  reported,  that  radical  cures  will  not  last  a 
lifetime,  and  that  the  term  will  have  to  be  largely  replaced  by  the 
following,  according  to  the  degree  of  cure  obtained — viz.,  "complete 
successes,"  "partial  successes,"  "  complete  failures." 

Since  Bassini  published,  in  1888,  the  description  of  his  operation,  this 
method,  either  as  first  described  or  modified  in  some  slight  degree,  has 
become  more  and  more  popular,  and,  at  the  present  time,  its  adop- 
tion may  be  said  to  be  almost  universal.  Dr.  Coley  (Ann.  of  Surg., 
June,  1903)  published  an  account  of  1000  operations  for  inguinal  and 
femoral  hernise  performed  between  1891  and  1902  ;  937  of  these  were 
inguinal  and  66  femoral.  In  917  inguinal  operations  by  the  Bassini 
method  there  were  only  10  known  relapses,  or  a  little  over  I  per  cent. ; 
but  these  cases  were  not  all  traced  for  long  enough  time.  Thus  out  ot 
the  total  1003  cases  647  were  traced  and  found  well  from  six  months 
to  eleven  years,  410  were  well  from  two  to  eleven  years.  There  were 
six  relapses  in  20  cases  of  inguinal  hernia  in  which  the  cord  was  not 
transplanted.  In  181  cases  of  inguinal  hernia  in  women  there  were 
no  relapses  and  no  deaths  ;  the  round  ligament  was  not  transplanted 
in  these.  Coley  gives  statistics  to  prove  that  patients  very  rarely  get 
recurrences  after  one  year ;  over  90  per  cent,  of  the  relapses  appear 
in  the  first  year. 

It  may  be  said,  therefore,  that  after  one  year  the  chances  of 
relapse  are  not  great,  although  no  absolute  time  limit  can  be  given 
after  which  cure  may  be  said  to  be  absolute.  Jonathan  Hutchinson, 
jun.  (Lancet,  1906,  vol.  i.  p.  903),  gives  a  very  valuable  and  candid  account 
of  the  results  of  his  own  cases  at  the  London  Hospital  during 
the  last  fifteen  years.  Out  of  360  operations  for  radical  cure 
of  inguinal    hernia,    he    was   able    to    trace    100  for  over  two    years, 

*  Many  will  say  that  if  any  truss  or  support  is  worn  afterwards  the  cure  is  not 
radical;  I  admit  this,  but  reply  that  until  published  series  of  cases  have  been  watched 
for  a  much  longer  period,  we  shall,  as  relapses  may  occur  five  or  eight  years  after 
operation,  do  wisely  to  advise  thi  above  class  of  patients  to  support  the  restored  region 
with  a  well-fitting  truss  of  light  pressure,  and  so  bring  about  a  permanent  cure  instead  of 
a  liability  to  relapse. 


RADICAL    CURE    OF    II IM  IMA.  65 

the  average  being  traced  for  six  years.  There  were  eight  relapses, 
five  pronounced,  one  very  slight,  and  two  doubtful  relapses,  having 
only  a  slight  bulging  at  the  site  of  the  hernia.  In  five  of  the 
relapsed  eases  the  sac  had  been  twisted  and  displaced,  but  the  canal 
had  not  been  sutured. 

In  only  two  liad  Bassini's  method  been  used  and  MacEwen's  method 
in  one  case.  It  is  interesting  to  note  that  seven  of  the  100  cases  had 
developed  some  other  hernia. 

Bull  and  Coley  (Med.Rec,  April  18,  1905)  publish  an  accountof  1076 
operations  on  children  after  Bassini's  method,  with  only  six  relapses, 
but  mention  five  relapses  in  125  operations  performed  about  1892  by 
other  methods. 

It  is  very  striking  to  notice  that  in  nearly  all  the  relapsed  cases  some 
suppuration  had  occurred,  and  this  is  no  doubt  the  main  cause  of  the 
relapse  ;  a  severe  cough  is  another,  especially  if  present  during  the  first 
few  weeks  after  the  operation. 

From  the  above  it  is  clear  that,  when  consulted  as  to  the  performance 
of  a  radical  cure  by  patients  the  subject  of  hernia,  they  can  be  assured 
as  to  the  safety  of  the  operation  and  the  probable  permanence  of  the 
cure  in  favourable  cases  (vide  supra).  In  the  practice  of  experienced 
and  aseptic  surgeons  the  mortality  ought  not  to  be  more  than  '5  per 
cent.,  and  the  recurrences  should  be  considerably  under  5  per  cent. 
Furthermore,  it  is  certain  that  if  a  relapse  should  occur  the  majority  of 
patients  will  be  better  off  than  before  the  operation.  The  protrusion 
that  appears  will  be  smaller  than  the  original  rupture,  more  readily 
kept  within  bounds  like  a  bubonocele,  and  a  truss  will  be  worn  with 
greater  comfort.  On  the  other  hand,  if  suppuration  occur,  and  a  thin- 
walled  feeble  cicatrix,  sure  to  yield  increasingly  as  years  go  on,  is  the  only 
result,  the  outcome  of  the  operation  may  leave  the  patient  worse  off 
than  he  was  before. 

A  question  that  often  arises  relates  to  the  wearing  of  a  truss  and  the 
possibility  of  the  hernia  being  cured  by  this  means  alone. 

The  answer  deciding  between  the  wearing  of  a  truss  and  an  operation 
for  radical  cure  will  depend  greatly  on  the  mind  of  the  surgeon  consulted. 
If  he  is  one  of  those  who  believe  that  this  operation  is  too  indiscrimi- 
nately resorted  to,  he  will  hold  that  no  operation,  save  for  special 
reasons  (vide  Indications  for  Operation),  is  to  be  advised  where  the 
hernia  can  be  kept  up  by  a  truss,  and  that  a  light  and  well-fitting 
truss  is  not  the  bugbear  it  is  too  often  made  out  to  be  by  those  who 
advocate  operation  as  the  rule.  It  would  be  well  if  surgeons  would 
spend  some  of  that  pain  and  trouble  in  ensuring  that  the  truss  fits, 
before  it  is  thrown  aside,  which  they  give  to  inventing  or  modifying 
operations  for  radical  cure,  and  if  patients  would  exert  a  little  more 
trouble  and  pains  in  getting  a  proper  and  well-fitting  truss  at  a  duly 
qualified  instrument-maker's,  instead  of  the  first  cheap  trash  which  they 
see  in  a  chemist's  shop.  I  have  pointed  out  below,  under  the  heading 
Indications  for  Operation,  the  cases  where  this  question  of  wearing  a 
truss  does  not  arise.* 

When    this    question,  whether  the  wearing  of  a  truss  will  effect  a 


*  An  ill-fitting  truss  is,  of  course,  worse   than  useless,  and  may  mat  together  the 
tissues. 

S. — VOL.  II.  5 


66  OPERATIONS  ON  THE  ABDOMEN. 

radical  cure,  arises  in  the  case  of  infants  and  children,  these  cases  may 
be  divided  into  the  following  groups.  In  one — and  this  is  the  largest  of 
the  three — the  careful  wearing  of  a  truss  by  a  child  will  permanently 
cure  the  rupture.  In  a  second  group — a  large  one — the  hernia,  though 
not  cured,  will  be  perfectly  controlled  with  very  slight  inconvenience  to 
the  patient.  In  the  third — a  small  one — there  is  no  tendency  to 
spontaneous  cure  even  when  a  suitable  truss  has  been  diligently  worn. 
Very  large  hernise,  and  especially  those  containing  the  caecum,  which 
may  be  irreducible,  belong  to  this  class.  With  the  very  small 
mortality  of  the  present  day  and  the  few  recurrences,  surgeons 
attached  to  children's  hospitals  operate  more  and  more  frequently. 
It  is  very  difficult  to  keep  the  children  of  the  poor  supplied  with  new 
trusses  often  enough  to  render  them  effectual.  If  the  truss  break  or 
be  left  off  and  the  hernia  descends,  the  work  of  years  is  undone,  and 
strangulation  may  occur  at  any  time.  Again,  a  number  of  patients 
supposed  to  have  been  cured  by  trusses  in  infancy  have  a  return  of 
their  trouble  in  adolescence,  or  early  manhood. 

Mr.  Hamilton  Russell  (Lancet,  vol.  i.  1905,  p.  7)  even  believes  that 
all  the  oblique  inguinal  hernias  of  adults  have  descended  into  congenital 
sacs.  We  agree  with  Mr.  Russell  that  a  large  majority  of  the  so-called 
acquired  hernias  of  adults  have  congenital  sacs  of  the  incomplete  or 
funicular  type,  but  we  do  still  believe  in  the  existence  of  acquired 
inguinal  hernia. 

Mr.  Murray  (Lancet,  vol.  i.  1906,  p.  363)  adduces  several  arguments 
in  support  of  Mr.  Russell's  views,  and  shows  that  in  100  autopsies 
potential  hernial  sacs  were  found  in  21  cases  ;  13  sacs  occurred  in  61 
males,  and  8  sacs  in  39  females. 

On  this  follows  naturally  the  next  question  :  (3)  What  is  the  earliest 
age  at  which  an  operation  should  be  performed  ?  Below  I  have 
stated  my  opinion  that  while  it  is  occasionally  justifiable  to  operate  in 
the  second  year  of  life,  where  a  persisting  hernia  is  large,  it  is,  as  a  rule, 
better  to  defer  operation  till  the  age  of  four  or  later. 

Bull  and  Coley  (Med.  Rec,  March  18,  1905)  operate  on  about  one 
in  ten  of  the  children  that  come  to  their  out-patients  seeking  treat- 
ment for  hernia,  but  they  rarely  operate  without  trying  a  truss  for  one 
or  two  years,  and  rarely  under  the  age  of  four  years.  They  advise 
operation  in  the  worst  of  the  cases  over  four.  They  also  perform  a 
radical  cure  in  all  cases  of  (1)  strangulated  hernia,  and  cases  of 
strangulated  hernia,  which  have  been  reduced  by  taxis  some  days 
before  ;  (2)  irreducible  hernia  rare  in  children ;  (3)  hydrocele  of  a 
hernial  sac  ;  (4)  the  rare  cases  of  femoral  hernia  in  children — they 
regard  these  as  incurable  b}7  truss. 

Stiles  (Brit.  Med.  Journ.,  Oct.  1,  1904)  gives  the  results  of  360 
operations  for  hernia  in  infants  and  young  children,  with  five  deaths 
and  only  four  recurrences. 

For  the  reasons  given  above,  surgeons  now  frequently  operate 
on  poor  children  under  the  age  of  four,  and  with  results  at  least 
as  satisfactory  as  those  obtained  in  older  children  and  adults. 

(4)  The  Advisability  or  Need  of  wearing  a  Truss  afterwards. — 
The  tendency  of  the  present  day  to  condemn  offhand  or  to  deprecate 
strongly  the  use  of  a  truss  after  an  operation  for  radical  cure  is,  I  think, 
a  great  mistake.     Each  case  must  be  judged  separately.     With  regard 


RADICAL   CURE   OF    HERNIA.  67 

to  children,  from  an  experience  of  my  cases,  I  think  that  if  the  recum- 
bent position  be  insisted  on  for  three  months  after  the  operation,  so  as 
to  give  the  newly  restored  parts  time  to  consolidate  firmly,  a  truss  will 
not  be  subsequently  required,  so  great  is  the  tendency  to  repair  in  early 
life.  Umbilical  hernia  I  am  inclined  to  make  an  exception.  The  nom- 
munication  which  has  here  been  closed  has  been  relatively  so  large,  the 
stress  thrown  upon  it  after  repair  in  expiratory  efforts  (as  when  the  child 
cries  every  time  at  the  approach  of  the  surgeon  or  dresser  during  the 
after-treatment)  is  so  direct,  that  the  scar  should,  I  think,  have  support 
for  some  time  in  the  form  of  a  well-fitting  belt.* 

In  adults  the  objection  usually  made  to  a  truss  is  that  its  pressure 
will  produce  absorption  of  the  scar.  While  it  will  be  granted  at  once 
that  any  continuous  pressure  in  the  form  of  a  pad  with  a  strong  spring 
will  tend  to  weaken  and  remove  the  inflammatory  thickening  resulting 
from  the  operation,  I  am  distinctly  of  opinion  that  some  well-fitting 
slight  support  in  the  form  of  a  flat-bladed  truss  or  belt  should  be  worn 
in  the  following  cases — viz.,  where  the  abdominal  walls  are  very  fat, 
flabby  and  pendulous ;  where  there  is  heavy  work  either  done  con- 
tinuously or  by  fits  and  starts;  where  any  silk  has  worked  out,  or 
where  the  wound  has  healed  by  suppuration  (vide  supra,  p.  65)  ;  in 
some  cases  where  the  radical  cure  has  been  done  after  an  operation  for 
the  relief  of  strangulation,  and  the  surgeon  has  perhaps  been  hurried, 
or  has  operated  at  night ;  and,  of  course,  in  cases  where  there  is  any 
return  of  the  hernia.  Other  cases  are  umbilical  herniee,  both  in  adults 
and  children,  for  the  reason  I  have  given  above  ;  in  some  cases  of 
femoral  hernia  in  which  the  crural  ring  has  been  very  large  and 
difficult  to  close  in  stout  patients ;  moreover  the  sex  and  dress  of 
the  patient  usually  make  the  wearing  of  a  truss  less  irksome.  On 
the  other  hand,  in  early  congenital  cases,  in  boys,  in  young  adults 
without  laborious  work,  or  where  the  reparative  power  is  good,  where 
sufficient  rest  has  been  taken  after  the  operation,  and  where  primary 
union  has  been  secured  and  remains  firm,  no  truss  need  be  worn. 
But  the  importance  of  intelligent  supervision  at  intervals  should  be 
insisted  upon. 

The  presence  of  a  cough,  carelessness  about  constipation,  or  a  stricture 
will,  of  course,  be  duly  weighed ;  and  I  may  remind  my  readers  of  a 
warning  uttered  at  p.  63,  that  relapse  may  take  place  as  late  as  four  or 
even  eight  years  after  a  skilfully  performed  operation. 

On  the  other  hand,  it  is  only  fair  to  say  that  the  opinion  on  this 
matter  expressed  by  others  is  widely  divergent  on  some  points  from  that 
given  above.  For  instance,  Drs.  Bull  and  Coley  (loc.  supra  cit.)  say: 
"  Personally  we  never  advise  a  truss  in  children  after  operation,  and  we 
consider  the  recumbent  position  for  three  months  entirely  unnecessary. 
Our  experience,  based  on  a  series  of  upwards  of  600  cases  of  hernia  in 
children  under  fourteen  years  of  age,  has  shown  that  two,  to  two  and  a 
half  weeks  is  ample  time  for  the  child  to  remain  in  bed.  The  subsequent 
history  of  these  cases  has  been  traced  with  scrupulous  care,  and  some  of 
them  have  been  well  upwards  of  seven  years.  Even  in  adults  we  very 
seldom  advise  a  truss  after  operation.  There  are,  however,  some  cases  in 
which  a  permanent  cure  will  be  more  likely  to  be  obtained  if  a  support 

*  Any  phimosis  or  cough  should,  of  course,  be  treated. 


68  OPERATIONS  ON  THE  ABDOMEN. 

be  worn  after  operation.  Such  cases  are  those  beyond  middle  age,  with 
poorly  developed  and  flabby  abdominal  muscles  and  a  superabundance 
of  fat.  We  would  also  include  cases  in  which  the  hernia  is  of  unusual 
size  in  adults  past  middle  life." 

Lockwood  (Hernia,  Hydrocele,  and  Varicocele) ,  again,  does  not  order 
a  truss  after  operation,  except  in  cases  in  which  some  support  is  specially 
called  for.  He  says  :  "  So  far  as  I  can  see,  it  is  time  enough  to  order  a 
truss  when  signs  of  recurrence  appear.  After  radical  cure  has  been 
done,  relapse  seldom  occurs  suddenl}'.  When  the  sac  has  been  thoroughly 
obliterated  by  the  operation,  the  hernial  protrusion  has  to  make  for  itsef 
a  new  one  ;  this  is  usually  a  slow  process  and  accompanied  by  pain  from 
the  beginning."  This  practice  is  clearly  justified  by  results,  for  Lock- 
wood's  list  of  cases  shows  only  five  relapses  in  ninety-one  cases,  in  periods 
varying  from  six  months  to  seven  years.  It  may  be  noted,  also,  that  in 
each  of  these  five  cases  the  relapse  occurred  within  twelve  months. 

(5)  The  Best  Form  of  Suture. — Surgeons  still  hold  different  views 
upon  this  point.  The  ideal  suture  should  be  aseptic,  absorbable, 
supple,  and  strong.  Silk  is  most  satisfactory  to  work  with  at  the 
time ;  it  can  be  obtained  at  once,  it  is  soon  sterilised,  it  is  strong,  and 
it  lends  itself  readily  to  easy  tying  and  a  secure  knot.  But  the  after- 
result  is,  in  my  opinion,  less  satisfactory,  owing  to  its  liability  to  come 
away,  often  persistently.  There  is  a  tendency  to  believe  and  teach 
that  wherever  silk  comes  away  after  an  operation,  it  must  always  be 
due  to  some  deficient  sterilisation  of  the  silk,  or  to  some  failure  to  keep 
the  wound  aseptic.  While  these  are  leading  causes,  they  are  not,  I  am 
persuaded,  the  only  ones ;  the  site  and  the  character  of  the  tissues 
•concerned  play  a  very  important  part.  Inside  the  peritonseal  cavity, 
where  the  ligature  lies  deep  and  is  surrounded  by  a  serous  membrane, 
as  in  an  ovarian  pedicle,  we  are  certain  our  silk  ligature  will  give  no 
trouble;  in  ligature  of  the  carotid  or  femoral  artery,  where  the  ligatui'e 
also  lies  deep  and  is  surrounded  b,y  vascular  structures,  we  have  rarely 
trouble  with  our  silk  ligatures ;  but  here,  where  any  silk  used  lies 
comparatively  superficially  and  embedded  in  fibrous  tissues  such  as  the 
conjoined  tendon  or  Poupart's  ligament,  its  surroundings  are  so  different 
that  a  surgeon  need  not  always  blame  himself  for  deficient  asepsis  or 
faulty  tying  when  his  silk  comes  away.  In  a  certain  and  large  propor- 
tion I  know  from  experience  that  silk  can  be  used,  but  in  a  considerable 
number  this  and  the  other  materials  most  certainly  cause  trouble  later 
on.  The  wound  runs  an  aseptic  course,  heals  without  sujDpuration,  and 
then,  after  a  varying  period,  up  to  several  years  sometimes,  a  sinus 
appears,  and  one  or  more  of  the  sutures  have  to  be  removed.  Drs. 
Bull  and  Coley,  in  the  papers  referred  to  above,  used  kangaroo-tendon 
chromicised  enough  to  resist  absorption  for  from  four  to  six  weeks,  and 
though  the  interval  between  the  date  of  operation  and  that  of  publication 
is  in  many  of  them  far  too  brief  for  the  cure  to  deserve,  in  my  opinion, 
the  term  "  radical,"  the  constancy  with  which  primary  union  was 
secured  speaks  very  strongly,  I  think,  for  the  use  of  kangaroo-tendon 
in  preference  to  silk.  Catgut  can  also  be  prepared  in  a  similar  way  and 
is  certainly  preferable  to  silk.  Hutchinson  (loc.  supra  cit.)  also  strongly 
recommends  kangaroo-tendon  because  it  is  strong,  supple,  and  non- 
irritating,  and  can  be  kept  for  years  without  deterioration  in  an  alcoholic 
solution  of  carbolic  acid. 


RADICAL   CURE   OF    EERNIA.  69 

Prof.  Macewen  in  his  address  on  Surgery  at  Oxford  (Lancet, 
Aug.  6,  1904),  discusses  the  advantages  and  disadvantages  of  the 
various  suture  materials  very  fully.    He  points  out  that  it  is  not  enough 

to  secure  an  aseptic  ligature,  but  that  it  is  necessary  to  select  one  thai 
is  absorbed  after  its  work  is  done  in  about  three  weeks.  He  also 
draws  attention  to  the  important  fact  that  non-absorbable  sutures  are 
incapable  of  holding  living  structures  together  for  more  than  a  few  weeks. 
"  After  a  period  of  twenty-one  days  the  continued  traction  of  the  suture 
causes  the  soft  tissues  to  give  way  before  it.  And  this  goes  on  until 
the  suture  lies  loose  and  functionless  in  their  midst."  The  tissues 
within  the  grip  of  permanent  sutures  of  silk,  wire  and  salmon-gut  become 
gradually  absorbed  even  without  any  suppuration,  and  this  clearly 
leaves  the  sutured  area  much  weaker  than  after  the  use  of  an  absorbable 
suture  like  catgut,  which  does  not  induce  nearly  so  much  of  this  quiet  and 
aseptic  necrosis  of  the  tissues  if  care  be  taken  not  to  tie  it  too  tightly. 

Macewen  strongly  condemns  the  use  of  wire  sutures,  and  relates  five 
cases  of  inguinal  hernia  in  which  gold  wire  had  been  employed  by  other 
surgeons.  Three  of  these  came  to  Macewen  for  recurrence  of  the 
hernia  and  the  two  others  for  strangulation  of  the  bowel  by  the  loops 
of  wire.  In  one  of  these,  perforation  of  the  bowel  had  already  occurred 
at  the  site  of  constriction  by  the  wire. 

Macewen  states  that  kangaroo-tendon  does  not  get  absorbed  for 
months,  and  Hutchinson  has  found  some  of  his  sutures  to  remain 
unabsorbed  for  over  two  years. 

Macewen  prefers  catgut  to  all  other  materials  for  sutures,  and  the 
following  remarks  are  quoted  from  his  address : 

"  Catgut  is  one  of  the  best  substances  generally  available  for  sutures 
and  ligatures,  but  care  ought  to  be  exercised  in  choosing  good  material. 
For  ligatures  and  sutures  raw  catgut  ought  to  be  selected,  preference 
being  given  to  such  specimens  as  present  the  best  physical  properties 
and  show  that  care  has  been  bestowed  on  its  manufacture.  It  must 
be  evident  that  the  subsequent  preparation  does  not  remedy  physical 
defects  originally  in  the  gut,  such  as  want  of  strength  or  roughness. 
When  the  catgut  is  selected  it  is  then  placed  in  a  solution  prepared  for 
the  purpose  of  increasing  the  resistance  offered  by  the  gut  to  the  action 
of  the  living  tissues.  As  the  resistance  required  varies  according  to 
the  use  to  which  the  catgut  is  to  be  put,  so  the  catgut  is  prepared  with 
various  degrees  of  resisting  power,  some  hanks  for  rapid  absorption 
and  some  capable  of  resisting  the  action  of  the  tissues  for  longer 
periods.  The  gut  must  not  be  hardened  in  such  a  manner  as  to 
prevent  leucocytal  penetration,  otherwise  it  will  be  too  resistant  and 
in  this  way  ma}r  be  no  better  than  silk  or  wire.  Experiments  have 
been  made  in  many  directions  with  the  view  of  obtaining  a  suitable 
medium  for  the  preparation  of  catgut  so  as  to  obtain  the  objects  in 
view.  One  of  the  best  media  which  we  have  used  is  obtained  by  adding 
an  aqueous  solution  of  chromic  acid  to  glycerine  in  definite  proportions. 
This  compound  is  found  to  act  upon  the  catgut  in  the  way  of  increasing 
its  resistance  to  the  action  of  the  living  tissue.  Though  producing  a 
soft,  pliable  catgut,  the  degree  of  resistance  imparted  to  the  gut  can 
be  varied  according  to  the  time  which  the  gut  is  immersed  in  the 
solution.  The  longer  it  is  kept  in  the  solution  the  more  resistant  it 
becomes.     After  it  has  thus  been  prepared  it  is  stored  in  a  carbolised 


70  OPERATIONS  ON  THE  ABDOMEN. 

glycerine  solution.  It  is  ready  for  use  a  fortnight  after  it  has  been 
introduced  into  the  storage  solution.  When  kept  in  this  storage  solu- 
tion for  a  longer  period — many  months  or  several  years — it  becomes 
slightly  more  resistant  to  the  tissues." 

It  seems  to  us  that  the  choice  lies  between  chromicised  catgut  and 
kangaro°-tendon.  The  latter  is  stronger  but  more  expensive.  Sup- 
puration, late  stitch  sinus,  and  recurrence  of  the  hernia  is  less  common 
with  these  materials  than  with  any  of  the  permanent  sutures. 

I  use  catgut  which  has  been  sterilised  by  boiling  in  xylol,  or  by  the 
action  of  iodine. 

WOUND    HEALING. 

The  mortality  and  the  relapses  after  radical  cure  of  hernia  depend 
more  upon  the  occurrence  of  suppuration  than  upon  anything  else,  there- 
fore it  is  of  the  utmost  importance  to  prevent  the  slightest  suppuration. 
With   modern  precautions  in  sterilising   sponges,   instruments   and 
sutures,  the  most  frequent  sources  of  infection  are  : 

(i)  The  Hands  of  the  Surgeon   and    his   assistants  ;    the  risk   of 
infection  from  these  can  be  greatly  diminished  by  the  wearing  of  boiled 
rubber  gloves  by  all  concerned.     It  must  not  be  forgotten,  however, 
that  the  gloves  may  be  easily  contaminated   in  putting  them  on  or  by 
touching  the  patient's  skin.     The  hands  must  be  cleansed  as  thoroughly 
as  possible  before  putting  the  gloves  on,  for  the  latter  maybe  accidentally 
pricked  during  the  operation  and  the  wound  thus  infected  from  the 
operator's  hand. 

Bull  and  Coley  (loc.  supra  cit.)  had  4*4  per  cent,  of  suppurations,  in 
567  early  cases  before  the  use  of  rubber  gloves,  and  only  2*1  per  cent, 
in  933  later  operations.     This  difference  is  no  doubt  partly  due  to  the 
increased  experience  of  the  two  operators,  and  also  to  improvements 
in  their  technique  in  other  respects,   such  as  reducing  laceration  and 
bruising  of  the  tissues  to  a  minimum.     The  danger  from  the  hands  can 
also  be  lessened  by   abstaining  from  all  handling  of  the  tissues,  and 
sponges,  and  doing  all  the  work,  even  the  tying  of  sutures  with  the  aid 
of  instruments.     Sutures  are  often  infected  by  forcibly  dragging  them 
into  the  skin  of  the  fingers  in  tying.     The  writer  has  had  no  suppuration 
in  any  case  in  which  he  and  his  assistants  have  worn  gloves  in  the  last 
two  years. 

(2)  The  Patient's  Skin. — That  this  risk  is  considerable  even  with 
much  care  in  scrubbing  and  compressing  is  evident  from  the  following 
facts:  Bull  and  Coley  (Med.  Rec,  Mar.  18,  1905)  : 

"  A  careful  bacteriological  examination  of  some  fragments  of  skin 
taken  from  the  field  of  operation  just  prior  to  the  making  of  the  incision 
was  made  by  Dr.  M.  Jeffries,  in  290  cases,  with  the  following  results  : 
Total  number  of  skin  cultures         ...  ...  ...   290 

Number  of  instances  in  which  growth  was  obtained     27 
Per  cent,  not  sterile ...  ...  ...  •••  ■•■       9'S1 

Streptococcus  obtained         7  times 

})  ,,  ...  ...  ...  ...       2*41  percent. 

,,  ,,         alone  4  times 

,,  and  a  diplococcus    ...  ...  ...        2 

„     „  tetrad  I 

Micrococcus  tetragenous      ...  ...  ..  ...      10 


WOUND    HEALING.  71 

A  diploeoccus  ...  ...  ...  ...  ...        6 

Tetrad  and  bacillus  ...         ...         ...         ...         ...       1 

Bacillus  alone  ...  ...  ...  ...  ...        2 

Staphylococcus  and  a  bacillus        ...         ...         ...       1." 

Suppuration  occurred  in  33  per  cent,  of  Bull  and  Coley's  cases,  that 
i>.  in  47  out  of  1,424  operations.  It  was  very  slight  and  superficial  in 
35  of  these. 

This  source  of  infection  can  be  minimised  by  fixing  aseptic  pieces 
of  lint  to  the  very  edges  of  the  wound,  so  that  none  of  the  patient's 
skin  is  exposed,  and  sutures,  sponges,  or  gloved  fingers  cannot  convey 
any  infective  scales  from  it  into  the  wound. 

If  the  above  precautions  be  taken,  and  all  bruising  be  avoided,  and 
all  haemorrhage  arrested,  the  risk  of  infection  becomes  very  small. 

Indications. — The  following  are  given  only  as  types  of  appropriate 
cases.     Many  others  will  suggest  themselves  : 

i.  Cases  of  irreducible  hernia  where  other  treatment  has  failed, 
where  an  active  life  is  interfered  with,  or  where  attacks  of  inflammation 
have  occurred,  or  strangulation  is  threatened.  Subjects  of  inguinal 
hernia  with  adherent  omentum  are  never  really  safe,  especially  if  of 
active  life  :  from  this,  however,  they  are  usually  debarred.  Femoral 
hernia?  containing  irreducible  omentum  should  also  be  operated  on. 
These  hernias  are  difficult  to  fit  with  trusses  ;  the  omentum  keeps  the 
ring  open,  and  thus  paves  the  way  for  the  descent  of  bowel  on  any 
sudden  exertion.  Where  irreducible  hernia?  are  small,  and  the 
adhesions  easily  separated,  great  relief  will  be  given  the  patient  with 
very  slight  risk.  But  it  is  otherwise  where  the  sac  is  very  large,  or 
the  contents  adherent,  especially  about  the  neck  of  the  sac.  In  either 
case  the  risk  of  the  operation  is  increased,  in  the  one  case  from 
the  direct  opening  into  the  peritonseal  cavity  which  may  be  present, 
the  large  amount  of  contents  which  have  to  be  manipulated,  and  the 
difficulty  of  keeping  the  operation  extra-peritonasal.  Again,  intricate 
adhesions  about  the  neck  of  the  sac  may  either  lead  the  surgeon  to 
abandon  the  operation,  or  to  lay  open  the  abdominal  wall  in  order  to 
deal  with  them.  This  last  step  may  bring  about,  some  time  later, 
a  hernia  very  difficult  of  control,  the  ultimate  improvement  in  the 
patient's  condition  being  thus  of  a  very  limited  nature.  The  risk  of 
peritonitis,  even  in  these  cases,  should  be  very  small  at  the  present  day. 
ii.  Cases  of  strangulated  hernia,  where  the  patient's  condition  admits 
of  the  operation  being  prolonged. 

iii.  Cases  where  a  hernia  is  not  controlled  by  a  truss,  but  slips 
beneath  it.  Such  cases  would  be  extremely  rare  if  patient  and  surgeon 
alike  showed  sufficient  pains  and  patience  in  securing  a  well-fitting 
truss. 

iv.  Cases  of  hernia  with  ectopia  testis  where  the  fitting  of  a  truss  to 
keep  the  hernia  up  and  the  testicle  down  fails.  Castration  should  always 
be  performed  when  the  condition  of  the  testis  is  useless  or  doubtful. 

v.  Cases  where  the  hernia  can  be  controlled  by  a  truss,  but  the  use 
of  this  is  irksome  to  a  patient  of  very  active  life,  where  he  wishes  to 
join  the  army  or  navy,  or  where  he  may,  as  a  colonist,  be  far  removed 
from  surgical  help. 

vi.  Children  of  poor,  ignorant,  and  incompetent  parents,  with  large 
hernia?,  where  proper  attention  to  the  use  of  a  truss  cannot  be  secured, 


72  OPERATIONS  ON  THE  ABDOMEN. 

or  where  the  persevering  use  of  this  has  failed,  and  where  all  such 
causes  as  phimosis,  cough,  &c,  have  been  removed.  It  will  probably 
be  justifiable  to  go  further  than  this,  and  to  operate  for  radical  cure  in 
most  cases  of  hernia?  in  the  children  of  the  poor  in  which  the  hernia 
is  still  large  at  four  to  six  years  of  age.*  By  this  time  the  parts  are 
better  developed  and  more  easily  kept  aseptic.  The  sac  is  more 
easily  dealt  with  now  than  later.  The  presence  of  any  conditions 
which  call  for  exploration — viz.,  hydrocele,  adherent  omentum,  the 
presence  of  the  appendix — will  also  be  indications  for  operation  in 
children.  On  this  point,  operation  for  radical  cure  in  little  children,! 
I  will  quote  Mr.  Macready  (loc.  supra  cit.,  p.  256).  We  may  all  envy 
his  special  experience  and  strive  to  imitate  his  skill.  "  Uncontrollable 
ruptures  in  children  under  fifteen  are  very  rare  ;  to  me,  indeed,  they 
are  as  yet  unknown.  I  hope  it  does  not  imply  any  lack  of  charity  to 
say  that  one  can  measure  with  fair  accuracy  a  surgeon's  skill  in  the 
management  of  trusses  by  the  number  of  curative  operations  he 
performs  on  children." 

vii.  Large  hernia?,  even  colossal,  where  the  patients,  unfitted  for 
work  of  any  kind,  are  a  burden  to  themselves  and  others,  J  and  perhaps 
willing  to  run  great  risks ;  for  it  cannot  be  denied  that  these  are  very 
grave  cases:  "The  operation  usually  difficult  and  prolonged,  and  the 
dangers  to  be  met  and  overcome  both  numerous  and  various" 
(Banks).  The  chief  of  these  is  the  direct  and  gaping  communication 
with  the  peritonaeal  cavity  and  the  difficulty  in  keeping  the  operation 
extra-peritonseal.  The  best  proof  of  this  is  given  by  Sir  W.  M.  Banks' 
series  of  sixteen  very  large  and  enormous  hernias ;  of  these  he  lost 
four,  two  from  septicemia.  In  another,  even  his  hands  failed  to 
complete  the  operation. 

viii.  I  consider  ten  to  twenty-five  years  of  age  the  most  favourable 
time,  as  combining  parts  easy  to  handle,  the  possibility  of  keeping  the 
wound  aseptic,  probable  absence  of  any  difficult  adhesions,  and  good 
vitality  and  health. 

INGUINAL    HERNIA. 

Choice  of  Operation.  —  The  following  have  been  brought 
prominently  before  the  profession,  viz. :  The  operations  of  Bassini, 
Kocher,  Halstead,  and  MacEwen.  Of  these,  a  modification  of  Bassini's 
operation  is  by  far  the  best  and  the  most  generally  suitable  operation. 

Before  describing  the  different  methods  mostly  in  vogue,  I  will 
allude,  for  the  sake  of  my  younger  readers,  to  a  few  points  which  are 
always  of  importance,  whichever  method  is  selected. 

The  thigh  being  a  little  flexed,  an  ample  incision  is  made  over  the 
inguinal  -canal,  and  extending  an  inch  below  the  external  abdominal 
ring.     This  divides  skin  and  fascia?  and  several  branches  of  the  external 

*  This  age  is  mentioned  above  as  giving  time  for  sufficient  trials  with  a  truss. 

-j-  Before  deciding  that  a  well-made  truss  will  not  keep  up  a  difficult  case — e.g.,&  double 
inguinal  hernia — the  hernia  should  be  completely  reduced  with  the  aid  of  an  anaesthetic. 

J  As  in  three  cases  given  by  Sir  W.  M.  Banks  :  one,  a  labourer,  unfitted  for  work,  had 
become  an  inmate  of  a  workhouse  ;  the  second  was  a  wine  merchant,  who  had  been 
obliged  to  give  up  his  business,  rarely  venturing  out,  and  then  obliged  to  conceal  his 
deformity  under  a  large  overcoat  ;  the  third,  a  glass-blower,  reduced  to  perfect  helpless- 
ness, had  to  depend  on  his  wife  for  his  support. 


RADICAL    CURE   OF    INGUINAL    HERNIA. 


73 


pudic  arteries  ;  these  should  be  secured  with  Spencer  Wells's  forceps, 
which  will  also  open  oul  the  wound.  In  young  males,  especially,  where 
these  vessi  Is  arc  of  considerable  size,  care  must  be  taken  that  eacli 
point  is  firmly  closed  cither  by  the  forci-pressure  or  catgut  ligature  ; 

otherwise  tree  bleeding  may  readily  take  place  in  the  lax  tissues  of  the 
groin,  preventing  primary  union,  and  perhaps  leading  to  most  trouble- 
some tension  and  suppuration.  The  aponeurosis  of  the  external 
oblique  and  the  cremasteric  fascia  having  been  next  divided,  the  site  of 
the  cord  is  made  certain  of,  and  the  sac  most  carefully  defined.  This, 
if  empty,  is  by  no  means  always  easy,  especially  in  young  subjects.  In 
denning  the  sac,  care  should  be  taken  to  work  carefully  and  without 
any  needless  disturbance  of  the  parts,  or  separation  of  the  planes  of 
tissue  here  met  with.  So,  too,  with  the  cord — great  care  must  be 
taken  in  the  next  step,  when  the  sac  and  this  structure  are  separated ; 


Fig 


Fig.  12. 


A  normal  inguinal  canal.  Arciform 
fibres  compressing  the  cord  against  Pou- 
part:s  ligament.     (Lockwood.) 


Inguinal  canal  in  case  of  hernia.  The 
arciform  fibres  are  displaced  upwards,  the 
normal  valvular  condition  of  the  canal 
being  thereby  destroyed.     (Lockwood.) 


hasty  work  may  lead  to  needless  haemorrhage  from  ruptured  veins, 
injury  to  the  sac,  or  subsequent  epididymo-orchitis.  The  sac  having 
been  accurately  denned,  is  opened  so  that  the  operator  may  make  sure 
that  it  is  empty ;  otherwise  any  intestine  is  completely  reduced  or 
omentum  dealt  with  according  to  the  steps  given  at  p.  44.  If  the 
question  arise,  whether  the  sac  should  always  be  opened,  I  sheuld 
answrer  "  Yes."  Even  if  it  appear  empty  below,  it  is  satisfactory  to 
be  assured  by  visual  examination  that  nothing  lies  within  the  neck 
before  this  is  twisted  or  tied  as  high  up  as  possible.  A  case  of  Busch's 
(Klin.  Med.  Woch.,  1882,  No.  31,  p.  473)  shows  the  importance  of 
taking  this  step. 

Operating  on  a  boy  i\  years  old  for  a  right  inguinal  hernia,  Busch  tied  the  sac  before 
opening  it.  "When  it  was  cut  into  below  the  ligature  the  vermiform  appendix  was  found 
included.  This  was  released  and  returned.  Some  time  later  Busch  was  operating  on  the  left 
side,  and  again  found  that  he  had  included  the  appendix  in  his  ligature  round  the  sac. 

Hernias  with  Unusual  Contents. — These  may  be  (a)  Fat  hernias. 
Both  in  the  inguinal  and  femoral   regions,  but  especially  in  the  latter, 


74  OPERATIONS  ON  THE  ABDOMEN. 

the  extra-peritonaeal  tissue  near  the  rings  may  become  increasingly 
fatty.  Gradually  projecting  towards  the  surface,  it  drags  down  the 
peritonaeum  to  which  it  is  loosely  connected.  I  have  operated  on  one 
such  case  in  a  girl,  aged  19,  in  whom  the  fitting  of  a  truss  was  unsatis- 
factory. Here  I  expected  to  find  an  omental  hernia.  Into  the  pouch 
so  formed  intestine  or  omentum  may  protrude.  In  other  cases,  if  the 
extra-peri tonaeal  fat  thus  protruded  become  absorbed,  the  hollow 
thus  left  may  produce  a  space  for  the  peritonaeum  to  project  into. 
(/?)  Hernia  of  the  ovary.  This  is  much  more  commonly  met  with  in 
inguinal  herniae.  The  chief  points  in  the  diagnosis  of  these  difficult 
cases  are  the  characteristic  oval  shape  and  size  of  the  swelling ;  the 
peculiar  sickening  pain  when  the  swelling  is  pressed  upon  ;  the  swelling 
being  larger  and  the  tenderness  greater  during  menstruation ;  the 
swelling  may  sometimes  be  made  to  move  when  the  uterus  is  displaced 
laterally  with  a  vulsellum,  and  the  ovary  of  that  side  is  not  to  be  made 
out  per  vaginam.  Where  other  treatment  has  failed,  where  the  swelling 
is  irreducible  and  prevents  the  fitting  of  a  truss,  where  the  symptoms 
are  sufficiently  urgent  to  cripple  a  young  life,  the  displaced  ovary 
should  be  removed.  The  operation  should  be  rigidly  aseptic.  Adhesions 
are  not  uncommon.      (7)   Hernia  of  vermiform  appendix. 

I  met  with  a  case  of  this  early  in  1890,  in  a  lady,  aged  43,  a  patient  of  Dr.  Eraser's, 
of  Romford.  The  femoral  hernia  was  here  irreducible,  dull,  gave  a  feel  of  omentum, 
and  curved  upwards  and  outwards  in  the  usual  way.  As  no  truss  was  satisfactory,  and 
as  the  patient,  the  wife  of  a  missionary,  was  to  be  much  abroad,  a  radical  cure  was 
advised.  The  sac  contained  much  fluid,  but  no  omentum.  In  the  outer  part  of  the 
hernia  lay  a  thick  fleshy  body,  tubular  and  expanded  at  its  end.  Near  Gimbernat's 
ligament  it  was  constricted  and  distinctly  abraded.  After  notching  the  above  ligament 
this  body,  which  proved  to  be  the  appendix,  was  easily  returned.  The  sac  was  removed. 
The  case  did  excellently. 

In  another  case  I  should  remove  the  appendix  if  there  were  time  for 
making  the  necessary  suturing  secure.  (S)  Hernia  of  the  bladder. 
The  viscus  may  descend  either  partly  or  completely  covered  by  peri- 
tonaeum ;  in  the  first  and  commonest  form  the  bladder  majr  not  be 
recognised  until  it  is  wounded,  or  even  until  collapse  develops,  and 
haematuria  is  discovered  some  hours  later.  I  know  of  two  cases  in 
which  this  accident  occurred  during  the  radical  cure  of  femoral  hernia, 
and  one  of  the  patients  died.  The  bladder  protrudes  most  frequently 
into  an  inguinal  hernia. 

When  the  emptied  sac  is  next  separated  from  the  cord  and  adjacent 
parts,*  care  must  be  taken,  if  the  patient  strain  at  this  time,  that  no 
escape  of  intestine  occur,  an  assistant  maintaining  pressure  over  the 
internal  ring.  The  cord  must  be  treated  with  the  precautions  given 
above,  and  care  must  be  taken  that  the  testicle  is  not  dragged  need- 
lessly out  of  its  bed.  The  sac  is  now  treated,  and  the  canal  closed  by 
one  of  the  methods  given  in  detail  below.  The  wound  having  been 
thoroughly  dried  out,  it  is  closed  with  sutures  of  salmon-gut  or  horse- 
hair, care  being  taken  that  no  inversion  of  the  edges  is  present,  and,  of 
far  more  importance,  that  all  haemorrhage  has  been  entirely  stopped, 
including  those  points  from  which  Spencer  Wells's  forceps  have  been 
removed.     If  absolute  dryness  of  the   wound  has   been  secured,  and 

*  If  much  difficulty  is  met  with  here,  the  surgeon  should  begin  high  up,  as  near  the 
internal  ring  as  possible. 


RADICAL    CURE    OF    INGUINAL    BERNIA. 


75 


Fig. 


the  operation  lias  been  aseptic  throughout,  no  drainage  is  needed. 
Some  strips  of  aseptic  cyanide  gauze  are  then  placed  next  the  wound, 
and  covered  by  any  of  the  antiseptic  gauzes  or  wools.  In  applying 
the  bandages,  it  is  important  to  keep  the  scrotum  well  up  on  the 
pubes,  and  thus  to  minimise  the  risks  of  oedema  of  the  scrotum  and 
epididymo-orchitis. 

To  the  above  general  remarks  I  have  only  to  add  that  it  is  always 
well,  when  the  radical  cure  is  performed  in  patients  with  long-standing 
hernia  (with  important  parts  and  the  sac  perhaps  very  adherent),  or  a 
voluminous  one,  for  the  operator  to  obtain  leave  beforehand  to  sacrifice 
the  testicle  ;  and  the  same  course  will  be  taken  when  a  retained  testicle 
is  found  to  be  probably  functionless.  If  it  is  worth  while  to  fix  this 
again  in  the  scrotum,  this  should  be 
done  according  to  the  steps  given 
under  the  heading  of  Orchidopexy. 

Any  child  or  restless  patient  should 
be  secured  in  a  long  outside  splint. 

The  different  methods  that  have 
been  elaborated  are  very  numerous, 
and  only  those  which  are  chiefly  in 
vogue  at  the  present  time  can  be 
described  here  in  full.  Brief  mention 
will,  however,  be  made  of  some  of  the 
others.  It  will  be  seen,  if  these  vari- 
ous methods  be  compared  with  one 
another,  that,  whereas  most  of  them 
are  alike  in  aiming  at  reconstituting, 
in  some  degree,  the  original  valvular 
condition  of  the  inguinal  canal,  on  the 
other  hand,  they  differ  chiefly  as  regards  the  method  of  dealing  with 
the  hernial  sac. 

Taking  the  latter  point  first,  it  will  be  seen  that  the  various  special 
methods  that  have  been  devised  for  dealing  with  the  sac  aim  chiefly  at 
converting  the  normal  depression,  or  peritonseal  fossa,  at  the  position 
of  the  internal  abdominal  ring,  into  a  prominence  with  its  convexity 
towards  the  abdominal  cavity.  Even  if  the  operation  does  succeed  in 
attaining  this,  it  must  surely  be  only  temporary,  for,  clearly,  the  sac 
will  rapidly  shrink  and  undergo  partial  absorption.  Moreover,  since 
there  is  normally  a  slight  depression  in  this  position,  and  since  only  a 
very  small  proportion  of  all  individuals  suffer  from  inguinal  hernia,  it 
is  clear  that  the  removal  of  the  depression  at  the  site  of  the  internal 
abdominal  ring  is  not  to  be  looked  upon  as  the  most  important  part 
of  an  operation  for  the  radical  cure  of  a  hernia.  This  contention  is 
borne  out  by  the  results  of  operation,  for  in  Bassini's  operation,  which 
is  so  successful  as  to  be  almost  considered  perfect  (vide  p.  64  for  results), 
the  sac  is  simply  ligatured  at  its  neck,  and  the  rest  removed,  leaving, 
therefore,  a  depression  in  the  peritonseum  opposite  the  ligature.  With 
regard  to  the  question  of  the  inguinal  canal,  it  is  clear  that  the  normal 
valvular  arrangement  (vide  Fig.  11)  of  the  canal  is  extremely  satisfactory 
in  preventing  the  descent  of  an  inguinal  hernia,  since  such  a  very  small 
proportion  of  all  individuals  suffer  from  this  condition.  This  would 
lead  one  to  expect  that  that  operation  which  most  satisfactorily  and 


Bassini's  operation.  Showing  the 
method  of  inserting  the  deep  sutures. 
(Lock  wood.) 


76 


OPERATIONS  ON  THE  ABDOMEN. 


simply  reconstitutes  the  original  condition  of  the  inguinal  canal  will 
be  attended  with  the  most  satisfactory  results.  Bassini's  operation 
practically  does  reconstitute  the  normal  inguinal  canal,  and  moreover 
justifies  the  above  argument,  since  the  results  are  so  satisfactory  and 
'its  adoption  is  so  widespread.  Other  advantages  of  Bassini's  method 
are,  that  it  is  easy  and  straightforward  to  perform,  and  that  the  whole 
length  of  the  canal  is  exposed  to  view,  thus  allowing  (as  pointed  out  by 

Fig.  14. 


External 
oblique. 


Large 
Cremaster. 


External 
oblique. 


Scudder's  modification  of  Bassini's  operation.     Sewing  the  neck  of  the  sac,  a 
retractor  being  used  to  expose  it  well.     (Ann.  oj  Surg.) 

Lockwood)  the  removal  of  any  conditions  which  may  be  liable  to 
distend  the  inguinal  canal,  such  as  lipomata  of  the  cord  or  inguinal 
varicoceles.     For  these  reasons  Bassini's  operation  will  be  described 

(1.)  Bassini's  Method  (Fig.  13).— An  oblique  incision,  at  least  four 
inches  long  in  an  adult,  somewhat  less  in  a  child,  is  made  over  the 
position  of  the  inguinal  canal,  and  ending  below  opposite  the  pubic 
crest.  The  fascia  having  been  divided,  the  external  oblique  aponeurosis 
is  exposed  and  the  external  abdominal  ring  identified.     The  external 


RADICAL   CURE   OF    INGUINAL    HERNIA. 


77 


oblique  is  now  divided  along  the  length  of  the  canal,  and  flaps 
separated  in  both  directions  for  a  short  distance,  thus  thoroughly 
exposing  the  whole  length  of  the  inguinal  canal.  In  small  hernia;  it 
is  not  necessary  to  carry  the  incision  in  the  external  oblique  into  the 
external  ring,  and  as  this  is  difficult  to  reform  accurately,  the  ring  is 
best  saved  in  these  cases.  The  cremasteric  fascia  and  the  thin  infundi- 
buliform  fascia  are  then  divided.  The  sac  is  now  identified  and  care- 
fully separated  from  the  cord  well  up  to  and  an  inch   above  the  level 

Fig.  15. 


Interna 
oblique 


Poupart's 
ligament. 


Cord. 


Creniaster. 


Scudder's  modification  of  Bassini's  operation.     Note  method  of  passing  sutures, 
especially  those  above  and  external  to  the  cord.     {Ann.  of  Surg. .) 


of  the  internal  ring.  It  is  then  opened  and  carefully  emptied,  all 
adhesions  being  carefully  separated,  and  omentum  either  ligatured  and 
removed  or  reduced.  The  neck  of  the  sac  having  been  somewhat  pulled 
down,  is  transfixed  and  ligatured  with  silk  or  kangaroo-tendon  at  the 
highest  possible  point,  then  divided  about  half  an  inch  below  the 
ligature,  and  the  rest  of  the  sac  removed.  Next,  the  cord  is  raised 
carefully  from  its  bed,  and,  supported  in  a  loop  of  gauze,  is  held  forward 
by  an  assistant  while  the  sutures  are  introduced.  At  this  stage  an}r 
lipomata  of   the  cord  or    an    inguinal  varicocele    may  be  removed,  as 


78 


OPERATIONS^  ON    THE 


ABDOMEN. 


advised  by  Lockwood.  The  posterior  wall  of  the  inguinal  canal  is  now 
repaired  by  means  of  sutures.  These  will  vary  in  number  from  four  to 
six,  according  to  the  size  of  the  gap  between  the  internal  oblique  or 
conjoined  tendon  on  the  one  hand,  and  Poupart's  ligament  on  the 
other  (vide  Fig.  13).  These  sutures  consist  either  of  kangaroo-tendon, 
chromicised  catgut,  or  silk,  and  are  passed  in  the  following  manner : — 
The  needle  is  first  passed  through  the  deep  aspect  of  Poupart's  liga- 

FlG.   16. 


Poupart's 
ligament. 

External 
oblique. 


Cord. 


Cremaster. 


Scudder's  modification  of  Bassini's  operation.     Sutures  above  and  below  the  cord 
tied  except  two.     (Ann.  of  Surg.') 


ment,  then  beneath  the  uplifted  cord,  and  finally  through  the  lower 
margin  of  the  internal  oblique  or  conjoined  tendon.  In  order  to  avoid 
wounding  the  peritonaeum,  the  needle  is  passed  through  the  conjoined 
tendon  from  its  deep  to  its  superficial  aspect  (vide  Fig.  13).  Sufficient 
sutures  having  been  passed,  they  are  tied  carefully  and  cut  short,  and 
the  cord  allowed  to  fall  back  into  its  place.  The  divided  edges  of  the 
external  oblique  are  now  united  by  means  of  a  fine  continuous  suture, 
and  the  external  ring,  if  large,  partially  closed  at  the  same  time.     All 


RADICAL    CURE    OF    INGUINAL    HERNIA. 


79 


bleeding  having  been  carefully  arrested,  the  skin  is  sutured  and  the 
dressings  applied. 

Scudder  (Ann.  of  Sun/.,  vol.  41,  1905,  p.  76),  modifies  Bassini's 
operation  in  several  respects  : — 

(a)  He  sutures  the  peritonaeum  above  the  neck  of  the  sac,  instead  of 
ligaturing  it  (vide  Fig.  14). 

(b)  He  also  places  a  couple  of  sutures  to  strengthen  the  attachment 
of  the  internal  oblique  to  Poupart's  ligament  above  and  outside  the 
cord.  Bull  and  Coley  also  use  this  improvement  to  prevent  recurrence 
at  this  likely  spot  (ride  Fig.  16). 

(c)  Scudder's  method  of  passing  his  sutures  is  also  an  improvement 
on  Bassini's  operation  (vide  Fig.  15). 

(d)  He  also  overlaps  the  fibres  of  the  external  oblique.     I  practise 


Fig.  17. 


Fig.  18. 


Kocher's  operation  by  lateral 
transposition  of  the  sac.  The  for- 
ceps, introduced  along  the  inguinal 
canal,  are  grasping  the  sac  at  the 
lower  end. 


Kocher's  operation  by  lateral  transposi- 
tion of  the  sac.  The  sac  is  drawn  out 
through  a  small  opening  in  the  internal 
oblique  muscle  and  the  external  oblique 
aponeurosis  ;  it  is  then  cut  off  and  its 
stump  is  fixed  by  suture. 


and  recommend  these  improvements  except  the  first,  which  I  only 
employ  for  sacs  with  wide  necks. 

Kocher's  Operations  (Kocher,  Operative  Surgery,  1903.  Translation 
by  Stiles). — Professor  Kocher  has  wisely  abandoned  his  earlier  method 
of  treating  the  sac  by  torsion,  and  drawing  it  out  through  the  external 
oblique  aponeurosis  and  fixing  it  as  a  buttress  along  the  anterior  wall 
of  the  inguinal  canal ;  the  sac  often  sloughed  after  being  treated  in 
this  way. 

Kocher  now  uses  two  simpler  and  less  dangerous  methods  of  dealing 
with  the  neck  of  the  sac. 

(a)  The  lateral  transposition  method. — The  external  oblique  aponeu- 
rosis, the  external  ring,  and  the  sac  are  exposed  in  the  usual  way,  but 
the  external  oblique  is  not  incised.  The  sac  is  completely  isolated  and 
emptied.     "  A   small    opening  is  made  in  the   strong  portion  of  the 


8o 


OPERATIONS  ON  THE  ABDOMEN. 


external  oblique  above  and  external  to  tbe  middle  of  Poupart's  liga- 
ment (above  and  external  to  tbe  region  of  tbe  internal  abdominal  ring), 
and  a  special  pair  of  curved  dressing-forceps  is  pushed  through  it,  i.e., 
through  tbe  aponeurosis  of  the  external  oblique  and  tbe  muscular  fibres 
of  tbe  internal  oblique,  and  along  tbe  canal  in  front  of  the  spermatic 
cord  to  emerge  at  tbe  external  ring,  where  they  are  made  to  seize  the 
fundus  of  tbe  isolated  hernial  sac,  which  is  drawn  from  below  upwards 
and  outwards  along  the  canal  and  through  the  small  opening  above 
mentioned.  Traction  is  now  made  on  the  sac,  so  that,  instead  of 
running  downwards  and  inwards  along  the  cord,  it  is  pulled  in  an  out- 

Fig.  19. 


rifconeun^ 
Transversalis  fascia 


Int.  oblique  muscle 

h  Transversalis 

Aponeurosis  of 

Ext.  oblicrue 


^cMP\b 


^v 


^1;  vK:- 


Invaginated • 
hernial    sac 


Sections  to  illustrate  Kocher's  second  method  of  treating  the  sac  by  invagination. 


ward  direction  from  the  internal  abdominal  ring,  and  tbe  funnel-shaped 
opening  at  the  neck  of  the  sac  is  drawn  well  into  the  small  opening  in 
the  abdominal  wall.  Tbe  portion  of  the  sac  which  is  brought  through 
the  opening  is  now  transfixed  and  stitched  to  the  adjacent  part  of  the 
abdominal  wall  by  a  silk  suture.  The  sac  is  cut  oft'.  It  is  still  better 
to  compress  the  sac  with  a  narrow  pair  of  pressure-forceps  and  then  to 
ligature  it.  A  very  small  stump  is  thus  obtained,  which  can  be  cut  off 
fairly  close  to  the  ligature.  The  narrow  stump  is  pushed  back  through 
the  fascia,  and  a  needle  is  passed  through  the  two  sides  of  the  opening 
in  the  fascia  and  through  tbe  stump,  by  which  means  the  stump  is 
stitched  to  the  small  opening  in  tbe  fascia,  and  tbe  latter  is  closed 
simultaneously.  The  peritonaeum  is  thus  stretched  in  a  lateral  direc- 
tion, and  the  descent  of  a  sac  in  the  direction  of  tbe  cord  is  rendered 
impossible  "  (vide  Figs.  17  and  18). 


RADICAL   CURE    OF    INGUINAL    BERNIA.  81 

(2.)  Transposition  by  invagination. — The  sac  is  exposed  and  isolated 
at  the  external  ring  as  ahove,  and  freed  as  high  up  in  the  canal  as 
possible.  "The  unopened  sac  is  now  seized  at  its  apex  with  long, 
narrow,  curved  forceps  and  invaginated  backwards  through  the  inguinal 

canal  up  into  the  abdominal  cavity.  The  point  of  the  forceps  is  then 
forced  against  the  abdominal  wall,  which  is  made  to  project  just  external 
to  the  internal  abdominal  ring."  A  small  incision  is  then  made  through 
the  abdominal  muscles  overlying  the  point  of  the  forceps.  The  parietal 
peritonamm  and  the  hernial  sac  are  then  pushed  outwards  through  the 
incision.  The  parietal  peritonaeum  is  incised,  and  the  edges  prevented 
from  retracting  into  the  abdomen.  "  The  whole  length  of  the  invagi- 
nated sac  is  forcibly  pulled  out ;  the  empty  forceps  in  the  inguinal  canal 
are  withdrawn  at  the  same  time.  ..."  "  The  base  of  the  sac  is 
crushed  with  a  pair  of  pressure  forceps  transfixed  with  a  silk  suture, 
and  the  two  halves  together  with  the  parietal  peritonaeum  are  tied. 
The  sac  is  cut  off  close  to  the  ligatures,  the  stump  pushed  back  under 
the  fascia  and  the  same  silk  suture  is  used  to  close  the  opening  in  the 
aponeurosis  of  the  external  oblique  (vide,  Fig.  19)." 

Kocher  completes  each  of  the  above  operations  thus  : — A  row  of 
deep  sutures,  including  the  aponeurosis  of  the  external  oblique  muscle 
and  the  muscular  fibres  of  the  internal  oblique,  is  then  inserted  in 
order  to  strengthen  and  narrow  the  inguinal  canal  in  its  whole  length. 

Prof.  Kocher  claims  that  "  this  extremely  simple  method,  besides 
causing  very  little  injury  to  the  tissues,  is  more  effective  in  entirely 
reducing  the  hernial  protrusion  than  any  other,  because  the  peritonaeum 
from  the  neighbourhood  of  the  internal  abdominal  ring  is  drawn  out 
and  firmly  fixed  in  the  opposite  direction  to  the  course  of  the  spermatic 
cord,  i.e.,  it  is  maintained  stretched  in  an  outward  direction. 

"  At  autopsies  performed  at  longer  or  shorter  intervals  after  the  opera- 
tion, we  have  had  the  opportunity  of  seeing  the  results  of  this  pro- 
cedure. On  the  peritonseal  aspect  at  the  spot  where  the  sac  was  drawn 
through  a  fine  circular  peritonseal  cicatrix  is  seen  as  a  prominence  with 
two  shallow  recesses  above  and  below  it.  The  parietal  peritonaeum  on 
the  mesial  aspect  is  raised  in  slight  folds  about  2  to  3  mm.  in  height. 
There  is  no  sign  of  any  invagination  into  the  inguinal  canal." 

However  perfectly  the  funnel  at  the  neck  of  the  sac  may  be  obliterated 
by  Kocher's  method,  we  do  not  like  his  way  of  narrowing  the  inguinal 
canal,  for  the  cord  is  not  dislocated  outwards,  so  as  to  lengthen  the 
inguinal  canal  and  make  it  more  oblique  and  valvular.  The  deep 
sutures  are  passed  somewhat  in  the  dark  as  regards  the  cord,  and  we 
prefer  to  open  the  canal  to  obtain  a  good  view  of  the  parts  to  be  sewn 
together.  In  women  and  girls  it  has  been  shown  that  transposition  of 
the  comparatively  small  round  ligament  is  not  essential,  therefore 
Kocher's  method  may  be  found  useful  in  them  ;  and  in  some  cases  of 
strangulated  hernia,  where  time  may  be  precious,  this  rapid  way  of 
performing  a  radical  cure  may  be  employed  with  advantage. 

We  prefer  to  use  catgut  or  kangaroo-tendon  for  all  the  deep  sutures 
for  the  reasons  above  given.  When  silk  is  used,  the  ligature  which  is 
employed  to  tie  and  fix  the  neck  of  the  sac  is  apt  to  cause  an  early  or 
late  stitch  sinus,  because  it  has  too  much  tissue  within  its  grasp. 

Kocher's  treatment  of  the  sac  is  not  so  simple  as  simple  suture  or 
high  ligation,  which  can  be  practised  when  the  canal  is  opened.     The 

s. — vol.  11.  6 


82 


OPERATIONS  ON  THE  ABDOMEN. 


thin  sacs  of  children  and  some  adults  cannot  be  treated  by  invagination 
without  considerable  risk  of  laceration  of  the  neck. 

Very  thick  inelastic  sacs  and  those  with  adherent  contents  are  also 
unsuitable  for  this  operation. 

Lebensohn  found  4  relapses  in  1 1 1  of  Kocher's  earlier  cases  in  which 
the  method  of  lateral  transposition  had  been  used  ;  "  Hirschkopf  found 
not  a  single  relapse  in  42  cases."     No  mention  is  made  of  the  time  of 

observation  of  these  cases,  so 
FlG-  2°-  that  it  is  difficult  to  estimate 

the  value  of  the  figures. 

(3.)  Mace  wen's  Operation* 
(Figs.  20  to  26). 

The  object  of  this  is  two- 
fold :  (1)  So  thoroughly  to 
separate  the  sac  as  to  allow  of 
its  being  completely  reduced 
into  the  abdominal  cavity, 
there  to  rest  on  the  inner  sur- 
face of  the  ring,  and  acting  as 
a  bulwark-like  pad  to  "  shed 
the  intestinal  waves  away" 
from  it.  Prof.  Macewen  thinks 
that  if  the  sac  be  merely  tied, 
however  carefully  and  high  up 
this  is  done,  there  remains  a 
funnel-shaped  puckering,  the 
apex  of  which  presents  in  the 
internal  ring,  and  that  this 
pouch  gradually  becomes  a 
wedge,  tending  to  open  up  the 
canal. 

Thorough  separation  of  the 
sac,  and  carrying  this  well 
within  the  peritonasal  cavity,  is 
absolutely  needful,  for  if  the 
sac  be  left  in  the  canal  it  will 
act  as  a  plug,  keeping  it  open. 
(2)  Again,  to  close  the  dilated 
canal  and  restore  its  natural  valve-like  condition  by  a  particular  mode 
of  inserting  sutures  which  bring  the  conjoined  tendon  in  close  apposi- 
tion with  PoujDart's  ligament,  beginning  with  that  part  of  the  ligament 
which  is  on  a  level  with  the  lowest  part  of  the  internal  ring. 

The  first  object  is  thus  ensured  : — The  external  ring  having  been 
exposed,  the  internal  ring  and  site  of  the  deep  epigastric  are  examined, 
and  the  sac  next  freed  and  raised.  When  this  has  been  done  it  is  kept 
pulled  down  while  the  index-finger  separates  the  sac  from  the  cord,  the 
canal,  and  finally  for  half  an  inch  around  the  abdominal  aspect  of  the 
internal  ringt  (Fig.  20).     The  sac  is  now  folded  on  itself  (Figs.  21,  22) 


Macewens  operation.  The  index  finger,  in- 
serted along  the  inguinal  canal,  is  separating 
the  peritonaeum  from  the  internal  aspect  of  the 
internal  ring.  The  folded  sac  is  behind.  In 
this  and  the  following  figures  a  flap  of  skin 
and  cellular  tissue  has  been  reflected,  and  the 
external  oblique  opened  up  so  as  to  expose  the 
canal  and  internal  ring. 


*  Ann.  of  Surg.,  Aug.  1886  ;  Brit.  Med.  Journ.,  Dec.  10,  1887. 

f  The  object  of  this  is  to  refresh  the  abdominal  aspect  of  the  internal  ring  so  that 
adhesions  may  form  between  it  and  the  pad  of  sac, 


RADICAL    <TKK    OF    INGUINAL    HERNIA 


83 


Flu.   21. 


by  means  of  a  stitcli  which  is  firmly  fixed  in  the  distal  end  of  the  sac. 
The  free  end,  threaded  on  a  hernia-needle  (Fig.  21),  is  introduced 
through  the  canal  to  the  abdominal  aspect  of  the  fascia  transversalis, 
and  there  penetrates  the  abdominal  wall  about  an  inch  above  the 
internal  ring  (Fig.  22).  The  wound  in  the  skin  is  pulled  upwards,* 
so  as  to  allow  the  point  of  the  needle  to  project  through  the  muscles 
without  penetrating  the  skin.  The  needle  being  withdrawn  and  un- 
threaded, by  traction  on  the 
thread  the  folded  sac  is 
drawn  still  further  back- 
wards and  upwards.  Trac- 
tion having  been  kept  up  on 
the  thread  while  the  sutures 
closing  the  canal  are  intro- 
duced, it  is  finally  secured 
by  passing  it  several  times 
through  the  external  oblique 
muscle. 

The  second  part  of  the 
operation,  closure  of  the  in- 
guinal canal,  is  now  under- 
taken. The  finger,  passed 
into  the  canal  and  lying 
between  the  inner  and  lower 
border  of  the  internal  ring 
in  front  of  and  above  the 
cord,  makes  out  the  position 
of  the  deep  epigastric  artery 
so  as  to  avoid  it. 

The  hernia-needle,  carry- 
ing chromic  gut,  then,  guided 
by  the  index,  is  made  to 
penetrate  the  conjoined  ten- 
don in  two  places  :  first, 
from  without  inwards  near 
the  lower  border  of  the  con- 
joined tendon  ;  and  secondly, 
from  within  outwards,  as  high  up  as  possible  in  the  inner  aspect  of  the 
canal :  this  double  penetration  of  the  conjoined  tendon  being  accom- 
plished by  a  single  screw-like  turn  of  the  instrument  (Fig.  23).  One  end 
of  the  suture  is  then  withdrawn,  and  the  needle,  with  the  other  end,  is 
removed.  Thus,  a  loop  is  left  on  the  abdominal  aspect  of  the  conjoined 
tendon,  which  is  penetrated  twice  (Fig.  24). 

Secondly,  the  other  hernia-needle,  threaded  with  that  part  of  the 


Mace  wen's  operation.  The  hernia-needle  is 
carrying  the  suture,  threaded  through  the  sac, 
through  the  abdominal  muscles,  from  behind  for- 
ward, about  an  inch  above  the  internal  ring. 


*  Beginners  will  find  it  best  to  divide  the  aponeurosis  of  the  external  oblique,  and  so 
obtain  sufficient  room  for  rightly  dealing  with  the  sac.  This  requires  an  additional  row 
of  sutures,  and  may  weaken  the  abdominal  wall.  On  the  other  hand,  beginners  will 
always  find  it  difficult,  however  much  the  upper  angle  of  the  wound  is  pulled  up.  to  get 
the  sac  detached  really  high  up,  and  to  put  the  needful  sutures  into  the  conjoined 
tendon  with  the  limited  incision  which  is  sufficient  for  the  experienced  hands  of  Prof. 
Macewen. 

6—2 


84 


OPERATIONS  ON  THE  ABDOMEN. 


suture  which  comes  from  the  lower  part  of  the  conjoined  tendon,  guided 
by  the  index  in  the  inguinal  canal,  is  passed  from  within  outwards 
through  Poupart's  ligament,  which  it  penetrates  at  a  point  on  a  level 
with  the  lower  suture  in  the  conjoined  tendon  (Fig.  25).  The  needle 
is  then  completely  freed  from  the  suture  and  withdrawn. 

Thirdly,  the  needle,  now  threaded  with  that  part  of  the  catgut  which 
protrudes  from  the  upper  border  of  the  conjoined  tendon,  is  passed  from 
within  outwards  through  the  transversalis  and  internal  oblique  muscles 
and  the  aponeurosis  of  the  external  oblique  at  a  point  on  a  level  with 
the  upper  stitch  in  the  conjoined  tendon.     It  is  then  quite  freed  from 


Fig.  23 


Fig.  22. 


On  the  left  is  one  of  Prof. 
Mace  wen's  needles.*  They  are 
made  of  one  piece  of  steel. 
To  the  right  is  the  sac,  trans- 
fixed and  thrown  into  a  series 
of  folds  by  a  thread  which 
should  be  shown  emerging 
above  as  well  as  below. 


Macewen's  operation.  A  hernia-needle  (loaded) 
has  been  made  to  penetrate  the  conjoined  tendon 
in  two  places. 


the  suture  and  withdrawn.  There  are  now  two  free  ends  in  the  outer 
surface  on  the  external  oblique,  continuous  with  the  loop  on  the 
abdominal  surface  of  the  conjoined  tendon  (Fig.  26).  The  two  free 
ends  being  drawn  together  tightly,  and  tied  as  a  reef-knot,  the  internal 
ring  is  firmly  closed.  The  same  stitch  may  be  repeated  lower  down  in 
the  canal,  especially  in  adults,  with  wide  gaps.  The  pillars  of  the 
external  ring  may  likewise  be  brought  together.  In  the  great  majority 
of  cases  the  first  or  uppermost  stitch  is  all  that  is  required.  The  cord 
should  lie  behind  and  below  the  sutures  and  be  freely  movable  in  the 


*  These  are  two  in  number,  one  for  passing  the  thread  from  right  to  left,  and  the 
other  from  left  to  right.  I  have  found  Mr.  Watson  Cheyne's  modification  of  the  above 
needles,  in  which  the  instrument  is  angular  instead  of  curved,  much  more  convenient  for 
picking  up  the  conjoined  tendon  and  external  oblique. 


IJADK'AL    VVHK    <»|'    I  \  < ;  l  [NAL    HERNIA. 


85 


canal.  It  is  advisable  to  introduce  all  the  sutures  before  tightening 
any  of  them.  They  may  then  be  experimentally  drawn  tight  while  a 
finger  is  introduced  into  the  canal  to  learn  the  result.  During  the 
operation  the  skin  is  drawn  from  side  to  side  to  bring  the  parts  into 
view.  The  skin  falling  into  position,  the  wound  is  opposite  to  the 
external  ring,  the  operation  being  partly  subcutaneous. 

In  congenital  hernia  the  sac  is  first  separated  from  its  connection 
with  the  canal.  It  is  then  opened,  and  divided  transversely  into  two 
parts,  care  being  taken  to  preserve  the  cord.  The  lower  part  forms 
a  tunica  vaginalis.  The  upper  is  pulled  down  as  far  as  possible,  split 
behind  longitudinally,  so  as  to 
allow  the  cord  to  escape,  and  its 
lower  end  closed  by  a  stitch  or 
two.  It  is  then  dealt  with 
quite  as  the  sac  of  an  acquired 
hernia. 

The  following  points  deserve 
attention. 

The  method  has  been  objected 
to  as  complicated  and  difficult, 
and  as  inapplicable  to  infants 
on  account  of  the  difficulty  of 
making  out  any  conjoined  ten- 
don at  this  age.  The  above 
objections  will  disappear  with 
practice.  As  Prof.  Macewen 
has  stated,  a  skilled  finger  will 
detect  the  conjoined  tendon  even 
in  early  life.  Smaller  needles 
must,  of  course,  now  be  used. 
Other  difficulties  are  met  with 
in  this  method  when  the  sac  is 
unusually  coarse  and  thick,  or 
when  it  is  extremely  thin  ;  such 
sacs  are,  no  doubt,  difficult  to 
manipulate  satisfactorily,  so  as 
to  get  the  pad  well  within  the 
internal  ring. 

Professor  Macewen  kindly  forwarded  to  me  the  following  statement 
(July  1895)  as  to  his  results : 

"I  have  had  164  completed  cases  of  operation  for  oblique  inguinal 
hernia.  Regarding  radical  cures,  one  must  necessarily  be  guarded  in 
drawing  conclusions  when  dealing  with  large  numbers,  as  many  of  the 
patients  pass  from  observation,  and,  though  asked  to  report  themselves, 
do  so  only  a  few  times,  and  then  cease.  Thus  out  of  164  there  are  55 
who  have  dropped  entirely  out  of  view.  Many  of  these  had  previously 
been  seen  three  to  nine  months  after  operation,  when  they  had  firm  occlu- 
sion of  the  abdominal  wall.  Two  children  died  after  the  operation — one 
from  scarlet  fever,  epidemic  at  the  time,  and  one  from  measles  and 
meningitis,  the  latter  rather  a  weak  child.  This  leaves  107;  of 
these,  five  are  known  to  have  had  return.  Two  of  these  were  steel 
workers,  doing  the  heaviest  kind  of  work.     One  was  cured  during  eight 


Macewen's  operation.    A  loop  has  been  left  on 
the  inner  surface  of  the  conjoined  tendon. 


86 


OPERATIONS  ON  THE  ABDOMEN. 


years,  and  then  a  slight  bulge  appeared  near  the  seat  of  the  former 
hernia.  He  now  has  a  bubonocele.  The  other  was  two  years  free  from 
hernia,  and  then  had  a  slight  rupture.  Each  of  those  wear  belts  — 
light  ones,  which  retain  the  hernia  even  during  their  work.  A  third 
remained  well  for  two  years,  then  had  an  attack  of  what  was  stated  to 
be  enteric  fever,  and  subsequently  became  affected  with  tubercle  of  the 
lun£s.     He  had  a  distinct  recurrence  of  the  hernia.     A  fourth  I  have 


Fig.  25 


Fig.  26. 


(X 


Macewen*s  operation.  The  thread  from 
the  lower  part  of  the  conjoined  tendon  has 
been  carried  through  Poupart's  ligament. 


Macewen's  operation.  Two  of  the 
threads  which  are  to  draw  the  conjoined 
tendon  over  to  Poupart's  ligament  are 
in  position  ready  for  tying. 


heard  of  as  having  a  return  to  a  slight  extent,  and  a  fifth  wrote  to  say 
that  he  had  a  return. 

"  If  we  strike  off  nine  cures  under  two  years,  which  are  well,  but 
which  are  too  recent  to  be  judged  as  cures,  this  leaves — 

20  reported  or  seen  cured — no  truss — at  10  years  and  over. 

H  >>  )>  ■)  !»  O  ,  ,  ,, 

IO  . ,  ,.  ,,         D       ,,  ,, 

29         >»  •  >  »»  ' »      4     ■>  >' 

15  "  "  •'  "         *       "  >> 


93 

Some  of  the  older  ones  have  been  good  enough  to  keep  me  well 
informed  as  to  their  state.  Two  have  gone  through  a  great  deal  of  hard 
riding  in  Cape,  for  many  months  at    a  time,  and    have  never    been 


RADICAL    CIIIl-:    OF    INCIINAL     IIFKNIA. 


87 


bothered  with  their  old  enemy.  One,  a  surgeon  in  the  Cumberland 
district,  rides  a  great  deal  and  never  is  troubled.  Pie  says  he  has 
forgotten  that  he  ever  had  a  hernia." 

Although  in  Prof.  Macewen's  hands  this  method  has  been  attended 
with  good  results,  when  performed  by  other  surgeons  the  results  have 
not  been  so  satisfactory.  It  is  clearly  a  more  difficult  and  complicated 
procedure  than  Bassini's,  and  moreover  the  results  of  Bassini's  method 

Fig.  27. 


Halstead's  operation.     Before  the  veins  and  fat  have  been  excised. 


are  better  (ride  supra,  p.  64).  Probably  it  is  for  these  reasons  that 
Bassini's  method  is  preferred  by  the  majority  of  operators. 

It  does  not  lengthen  the  inguinal  canal,  and  render  it  more  oblique 
and  valvular,  points  which  we  regard  as  of  the  first  importance  in  the 
radical  cure  of  inguinal  hernia. 

(4.)  Halstead's  Operation  (Johns  Hopkins  Bulletin,  August,  1903). 

Halstead's  original  operation  has  been  very  much  modified  by 
Halstead  and  Bloodgood.  The  inguinal  canal  is  opened  as  in  Bassini's 
operation  and  the  cremasteric  fascia  and  muscle  are  then  incised  along 
the  superior  border  of  the  spermatic  cord.  The  internal  oblique 
muscle  and  the  conjoined  tendon  of  this  and  the  transversalis  muscle  are 
thoroughly  exposed  and  denned.     The  spermatic  veins,  if  enlarged  as 


88  OPERATIONS  ON  THE  ABDOMEN. 

usual,  are  excised,  care  being  taken  to  avoid  any  extravasation  of  blood 
into  the  loose  areolar  tissues  around  the  vas  deferens,  and  the  small 
veins  which  accompany  it.  The  vas  is  not  touched  or  moved  lest 
thrombosis  of  its  veins  occur. 

The  spermatic  veins  are  pulled  down,  transfixed  and  tied  as  high  up 
as  possible  ;  another  ligature  is  similarly  applied  to  these  veins  just 

Fig.  28. 


Halstead's  operation.     Sewing  the  crernaster  deep  to  the  internal  oblique. 


below  the  external  ring,  and  the  intervening  bundle  is  excised  leaving 
no  large  veins  in  the  canal,  which  can  therefore  be  almost  completely 
obliterated  by  the  following  steps. 

The  neck  of  the  sac  is  transfixed  and  tied  as  high  up  as  possible, 
and  the  ends  of  the  ligature  are  threaded  on  long  curved  needles  which 
are  passed  deep  to  the  arching  fibres  of  the  internal  oblique  and 
transversalis,  to  pierce  these  muscles  at  two  points  one-eighth  of  an 
inch  apart  well  above  and  outside  the  internal  abdominal  ring.  The 
ligatures  are  tied ;  they  serve  to  displace  the  neck  of  the  sac  outwards, 


RADICAL    CURE    OF    [NGUINAL    HERNIA. 


89 


Fio.  29. 


Halstead's  operation.     Sewing  the  deep  muscles  to  Poupart's  ligament. 


Fig.  30. 


Halstead  s  operation.     Overlapping  the  external  oblique. 


90 


OPERATIONS  ON  THE  ABDOMEN. 


and   any  funnel  that  may  remain    above  the  ligature   (vide  Kocher's 
lateral  transposition  method). 

The  lower  flap  of  cremasteric  fascia  and  muscle  is  now  drawn  up  deep 

Fig.  31. 


Halstead's  operation.     Sewing  down  the  edge  of  the  external  oblique. 


Internal 
oblique 


Aponeurosis  of 
ext.  obUqxie 


Poupart's 
ligt 

Halstead's  operation.     Section  to  show  the  overlapping. 

to  the  internal  oblique  and  the  conjoined  tendon,  and  fixed  there  by 
fine  interrupted  sutures  (vide  Fig.  28  I.). 

The  internal  oblique  muscle  and  the  conjoined  tendon  are  then 
joined  to  the  deep  surface  of  Poupart's  ligament  by  means  of  stouter 
interrupted  sutures  (vide  Fig.  29  II.). 

If  necessary  the  rectus  sheath  may  be  incised  vertically  in  order  to 
allow  the  lower  sutures  to  be  tied  without  undue  tension. 


ftADlCAL   CURE   ()K    INGUINAL    HKIlNIA. 


9i 


This  is  found  very  useful  when  the  conjoined  tendon  is  narrow  and 
atrophied.  The  wound  in  the  external  oblique  aponeurosis  is  dosed 
by  the  Andrews-Halstead  overlapping  method  (vide  Figs.  30  to  32). 

If  the  hernial  orifice  is  very  large,  a  flap  of  the  anterior  wall  of  the 
rectus  sheath  may  be  reflected  downwards  and  outwards  and  sewn  to 
the  deep  surface  of  Poupart's  ligament  (vide  Fig.  33)  ;  or  the  outer 
margin  of  the  rectus  sheath  may  be  slit  up  to  liberate  the  rectus 
muscle,  which  may  then  be  sutured  to  Poupart's  ligament  (Bloodgood, 


Fig.  33. 


Halstead  and  Bloodgood's  operation.     Turning  down  a  flap  of  rectus  sheath  to 
strengthen  the  lower  and  inner  part  of  the  canal. 

Johns  Hopkins  Reports,  vol.  vii.,  and  "Wofler,  "  Beitrage  z.  Fest.  f.  Th. 
Billroth  "). 

The  results  of  this  very  extensive  and  elaborate  operation  are  very 
good  as  regards  the  cure  of  the  rupture,  and  Halstead  states  that  not  a 
single  recurrence  has  been  charged  to  him  from  1892  to  1903.  The 
difficulties  of  following  up  cases,  especially  unsuccessful  ones,  must 
not  be  forgotten,  however. 

When  it  was  customary  to  dislocate  the  vas  deferens,  atrophy  of 
testis  used  to  follow  the  operation  in  10  per  cent,  of  the  cases,  but 
since  1899  not  a  single  case  of  this  serious  complication  has  been 
observed  at  the  Johns  Hopkins  Hospital,  although  epididymitis  and 
vaginal  hydrocele  are  not  uncommon. 

Halstead's  operation  in  its  modern  and  modified  form  is  no  doubt 


92  OPERATIONS  ON  THE  ABDOMEN. 

suitable  for  mai^  cases  of  large  inguinal  hernia  with  large  canals  and 
fatty  bulky  cords.  The  removal  of  nearly  the  whole  cord  greatly 
facilitates  the  radical  cure,  for  "  the  cord  is  the  first  cause  of  the  hernia 
and  the  ultimate  obstacle  to  its  cure  "  (Halstead). 

(5.)  NicoWs  Operation  (Ann.  of  Surg.,  January,  1906). 

Nicoll  only  recommends  this  extension  of  his  operation  for  femoral 
hernia  to  some  cases  of  very  large  inguinal  hernia,  especially  to  those 
with  wide  necks,  which  occur  in  elderly  men.  In  them  Poupart's 
ligament  is  too  weak  and  mobile  to  be  used  as  a  fixation  point  for  the 
internal  oblique  and  conjoined  tendon  ;  Prof.  Nicoll  therefore  sutures 
these  structures  to  the  horizontal  ramus  of  the  pubis. 

The  sac  having  been  treated  as  in  Nicoll's  operation  for  femoral 
hernia  (vide  p.  99),  the  periosteum  of  the  horizontal  ramus  is  incised 
from  the  femoral  sheath  to  the  pubic  spine.  This  incision  is  just  below 
and  parallel  to  the  ilio-pectineal  line.  The  bone  is  drilled  horizontally 
at  two  points  about  three-quarters  of  an  inch  apart.  The  drill  may  be 
passed  through  the  pubic  fascia  lata  just  below  Poupart's  ligament ;  this 
enables  the  operator  to  pass  the  drill  more  horizontalby  than  is  possible 
from  above  Poupart's  ligament.  Two  stout  mattress  sutures  of  catgut 
or  kangaroo-tendon  are  then  employed  to  bring  the  internal  oblique  and 
conjoined  tendon  down  to  the  bone.  Each  suture  takes  a  broad  grip  of 
these  structures,  and  each  is  withdrawn  through  both  of  the  holes  in  the 
bone  and  tied  either  deeply  or  superficialby  to  the  pubic  fascia  lata. 

A  special  silver  probe,  with  an  eye  close  to  its  end,  greatly  facilitates 
the  withdrawal  of  the  sutures  from  above  downwards  through  the  bone 
(vide  Fig.  41). 

The  sutures  may  be  passed  either  behind  or  in  front  of  the  spermatic 
cord.  We  should  always  prefer  to  pass  them  behind  the  cord,  thus 
rendering  the  new  inguinal  canal  more  oblique  and  valvular. 

Poupart's  ligament  is  now  sewn  to  the  anterior  surface  of  the  con- 
joined tendon  and  internal  oblique  in  front  of  the  cord. 

We  regard  this  operation  as  worthy  of  trial  in  suitable  cases.  Prof. 
Nicoll  publishes  a  modification  of  the  operation,  which  consists  in 
suturing  the  conjoined  tendon  and  internal  oblique  to  the  anterior 
lip  of  the  periosteal  wound  on  the  horizontal  ramus  of  the  pubis :  this 
ma}'  be  used  if  suitable  instruments  be  not  available  for  the  more 
radical  operation. 


RADICAL    CURE    OF    FEMORAL    HERNIA. 

There  is  less  necessity  for  operative  interference  here — women,  in 
whom  the  above  variety  is  so  much  more  frequent,  finding  a  truss  more 
efficient  and  less  irksome,  owing  to  their  less  active  life  and  their  mode 
of  dress.  On  the  other  side  it  must  not  be  forgotten  that  strangulation 
is  proportionately  more  frequent,  more  often  overlooked,  and  more 
fatal  in  femoral  than  in  inguinal  hernia.  In  omental  hernia,  where 
there  is  difficulty  in  fitting  or  unwillingness  to  wear  a  truss,  in  irre- 
ducible hernia,  and  in  all  cases  of  strangulated  hernia,  where  the 
patient's  condition  and  the  surroundings  of  the  operator  admit  of  it, 
an  attempt  should  be  made  to  cure  the  hernia  permanently.  We  are 
met  here  by  a  difficulty  less  present  in  inguinal  hernia — i.e.,  that  of 


RADICAL    CFRF    OF    FEMORAL    IIFRNIA. 


dosing  the  canal  satisfactorily,  owing  to  the  rigidity  of  sonic  of  its 
immediate  surroundings  and  the  importance  of  others. 

Finding  the  sac. — Care  must  be  taken  not  to  mistake  the  distended 
fascia  propria  or  the  anterior  wall  of  the  femoral  sheath  for  the  sac,  and 
the  subperitoneal  fat  for  adherent  omentum  (ride  p.  44). 

(A.)   Different  methods  of  treating  the  sac. 

i.  The  empty  sac  having  been  thoroughly  separated  from  its  sur- 
roundings— a  step  here  usually  carried  out  with  ease — is  twisted  up 
tightly,  transfixed,  and  tied  as  high  as  possible,  and  then  thoroughly 
invaginated  within  the  femoral  ring. 

ii.  Kocher's  method  (p.  81)  may  be  employed.  The  empty  sac 
having  been  isolated  is  invaginated  into  the  abdominal  cavity  by  means 
of  a  pair  of  long  curved  forceps,  and  then  brought  out  through  a  small 


Fig.  34. 


Bassini's  operation  for  femoral  hernia  (modi- 
fied from  Binnie's  Operative  Surgery).  Passing 
the  first  set  of  sutures. 


Bassini's  operation  for  femoral 
hernia  (modified  from  Binnie). 
The  second  set  of  sutures  ready 
for  tying. 


opening  made  in  the   whole   thickness  of  the   abdominal  wall    above 
Poupart's  ligament,  and  its  stump  fixed  there  by  suture. 

iii.  The  sac  may  be  treated  much  as  in  the  methods  of  Barker  and 
Bennett.  Thus,  after  it  has  been  isolated  and  emptied,  the  neck  is 
thoroughly  cleared  with  the  finger  passed  up  the  femoral  canal.  The 
neck  is  now  ligatured  as  high  up  as  possible,  the  body  of  the  sac  cut 
away,  and  the  ends  of  the  ligature,  which  have  been  left  long  around 
the  neck  of  the  sac,  are  carried  up  the  femoral  canal  by  means  of 
needles  on  handles  along  the  index  finger,  and  made  to  emerge  in 
front  of  the  peritonaeum  through  the  external  oblique  aponeurosis 
just  above  Poupart's  ligament,  about  half  an  inch  apart.  When  these 
are  tied  the  neck  of  the  sac  and  any  funnel  that  may  remain  above  the 
ligature  will  be  drawn  away  from  the  region  of  the  femoral  ring. 
While  the  above  ligatures  are  being  passed  one  assistant  should 
protect  the  femoral  vein,  while  another  draws  up  the  upper  angle  of  the 
skin  incision  so  that  the  needles  may  emerge  in  the  wound. 


94 


OPERATIONS  ON  THE  ABDOMEN. 


iv.  The  sac  having  been  isolated  below  Poupart's  ligament,  may  be 
drawn  upwards  through  the  femoral  canal  into  a  wound  made  by  slit- 
ting the  fibres  of  the  external  oblique  muscle  ;  its  neck  can  then  be  tied 
higher  up  than  by  mere  separation  and  traction  from  below  (vide 
Lotheissen's  Operation). 

v.  MacE  wen's  method  of  dislocation  of  the  sac,  and  fixing  it  as  a  pad 
above  the  femoral  ring  (vide  p.  82). 

vi.  Nicoll's  modification  of  the  above  (vide  p.  99). 

(B.)  Closure  of  the  Femoral  Canal. — The  other  cardinal  step  in 

Fig.  36. 


a,  Poupart's  ligament,  b,  Lacuna  muscularis.  c,  Lacuna  vascularis,  d,  Cooper's 
ligament,  e,  Gimbernat's  ligament.  g,  Ilio-pectineal  ligament,  h,  Ilio-pectineal 
eminence,     s,  Spermatic  cord.     (Lockwood.) 


the  radical  cure  of  femoral  hernia — closure  of  the  femoral  canal  and 
ring — is  much  more  difficult  here,  for  reasons  above  given. 

1.  Bassini's  Method. — After  high  ligation  and  removal  of  the  sac,  the 
canal  is  closed  in  the  following  manner: — Three  sutures  are  passed 
through  Poupart's  ligament  and  the  pectineal  fascia  (vide  Figs.  34  and 
35).  These  are  left  untied  while  three  or  four  more  sutures  are  inserted 
and  tied.  These  unite  the  falciform  ligament  to  the  pectineal  fascia,  the 
lowest  being  placed  close  to  the  saphenous  vein.  Bassini  has  published 
fifty-four  cases  operated  upon  by  this  method,  without  any  recurrence 
in  forty-one  cases,  traced  from  one  to  nine  years. 

2.  Lockwood' s  Method*  (Figs.  36,  37,  and  38). — The  stump  of  the  sac 
is  first  drawn  up  and   fixed   as   above  described   (iii.,   p.   93).     The 

*  Hernia,  Hydrocele,  and  Varicocele,  p.  192. 


RADICAL    (TI!K    OF    FEMORAL    IIKRNIA. 


95 


subsequent  steps  are  described  by  the  author  as  follows:  "For  this 
purpose  the  index  finger  of  the  left  hand  is  pushed  up  the  femora] 
canal  so  that  it  lies  with  its  dorsum  against  the  common  femora]  vein, 
and  its  tip  upon  and  a  little  within  the  ilio-pectineal  ridge.  The  finger 
is  intended  to  protect  the  vein  from  the  point  of  the  herniotomy-needle, 
and  to  guide  the  latter  as  its  point  is  thrust  beneath  Cooper's  ligament 
(vide  Fig.  36).  In  cases  in  which  the  femoral  canal  has  been  distended 
and  stretched,  the  needle  can  be  guided  by  vision.  The  herniotomy- 
needle  is  passed  in  the  following  manner: — Having  been  armed  with 
about  one  and  a  half  feet  of  No.  4  or  5  twisted  silk,  its  point  is  guided 
up  the  femoral  canal  until  it  rests  against  the  inside  of  the  linea  ilio- 
pectinea,  opposite  the  outer  edge  of  Gimbernat's  ligament.     The  needle 

Fig.  37- 


Lockwood's  operation.     Showing  the  mode  of  suturing  the  femoral  canal. 

is  then  rotated  so  that  its  point  scrapes  over  the  linea  ilio-pectinea  and 
picks  up  Cooper's  ligament.  Finally,  the  point  emerges  through  the 
upper  part  of  the  pectineal  fascia,  where  is  is  unthreaded  and  with- 
drawn, leaving  the  suture  beneath  Cooper's  ligament  (vide  Fig.  37). 
Additional  sutures  are  passed  in  exactly  the  same  way,  but  each  a  little 
farther  outwards  until  the  last  lies  at  the  inner  edge  of  the  common 
femoral  vein.  Two  or  three  sutures  generally  suffice,  but  I  have 
used  as  many  as  five.  The  next  step  is  to  again  thread  the  upper 
end  of  each  ligature  in  turn  through  the  herniotomy-needle,  and,  by 
pushing  the  point  of  the  needle  half-way  up  the  femoral  canal  and 
rotating  it  forwards,  pass  the  thread  from  within  outwards  through 
Hey's  ligament  close  to  its  junction  with  Poupart's  ligament  (vide 
Fig-  37)-  Before  knotting  these  threads  they  are  pulled  tight,  to 
see  whether  enough  have  been  passed  to  make  a  thorough  and  firm 
closure   of  the   femoral  canal,  but   without  compressing  the   femoral 


96 


OPERATIONS  ON  THE  ABDOMEN. 


vein  (vide  Fig.  34)."  The  final  results  of  Mr.  Lockwood's  cases  are 
not  fully  given,  owing  to  the  difficulty  in  following  them  up.  Ten 
cases,  however,  are  mentioned.  In  nine  of  these  the  result  was  satis- 
factory after  periods  varying  from  one  to  seven  years  ;  the  tenth  case 
relapsed  suddenly  at  the  end  of  six  months. 

3.  Kocher's  method  differs  very  little  from  the  above ;  he  sews 
Poupart's  ligament  down  to  the  ligament  of  Cooper  and  the  pectineal 
fascia  and  muscle. 

Professor  De  Garmo  (Ann.  of  Surg.,  vol.  42  ;  1905),  after  ligaturing 
the  sac  high  up  and  removing  it,  closes  the  femoral  canal  in  a  manner 
almost  identical  with  that  of  Kocher. 

Since  1890,  De  Garmo  has  used  his  method  for  no  cases,  with  only 
one  certain  and  one  doubtful  recurrence,  and  one  death  which  occurred 


Fig.  38. 


Lockwood's  operation.     Showing  the  closure  of  the  femoral  canal  completed. 

in  a  late  case  of  strangulated  hernia  from  perforation  of  the  bowel 
after  its  reduction  by  operation.  Of  the  no  hernias,  28  were 
strangulated  at  the  time  of  the  operation,  and  the  remaining  operations 
were  simple  radical  cures.  In  three  of  the  patients  the  hernia  had 
relapsed  after  operation  elsewhere  ;  all  these  recurrent  cases  have 
remained  well  for  over  four  years. 

The  above  results  are  somewhat  misleading,  for  it  is  not  stated  how 
many  of  the  cases  were  traced  and  thoroughly  examined.  It  is  written 
that  "by  far  the  greater  number  have  been  traced  and  the  permanence 
of  the  cure  ascertained  "  ;  this  is  too  vague  to  be  of  much  value.  Again, 
the  time  of  observation  is  not  mentioned,  although  it  is  probable  that 
it  extended  over  some  years  in  the  majority  of  the  cases.  It  is  pretty 
certain  that  recurrences  after  the  radical  cure  of  femoral  hernia  come 
late,  the  majority  appearing  after  two  years  if  the  canal  has  been  closed 
by  sutures  (Kammerer,  Ann.  of  Surg.,  p.  983,  vol.  39,  1905). 


RADICAL   CUKE    OF    FEMORAL    HERNIA. 


97 


Hutchinson  carefully  observed  sixteen  of  his  own  cases  treated  as 
above  (Lancet,  vol.  i.  1906,  p.  964).  The  patients  were  traced  for  from 
two  to  ten  years.  Two  relapses  occurred,  one  after  three  years;  the 
other  came  earlier  in  a  case  of  strangulated  hernia  in  a  woman  who 
had  bronchitis  utter  the  operation. 

4.  The  Purse-string  Method  of  Cushing  and  Curtis,  adopted  by 
Coley  (Annals  of  Surgery,  vol.  xxxvii.,  p.  801,  1903). 

After  high  ligation  of  the  sac  and  removal  of  all  sub-peritoneal  fat 
from  the  femoral  canal  Coley  closes  the  femoral  canal  high  up  with  a 
purse-string  suture  of  kangaroo  tendon.  This  stitch  is  introduced 
through  Poup art's  ligament  near  its  inner  end,  then  through  the 
pectineus  fascia  and  muscle,  the  fibrous  septum  of  the  femoral  sheath 
internal  to  the  femoral  vein,  and  forwards  through  Poupart'fl  ligament 
about  a   quarter  of  an  inch  from  the  point  of  entry.     This  suture  can 

Fia.  39. 


Aponeurosis  of 
Ext.  oblique  ""* 


Peritoneum 
Int.  oblique 
Transversalis 


Cooper's  li 

femoral  canal 
Poupart's  lig. 

Saphenous  opening'' 
in    Fascia    Lata 

Diagrammatic  section  to  illustrate  Lotbeissen's  operation  for  femoral  hernia. 

be  passed  more  safely  in  the  opposite  direction,  the  femoral  vein  being 
more  easily  avoided. 

This  operation  is  very  simple,  and  can  be  performed  quickly ;  hence 
it  is  especially  useful  in  critical  cases  of  strangulated  hernia. 

Coley  (loc.  supra  cit.)  publishes  50  cases  with  no  recurrence,  also 
16  operations  by  Bassini's  method,  with  one  relapse  in  a  patient  whose 
wound  had  suppurated. 

Of  these  66  cases,  46  were  traced  for  from  one  to  ten  years,  and  34 
from  two  to  ten  years.  The  chief  objections  to  this  operation  are  that 
it  is  difficult  to  retain  such  rigid  structures  as  surround  the  femoral 
canal  by  a  purse-string  suture,  and  that  the  femoral  vein  is  especially 
liable  to  be  wounded. 

5.  Lotheissen's  Operation  (Centralblatt  fiir  Chirurgie,  1898)  (Fig.  39). 

An  incision  is  made  half  an  inch  above  and  parallel  to  the  inner  half 
of  Poupart's  ligament,  separating  the  fibres  of  the  external  oblique 
aponeurosis. 

The  edges  of  this  incision  are  retracted  and  the  neck  of  the  sac 
exposed  and  isolated  just  above  the  femoral  ring  and  below  the  curved 
margin  of  the  internal  oblique  and  conjoined  tendon.     The  empty  sac 

s. — vol.  11.  7 


98 


OPERATIONS  ON  THE  ABDOMEN. 


can  generally  be  drawn  upwards  into  the  wound,  but  with  large  and 
irreducible  herniae  this  is  not  possible ;  in  them  the  lower  border  of 
the  cutaneous  wound  is  freed  and  retracted  sufficiently  to  expose  the 
sac  at  the  saphenous  opening  in  the  usual  way.  The  sac  is  opened  and 
emptied,  and  its  ligated  stump  is  drawn  upwards  through  the  femoral 
canal  into  the  wound  in  the  external  oblique.  The  neck  of  the  sac  is 
then  easily  tied  so  high  that  no  funnel  can  remain  above  the  ligature. 

The  essential  part  of  the  operation,  however,  is  the  closure  of  the 
upper  end  of  the  femoral  canal  by  joining  the  lower  margins  of  the 
internal  oblique  and  transversalis  to  Cooper's  ligament. 

Sutures  of  kangaroo  tendon  or  chromicised  gut  are  passed  by  means 
of  acutely  curved  round  needles  first  (vide  Fig.  40)  through  the 
mobile  muscular  arch  and  then  under  Cooper's  ligament,  which  is 
fixed  (vide  Fig.  39).  The  first  suture  should  be  passed  close  to 
Gimbernat's  ligament,  and  the  last  near  the  femoral  vein,  the  point  of 
the  needle  being  guided  by  the  finger  (introduced  through  the  saphenous 

opening),  which  should  also  care- 
fully protect  the  femoral  vein. 
Three  or  four  sutures  are  gene- 
rally enough.  Care  must  be 
taken  not  to  wound  or  compress 
the  vein  with  the  last  suture. 

The    wound    in    the    external 
oblique  is  now  closed  by  a  con- 
Eis  tinuous  catgut  suture.  The  writer 

Symonds'  needles.  overlaps  the  edges  of  this  wound 

to  give  greater  support.  Two 
years  later  Gordon  described  an  operation  almost  identical  with  the 
above  (Brit.  Med.  Journ.,  vol.  i.,  1900). 

According  to  Gilli,  this  operation  is  frequently  performed  at  Von 
Hacker's  clinic,  and  with  very  good  results  (Geniralblatt  filr  Chirurgie, 
I9°3)-  I  complete  the  operation  by  closing  the  saphenous  opening 
(vide  Fig.  35). 

It  seems  to  me  to  be  the  operation  which  most  closely  approaches 
the  anatomical  ideal,  for  the  canal  is  closed  at  its  upper  end,  instead  of 
lower  down,  as  in  all  the  older  operations,  and  the  sac  can  be  tied  at  a 
higher  plane.  In  practice  it  is  not  very  difficult  to  perform,  if  only 
suitable  needles  be  employed.  A  vertical  skin  incision  is  more  gene- 
rally useful  than  the  horizontal  one,  and  this  is  especially  true  of 
irreducible  and  strangulated  hernise,  in  which  the  sac  has  to  be 
isolated  and  emptied  from  below  Poupart's  ligament. 

This  operation  is  not  at  all  easy  in  very  stout  patients;  the  conjoined 
tendon  and  internal  oblique  muscle  are  then  fatty  and  difficult  to 
define  in  a  deep  wound. 

6.  Battle's  Operation  (Lancet,  vol.  i.  p.  302,  1901). 

Battle  separates  the  fibres  of  the  external  oblique  aponeurosis  and 
treats  the  neck  of  the  sac  in  the  same  way  as  Lotheissen.  He  then 
sutures  the  upper  margin  of  the  wound  in  the  external  oblique  to  the 
pectineal  fascia,  Gimbernat's  and  Poupart's  ligaments.  Care  must  be 
taken  to  avoid  injuring  the  femoral  vein  in  passing  these  stitches.  The 
lower  margin  of  the  same  wound  is  sewn  to  the  anterior  surface  of 
the  external  oblique  above  the  upper  margin,  which  it  overlaps,  thus 


RADICAL    CUBE    OF    FEMORAL    HERNIA. 


99 


strengthening  the  anterior  wall  of  the  inguinal  canal,  and  diminishing 

the  tension  on  the  first  set  of  sutures. 

The  upper  extremity  of  the  femoral  canal  can  he  very  thoroughly 
closed  in  this  way,  hut  it  is  somewhat  difficult  to  bring  the  tendinous 
external  oblique  down  to  the  pectineal  fascia  and  to  retain  it  there 
without  undue  tension.  It  is  far  easier  to  bring  the  more  movable  and 
elastic  internal  oblique  to  Cooper's  ligament,  and  the  strain  on  the 
stitches  is  much  less. 

7.  Nicoll's  Operation  (Annals  of  Surgery,  January,  1906)  (Fig.  41). 

Professor  Nicoll  first  described  his  operation  in  1902   {Brit.  Med. 

Fig.  41. 


Catgut  suture 


Poupart's  ligament 


Probe 


Femoral  ring. 
Horizontal  ramus 
of  pubis. 


NicolPa  operation  for  femoral  hernia.     Stout  catgut  sutures  are  passed  through  the  ramus  of 
the  pubis  and  Poupart's  ligament.     (Redrawn  from  Nicoll's  paper,  Ann.  of  Surg. ,) 

Journ.,  November,  1902),  and  recommended  it  for  difficult  cases  of 
femoral  hernia  ;  but  he  now  employs  it  in  nearly  all  his  cases. 

(A)  Treatment  of  the  Sac. 

This  is  isolated,  and  the  peritonaeum  is  separated  from  the  parietes 
for  about  one  inch  above  and  around  the  femoral  ring.  The  sac  is 
then  bisected  longitudinally,  and  one  of  the  halves  is  pierced  near  its 
base,  the  other  half  being  drawn  through  this  aperture.  The  neck  of 
the  sac  is  thus  closed  without  the  aid  of  a  ligature.  The  sac  is  then 
pushed  up  to  the  abdominal  aspect  of  the  femoral  ring,  where  it  raises 
the  parietal  peritonaeum  into  a  projection  towards  the  abdominal  cavity. 

This  procedure  is  alleged  to  save  time,  and  to  be  easier  and  safer 
than  other  methods  of  transplantation  of  the  sac,  which  may  inter- 
fere with  the  nutrition  of  the  sac  and  lead  to  sloughing  of  it.  I 
do  not  think  a  buttress  above  the  femoral  ring  is  either  necessary 
or  advantageous  ;  the  treatment  by  simple  and  high  ligation  is  far 
preferable. 

7—2 


ioo  OPERATIONS  ON  THE  ABDOMEN. 

(B)  Closure  of  the  Femoral  Ring. — i.  An  incision  is  made  from  the 
femoral  vein  to  Gimbernat's  ligament  through  the  pectineal  fascia  and 
periosteum  just  below  the  ileo-pectineal  line,  exposing  the  horizontal 
ramus  of  the  pubis.  Two  drill  holes  are  now  made  in  the  bone,  one 
near  Gimbernat's  ligament,  and  the  other  near  the  femoral  vein  ;  they 
are  about  three-quarters  of  an  inch  apart.  A  loop  of  stout  catgut 
is  passed  through  one  of  the  apertures  from  before  backwards  by 
means  of  a  silver  probe  with  an  eye  very  near  its  extremity.  The 
loop  is  divided  and  the  probe  withdrawn.  The  posterior  ends  of  the 
sutures  are  passed  as  mattress  sutures  through  Poupart's  ligament  at 
different  levels  by  means  of  a  curved  surgical  needle.  The  ends  are 
then  drawn  forwards  through  the  second  aperture  in  the  bone  with 
the  aid  of  the  pliable  probe. 

The  stitches  are  tied  separately,  bringing  Poupart's  ligament  into 
contact  with  the  postero-superior  surface  of  the  bone,  and  fixing  it 
there  firmly,  and  closing  the  femoral  ring.  In  passing  the  sutures 
through  Poupart's  ligament,  care  must  be  taken  to  avoid  wounding 
the  deep  epigastric  artery  and  the  cord  ;  and  in  making  the  punctures 
in  the  bone,  the  outer  one  should  be  neither  too  near  nor  too  far  from 
the  femoral  vein,  which  must  not  be  compressed  when  the  ligatures  are 
tied,  yet  the  femoral  ring  must  be  well  closed. 

ii.  The  pectineus  muscle  and  its  fascia,  which  form  the  lower  lip  of 
the  wound  made  to  expose  the  pubic  bone,  are  joined  to  Poupart's 
ligament  by  interrupted  catgut  sutures,  which  serve  to  reinforce  the 
mattress  sutures.  In  some  strangulated  herniae,  when  time  is  short, 
step  i.  may  be  omitted.  "Without  giving  statistics,  Professor  Nicoll 
states  that,  although  his  operation  ma}r  not  give  better  results  in  mild 
cases,  it  gives  much  better  results  than  those  obtained  by  any  of  the 
older  and  simpler  methods,  in  severe  cases.  He  claims  that  it  is  less 
severe  and  closes  the  hernial  aperture  higher  than  Roux's  operation  ; 
also  that  the  amount  of  closure  can  be  better  regulated,  and  that  the 
risks  of  complications  arising  later  are  much  less. 

8.  Eoax's  Operation. — The  sac  is  exposed  and  treated  as  in 
Bassini's  operation.  Roux  then  carefully  drives  a  metal  staple  through 
Poupart's  ligament  and  the  femoral  canal  into  the  horizontal  ramus  of 
the  pubis,  thus  closing  the  crural  canal  high  up.  The  staple  must  not 
be  hammered  in  too  tightly,  lest  Poupart's  ligament  be  torn. 

Crawford  Renton  *  speaks  well  of  the  operation,  and  records  25 
cases.  Roux  is  said  to  have  performed  the  operation  136  times  with 
only  two  recurrences  (Hutchinson,  Lancet,  April  7,  1906),  but  no  men- 
tion is  made  of  the  time  during  which  these  patients  were  observed,  so 
that  it  is  difficult  to  estimate  the  value  of  this  statement,  especially 
when  it  is  remembered  that  recurrences  usually  come  late  in  femoral 
hernia.  The  following  objections  have  been  made  to  the  operation, 
chiefly  on  theoretical  grounds.  The  staple  may  loosen  with  time 
and  come  away,  with  or  without  necrosis  of  the  pubis,  or  may  injure 
the  femoral  vessels  or  induce  pain.  Should  the  hernia  recur,  the 
staple  may  cause  serious  strangulation  and  even  perforation  of  the 
intestine,  like  silver  wire  sutures  have  been  shown  to  do  by  Macewen. 

9.  A  flap  of  the  pectineus  and  the  fascia  covering  it  may  be  turned 


Contributions  to  Clinical  Surgery,  p.  140. 


RADICAL    CURE    OF    UMBILICAL    HERNIA.  101 

up  and  sewn  to  Poupart's  ligament  (Watson  Cheyne,  Lancet,  1892; 
Salzer,  Centralblatt  fur  Chirurgie,  1892). 

The  Hap  is  apt  to  waste,  and  the  hernia  may  then  recur.  Moreover, 
as  the  Hap  only  closes  the  lower  end  of  the  femoral  canal,  it  is  not 
surprising  that  the  operation  has  been  abandoned  by  most  surgeons  in 
favour  oi  less  severe  and  more  hopeful  methods. 

In  conclusion  it  seems  to  me  that  Lotheissen's  operation,  being  the 
one  most  anatomically  ideal,  is  destined  to  become  the  operation  of 
the  future,  but  more  statistics  are  needed  before  coming  to  a  decision. 
The  operations  of  Bassini,  Lockwood,  and  Kocher,  have  stood  the 
test  of  time,  and  give  very  good  results.  It  is  probable  that  in  the 
future  the  results  of  operations  for  the  radical  cure  of  femoral  hernia 
will  become  as  good  as  those  for  inguinal  hernia. 


RADICAL    CURE    OF    UMBILICAL    HERNIA. 

This  operation  is  very  rarely  called  for  in  children  in  whom  the 
natural  tendency  to  cure  is  very  great.  In  adults  the  patients  usually 
met  with — stout  women  of  middle  age,  with  damaged  viscera,  bron- 
chitis, &c. — are  not  very  good  subjects  for  operative  interference. 
Until  recently  the  results  of  the  operation  were  so  bad  that  the 
name  of  "  radical  cure  "  could  hardly  be  given  to  it. 

Berger  states  that  relapses  used  to  occur  in  15  to  25  per  cent,  of  the 
small,  and  30  per  cent,  of  the  large,  hernias. 

Winslow  (Annals  of  Surgery,  vol.  xxxix.,  1904,  p.  245)  states  that 
until  recently  50  to  75  per  cent,  of  relapses  occurred  in  the  cases  of 
large  umbilical  hernias,  even  in  the  practice  of  the  best  operators ;  and 
that  50  per  cent,  of  the  strangulated  cases  died. 

The  recent  improvements  in  the  methods  of  operating  and  the 
consequent  amendment  of  the  results  justify  a  more  frequent  use  of 
the  operation  with  the  object  of  preventing  strangulation,  which  is 
attended  with  such  fatal  results  in  this  form  of  rupture.  It  is  also  very 
important  to  operate  early,  while  the  protrusion  is  still  small,  for  the 
prognosis  of  the  operation  varies  almost  inversely  with  the  size  of  the 
hernia.  Busse  found  that  75  per  cent,  of  recurrences  occurred  in  the 
cases  of  large  hernias,  50  per  cent,  in  the  medium-sized,  and  none  in 
the  small  ones  (from  the  size  of  a  hazel  nut  to  that  of  a  walnut). 

Suppuration  had  not  occurred  in  any  of  these  cases. 

A  radical  cure  may  be  performed — 

(a)  After  the  operation  for  relief  of  strangulation  in  suitable  cases. 

(/;)  In  those  rare  cases  of  infantile  hernia  where  the  wearing  of  a 
suitable  truss  has  not  been  sufficient. 

(c)  In  congenital  hernia  of  the  new-born  child. — In  these  cases, 
either  hernias  into  the  root  of  the  cord,  or  (from  deficiency  of  the 
abdominal  walls)  partial  eventrations,  interference  is  often  out  of  the 
question  from  the  co-existence  of  other  malformations.  If  the  hernia 
be  uncomplicated,  and  the  child  appear  likely  to  survive  otherwise,  an 
attempt  should  be  made  by  abdominal  section  to  return  the  contents, 
refresh  the  edges  of  the  opening,  and  unite  them  with  sutures. 

(d)  In  most  cases  of  small  and  medium-sized  hernia  in  the  adult, 
unless  the  rupture  is  easily  retained  by  means  of  a  truss  or  a  belt, 


102 


OPERATIONS  ON  THE  ABDOMEN. 


granting  that  the  patient's  general  health  is  good  enough  to  enable  her 
to  bear  the  operation,  and  the  subsequent  rest  in  bed. 

It  should  be  the  surgeon's  aim  to  prevent,  as  far  as  possible,  the 
development  of  (i.)  strangulation,  and  (ii.)  also  to  prevent  the  growth  of 
those  large  inflamed,  and  often  inoperable,  hernia?  which  are  now  to  be 
seen  far  too  frequently.     Earlier  operation   in  suitable  cases  will  do 

Fig.  42. 


Greig  Smith's  method  of  radical  cure  in  umbilical  hernia.  A,  Transverse 
d  through  hernia  and  parietes.  showing  sac,  contents,  and  ring,  in,  Intes- 
tine. OM.  Omentum.  SK,  Skin.  F.  Fascia  thickened  at  margin  of  ring. 
M,  Rectus.  P,  Peritonaeum.  1,  Incision  through  skin  of  sac.  which  is  continued 
along  the  sub-peritonaeal  tissue  to  the  margin  of  the  ring.  2,  The  same  on  the 
opposite  side.  3  and  4.  Incisions  carried  deeply  through  thickened  fascia  around 
the  ring  to  expose  the  recti.  B,  Gut  returned,  omentum  removed,  superfluous 
skin  and  sac  removed,  sutures  placed,  incisions  in  fascia  opened  up,  and  recti 
exposed.  References  same  as  in  A.  C.  Sutures  tied,  skin-suture  to  one  side  of 
parietal  line  of  junction.  D.  Bird's-eye  view  showing  double  set  of  sutures 
around  umbilical  ring  and  cutaneous  wound.     (Wakbam.) 


much  to  avoid  these  serious  complications.  The  neck  of  the  sac  may 
be  twisted,  transfixed,  and  tied,  and  even  displaced  as  in  inguinal 
hernia,  but  it  is  better  to  sew  it  up  in  most  cases. 

Operations. — The  old  operation  in  which,  after  dealing  with  the  sac, 
the  fibrous  edges  of  the  ring  were  sutured  together,  is  to  be  strongly 
condemned,  because  the  tension  on  the  stitches  is  so  great  that  the 
latter  may  give  way  or  tear  out,  and  lead  to  an  early  reappearance  of  the 
hernia  and  serious  strangulation,  or  to  a  more  certain  recurrence  later, 


RADICAL   CURE    OF    UMBILICAL    HERNIA.  103 

1.  Simple  Suture  of  Separate  Layers. — In  small  hernia?,  and  especially 
in  the  infantile  variety,  a  simple  method  is  to  explore  the  hernia  and 
reduce  the  contents,  and  then,  after  excising  the  sac  and  its  coverings, 
to  incise  the  fibrous  edges  of  the  ring  so  as  to  expose  the  margin  of 
each  rectus  muscle.  The  wound  is  then  closed  by  separate  layers 
of  sutures,  one  for  the  peritonaeum  and  the  deep  layer  of  the  rectus 
sheath,  one  for  the  muscles  and  the  anterior  layer  of  the  sheath,  and 
one  for  the  skin.  The  objection  to  this  method  is  that  the  wound  is  a 
direct  and  not  a  valvular  one,  and  that  this  makes  a  recurrence  likely 
if  the  abdominal  tension  be  much  increased  later. 

2.  In  these  cases  it  is  clearly  better  to  suture  the  various  layers  in 
the  overlapping  manner  so  strongly  recommended  by  Winslow  (Annals 
of  Surgery,  vol.  xxxix.,  1904,  p.  245)  (vide  Fig.  43). 

\Yinslow  quotes  Coley  to  the  effect  that  Bull  and  Coley  had  twelve 
relapses  after  simple  suture  of  separate  layers  in  twenty-one  cases  of 
ventral  and  umbilical  hernia. 

In  the  majority  of  cases,  however,  the  hernia  is  large,  its  coverings 

Fig.  43. 


Rectus  sheath 
Rectus  muscle 

Peritoneum  and 
deep  layer   of 
Rectus  sheath 

The'overlapping  method  of  sewing  the  abdominal  wall.     (Modified  from  Winslow, 

Ann.  of  Surg.) 

thin,  and  the  recti  widely  separated  and  atrophied.  In  these  it  is 
generally  impossible  to  keep  the  muscles  and  aponeuroses  together  by 
simple  suture  without  undue  tension  on  the  stitches,  which  may  tear 
out  and  lead  to  an  early  and  sometimes  a  disastrous  return  of  the 
rupture.  For  the  same  reasons  Winslow's  method  of  suture  is  im* 
practicable.  For  these  cases  one  of  the  flap  operations  is  suitable,  and 
Mayo's  operation  is  by  far  the  simplest  and  the  best.  It  is  based  on 
the  fact  that  in  -the  subjects  of  umbilical  hernia  the  abdominal  wall  is 
too  long  and  pendulous  in  a  vertical  direction,  so  that  it  is  far  easier  to 
get  superior  and  inferior  flaps  than  to  obtain  lateral  ones. 

3.  Mayo's  Operation  *  (Jour.  Amer.  Med.  Assoc.,  July  25,  1903).— 
An  elliptical  incision  is  made  in  a  transverse  direction  around  the 
hernia  near  its  base,  and  the  aponeurosis  of  the  external  oblique  is 
thoroughly  exposed  for  a  distance  of  2,\ — 3  inches  around  the  margin  of 
the  hernial  aperture.  The  fibrous  and  peritoneal  coverings  are  divided 
all  round  the  very  neck  of  the  rupture,  and  the  hernial  contents  are  easily 
examined  here,  because  there  are  rarely  any  adhesions  at  the  neck. 

If  the  intestine  be  adherent  within  the  body  of  the  sac  these  adhesions 
can  be  more  easily  and  safely  separated  by  working  forward  along  the 
free   bowel  found  at  the  neck.     This  is  reduced,  and  the  omentum 


*  Piccolo  and  Sapejko have  also  described  the  operation  {Centralblatt  fur  Chirunjh\ 
190?,  p.  36). 


104 


OPERATIONS  ON  THE  ABDOMEN. 


ligatured  at  the  hernial  orifice.     The  sac,  with  its  thin  and  adherent 
coverings,   and   omental  contents,    are   then   rapidly  removed  in    one 
mass  without  any  of  the  troublesome  and  tedious  dissection  which  is 
usually  necessary  when  the  sac  is  opened  at  its  fundus  (vide  Fig.  44). 
The  hernial  orifice  is  examined,  its  long  axis  is  generally  transverse, 


Fig.  44. 


Neck  of  sac. 
Omentum. 


Mayo's  operation  for  umbilical  hernia.     A  transverse  elliptical  incision  has  been  made 
to  expose  aponeurosis  and  neck  of  sac.     (Ann.  of  Surg.) 

and  its  edges  are  more  easily  approximated  by  traction  on  its  superior 
and  inferior  edges.  The  aponeurotic  ring  is  widened  by  making  two 
transverse  incisions  from  its  lateral  poles,  each  extending  for  an  inch 
or  more  outwards,  thus  making  superior  and  inferior  aponeurotic  flaps. 
The  peritoneum  is  now  separated  from  the  deep  surface  of  the  upper 
flap,  and  the  lower  flap  is  drawn  up  behind  the  upper  one  by  means  of 
strong  mattress  sutures,     Before  these  sutures  are  tied,   traction  is 


RADICAL    CURE    OF    UMBILICAL    HERNIA. 


i°5 


made  upon  them  to  allow  the  peritonaeum  to  be  closed  by  a  continuous 
cutout  suture  (vide  Fig.  45). 

The  mattress  sutures  are  tied,  and  the  lower  edge  of  the  upper  flap  is 
sewn  to  the  front  of  the  base  of  the  lower  one  (vide  Figs.  46,  47,  and  48). 

In  some  cases  lateral  Haps  may  be  more  easily  obtained,  and  should 
then  be  employed. 

Mayo  reported  thirty-five  cases  of  umbilical  hernia  operated  on  by  his 
method,  with  only  one  slight  recurrence  in  one  of  the  ten  cases  in 

Fig.  45. 


Mayo's  operation.     (Ann.  of  Surg.') 


which  he  had  used  lateral  flaps.  Moynihan  (Lancet,  July  23,  1904)  also 
publishes  eleven  recent  cases,  and  strongly  recommends  the  operation. 

Although  it  is  too  early  to  conclude  that  these  good  results  will 
remain  permanent  radical  cures,  yet  they  compare  very  favoui'ably  with 
those  obtained  hy  other  methods.  Busse  records  twenty-two  operations 
performed  in  the  five  years  ending  in  1901.  The  mortalit}'  was  10  per 
cent,  in  all  and  25  per  cent,  in  the  strangulated  cases,  although  suppura- 
tion did  not  occur  in  any.  In  the  fifteen  cases  that  were  followed  up, 
there  were  75  per  cent,  of  recurrences  in  the  large  hernias  and  50  per 
cent,  in  those  of  medium  size. 

Blake  (Med.  Record,  vol.  i.,  190 1)  has  also  independently  devised 
and  very  successfully  practised  an  operation  which  is  very  similar  to 
Mayo's  lateral  overlapping  method, 


io6 


OPERATION'S  ON  THE  ABDOMEN 


Fir;.  46. 


Mayo's  operation.     (Ann.  of  Surg.")     Aponeurosis  suture  in  an  overlapping  way. 

Fig.  47. 


Peritonaei 


Mattress 
suture. 

Aponeurosis. 

Sutures  at 
edge  of  flap. 


Bfayo'a  operation  for  umbilical  hernia.      {Ann.  of Surg .) 


UAhM'.Wi   CURE    OF    UMBILICAL    HERNIA. 


[07 


Noble,  Ferguson,  and  others,  have  used  flaps  of  the  anterior  wall  of 
the  rectus  sheath  to  close  the  hernial  orifice,  the  hase  of  each  lateral 
flap  being  at  the  margin  of  the  ring;  the  flaps  are  then  rotated  inwards 

and  sutured  together,  so  that  the  surfaces  formerly  anterior  now  become 
posterior. 

Barker,  Lucas  Championniere,  and  others,  have  attempted  to  secure 
a  broad  union  by  inverting  the  edges  of  the  hernial  aperture  by  means 
of  Lambert  sutures  passed  through  the 
anterior  surfaces  of  the  sheaths  of  the 
recti. 

None  of  these  operations,  however, 
can  be  compared  in  value  with  that 
described  by  Mayo. 

Wire 

large 

this 


Muscle  & 
Aponeurosis 

Peritoneum 


Peritoneal  stitch 
-Mattress  suture 
Peritoneum 


Muscle   & 
iponeurosis 


4.   The  Implantation  of  Silver 
Netting    or    Filigree. — For  very 
umbilical     and     ventral    hernias 
method  has  been  strongly  recommended 
by  Witzel,  Phelps,  Willy  Meyer,  Gopel, 
Bartlett,  and  others. 

For  such  cases  formerly  considered 
incurable,  yet  greatly  in  need  of  surgical 
aid,  this  operation  may  be  tried  if  the 
patient's  general  health  he  good  enough, 
and  the  coverings  of  the  rupture  can  be 
rendered  aseptic.  A  properly  fitting 
and  elastic  belt  should  however  be 
always  well  tried  first,  and  in  the 
majority  of  cases  will  be  found  suffi- 
cient. Winslow's  remarks  (loc.  supra 
cit.)  upon  this  subject,  although  some- 
what too  pessimistic,  are  well  worthy  of 
remembrance,  and  may  be  quoted  in 
full : — "  Such  a  mode  of  support  "  (wire 
netting)  "  has  of  course  no  anatomical 
basis,  and  but  limited  surgical  applica- 
tion, though  of  undoubted  value  in  those  exceptional  cases  in  which 
it  is  unfortunately  appropriate.  It  does  not  appear  to  be  appropriate 
as  a  routine  treatment  of  hernia.  Since  acting  as  a  foreign  body  the 
silver  wire  tends  to  set  up  suppuration  and  sinus  formation,  which 
weaken  the  Avound,  and  defeat  the  very  object  for  which  the  wire  net- 
ting is  used.  The  indication  for  the  netting  is  to  reinforce  the 
abdominal  wall  in  cases  where,  owing  to  thinning  out  of  stretched 
structures  entering  into  the  hernial  orifices  or  to  removal  of  diseased 
tissue,  normal  approximation  of  the  abdominal  wall  cannot  be  secured." 

Witzel  (Centralhlatt  fur  Chirurgie,  igoo,  pp.  257,  459,  and  1149)  in 
his  first  case  constructed  a  rude  network  in  the  wound  by  approxi- 
mating the  edges  as  far  as  possible  with  wire  sutures  and  then  weaving 
the  wire  amongst  these  sutures. 

Gopel  {Centralhlatt  fur  Chirurgie,  1900,  p.  458)  published  an  account 
of  his  work  with  ready-made  silver  wire  netting,  and  pointed  out  that 
this  method  saves  much  time,  and  that  the  tissues  are  less  damaged 
and  constricted, 


Skiu 


A  section  to  illustrate  Mayo's  opera- 
tion for  umbilical  hernia. 


OPERATIONS  ON  THE  ABDOMEN. 


Fig.  49. 


Bartlett's  wire  filigree. 


Fig.  50. 


He  reported  eleven  cases  of  umbilical  and  ventral  hernia  and  seven 

of  inguinal  hernia  with  only  two  failures.     The  wires  had  to  be  removed 

in  these  two  cases  owing  to  the  formation  of  blood-clots  in  the  wounds. 

Willy  Meyer  (Annals  of  Surgery,  vol.  xxxix.,  1902,  p.  767)  reports 

three  operations,  two  on  very  large 
ventral  hernia?,  with  a  very  slight  recur- 
rence in  each  after  sinus  formation  in 
one  and  fascial  necrosis  in  the  other. 
In  each  the  recurrence  came  within 
six  months  of  the  operation,  which  was 
ultimately  successful  in  greatly  reliev- 
ing the  patient.  The  other  operation 
was  for  an  umbilical  hernia  of  moderate 
size,  and  no  recurrence  had  appeared  a 
year  later.  It  is  probable  that  Mayo's 
operation  could  have  been  performed  in 
this  case. 
Bartlett  (Annals  of  Surgery,  vol.  xxxviii.,  1903,  p.  47)  maintains 
that  the   netting  generally  used,  consisting  of  wires   woven  at  right 

angles  to  one  another,  is  too  firm  and 
inelastic  to  properly  amalgamate  with 
the  mobile  abdominal  wall.  He  also 
holds  that  only  those  wires  running  at 
right  angles  to  the  axis  of  the  wound 
are  necessary,  for  wounds  only  stretch 
laterally  to  any  appreciable  extent. 
Bartlett  therefore  employs  the  pliable 
filigree  shown  in  the  figure  (Fig.  50). 
The  cross  wire  prevents  separation  of 
the  loops. 

He  has  operated  in  seven  cases,  six 
ventral  and  one  umbilical  hernia,  with 
no  suppuration,  no  removal  of  filigree, 
and  only  one  partial  recurrence,  which 
occurred  in  a  man  suffering  from  ascites. 
This  was  Bartlett's  first  case. 

One  patient,  the  subject  of  the  umbi- 
lical hernia  and  cirrhosis,  died  suddenly 
on  the  eleventh  day  after  the  operation, 
and  the  cause  of  death  was  not  ascer- 
tained. The  patients  had  not  been  ob- 
served long  enough  to  justify  the  con- 
clusion that  the  results  will  remain  as 
good  as  they  now  seem.  Only  two  of  the 
cases  had  been  followed  for  more  than  a 
year ;  and  recurrences  often  come  late 
after  radical  cure  of  umbilical  hernia. 
Operation. — The  sac  and  its  contents  having  been  dealt  with,  the 
layers  of  the  abdominal  wall  around  the  ring  are  dissected  apart.  The 
peritonaeum  and  the  posterior  wall  of  the  rectus  sheath  are  separated 
from  the  deep  surface  of  the  muscles  for  several  inches,  and  then  sutured 
by  a  continuous  wire  suture.     A  silver  filigree  one  and  a  half  times  as 


Wire  filigree   for  ventral  hernia. 
(Bartlett,  Ann.  of  Surg.') 


RADICAL    (TKK    OF    [rMBILICAL    HERNIA.  109 

long  as  the  hernial  aperture,  and  ij  inch  broader,  is  then  inserted 
between  the  recti  and  their  posterior  coverings,  and  secured  in  position 
by  a  few  sutures  which  pass  round  the  longitudinal  wire  and  through 
the  rectus  sheath.  No  attempt  is  made  to  fix  the  ends  of  the  loops,  for 
Bartlett  has  proved  that  this  is  unnecessary  and  damaging  to  the  tissues. 
The  loops  become  well  secured  by  the  granulation  tissue  that  forms 
within  and  around  them.  The  edges  of  the  muscles  and  their  fascial 
coverings  are  then  drawn  together  as  much  as  possible  by  mattress 
wire  sutures,  and  if  considered  necessary  another  filigree  may  be 
implanted  over  the  anterior  sheaths  of  the  recti,  and  the  skin  and  fascia 
united  over  it. 

Bartlett  makes  a  silver  netting  to  suit  each  case  by  twisting  silver 
wire  (gauge  27)  round  the  ends  of  nails  driven  through  a  board.  It  is 
to  be  noticed  that  the  net  has  no  sharp  corners  or  irritating  angles, 
which  might  injure  the  tissues  and  lead  to  haemorrhage,  serous  effusion, 
and  sinus  formation. 

Operations  for  Ventral  Hernia. — A  ventral  hernia  can  be  treated  in 
one  of  the  various  ways  described  above  as  suitable  for  umbilical  hernia, 
and  therefore  no  special  description  is  called  for  here. 

Causes  of  Death  and  of  Complications  which  may  be  met  with 
after  Operations  for  the  Radical  Cure  of  Hernia. 

1.  Sepsis.  2.  Peritonitis.  3.  Scarlet  fever.  4.  Tubercular  menin- 
gitis. This  may  occur  in  patients  the  subjects  of  other  apparently 
quiescent  tubercular  trouble — e.g.,  spinal  caries.  5.  Bronchitis  due 
to  the  anaesthetic,  a  danger  especially  to  be  avoided  in  a  child  who 
has  lately  had  measles.  6.  Pueumonia.  7.  Pulmonary  embolism. 
8.  Nephritis.  9.  Epididymo-orchitis.  10.  Sloughing  of  epididymis 
and  testicle,  n.  Flatulence,  with  troublesome  distension.  This  con- 
dition, so  well  known  after  operations  on  the  interior  of  the  abdomen, 
is  known  by  some  as  "  pseudo-peritonitis."*  It  is  best  met  by 
aperients — e.g.,  calomel  gr.  v.  and  Seidlitz  powders,  given  alternately 
every  three  hours,  until  the  bowels  act ;  or  the  following  enema  may 
be  useful:  castor  oil  §ij.,  turpentine  §j.,  soap  and  water  to  8  oz.  12.  Re- 
currence. This  may  be  due  to  the  patient's  fault,  i.e.,  his  not  having 
worn  a  truss  when  this  was  obviously  indicated.  More  often  it  is  due 
to  faulty  operating,  suppuration,  and  the  resulting  thin,  stretching 
scar,  or  to  stitch-abscesses  and  sinuses,  to  which  I  have  referred  above. 

*  Where  a  large  quantity  of  omentum  has  been  tied  close  by  the  colon,  the  action  of 
the  latter  may  be  inhibited,  and  the  above  complication  follow  to  a  marked  degree. 


CHAPTER  III. 
COLOTOMY. 

Under  this  term  are  included  the  anterior  iliac  or  inguinal  colotomy  of 
Littre,  in  which  the  sigmoid  colon  is  opened  in  the  left  iliac  region  ; 
that  of  opening  the  ascending  or  descending  colon  in  the  loin,  or 
lumbar  colotomy — an  operation  with  which  the  name  of  Amussat*  is 
justly  associated  ;  finally,  the  question  of  making  an  artificial  anus  in 
the  csecuin  or  transverse  colon  is  considered. 

The  question  of  the  value  of  colotomy,  compared  with  excision  of 
the  rectum,  in  cases  of  cancer  is  dealt  with  later  on. 

Before  describing  and  comparing  the  different  modes  of  performing 
colotomy  I  shall  deal  with  those  conditions  which  call  for  this  procedure, 
then  the  advantages  of  the  chief  methods  and  the  cases  to  which  they 
are  relatively  adapted,  describing  finally  the  operations  themselves. 

Indications  for  Colotomy. — (i)  Certain  cases  of  malignant  disease 
of  the  rectum.  I  say  "  certain  cases  "  advisedly,  for  it  is  far  too  much 
the  rule  to  recommend  colotomy  as  soon  as  rectal  cancer  is  detected,  as  if 
no  other  lines  of  treatment  existed ;  and  it  is  too  much  the  habit  of 
students,  when  they  see  an  artificial  anus  neatly  made  in  these  cases, 
to  think  that  now  the  patient's  troubles  are  over.  In  reality  he  is  pro- 
bably only  exchanging  one  set  of  troubles  for  another. 

Where  obstruction  is  present,  impending,  or  threatening,  where,  in 
cases  which  are  too  advanced  for  excision,  there  is  extensive  ulceration,! 
great  pain,  difficult  defecation,  loss  of  sphincter  power,  profuse  blood- 
stained or  fseco-purulent  discharge  from  the  bowel,  or  multiple  fistulas, 
especially  recto-vesical  fistula,  the  operation  is  abundantly  justified. 

In  less  urgent  cases,  if  the  surgeon  be  doubtful  as  to  recommending 
this  operation,  he  cannot  do  wrong  if  he  lay  stress  on  two  points — one, 
that  there  is  always  the  risk  of  obstruction  setting  in,  and  none  can  say 
how  soon  this  may  call  for  colotomy  under  circumstances  much  less 


*  Students  are  frequently  perplexed  as  to  the  difference  between  Amussat's  and 
Callisen's  operations.  Callisen  (179C)  was  the  first  to  suggest  such  an  operation  as  colotomy, 
and  planned  to  open  the  descending  colon  by  a  vertical  incision.  This  proposal  was  con- 
demned by  contemporary  surgeons.  Amussat  revived  the  retro-peritonajal  operation,  if  he 
was  not  the  first  to  perform  it,  but  modified  it  by  extending  it  to  the  ascending  and 
descending  colons  alike,  and  by  making  use  of  the  transverse  incision.  Long  before 
Amussat's  time,  Littre  (1710)  had  opened  the  sigmoid  flexure  through  the  peritonaeum,  and 
in  1776  Pillore  had  opened  the  caecum. 

t  Asa  rule,  the  first  time  the  surgeon  examines  a  patient,  the  more  the  growth  tends 
to  become  annular,  the  less  limited  it  is  to  one  aspect  of  the  bowel ;  or  the  more  it  projects 
into  the  lumen  in  tuberous  masses,  the  more  likely,  cceteris  paribus,  is  obstruction  to 
threaten. 


COLOTOMY. 


in 


favourable  ;  the  other,  that  there  is  just  a  possibility  that  the  operation 

by  diverting  the  faeces,  will  arrest  the  rate  at  which  the  growth  would 
otherwise  spread. 

As  a  rule,  the  more  complete  the  failure  of  previous  treatment,  the 
more  painful,  difficult,  frequent,  and  unsatisfactory  the  action  of  the 
bowels,  the  greater  the  tendency  to  distension  of  the  sigmoid  or  lower 
intestines  generally,  the  more  frequent  the  attacks  of  gripings  and 
partial  obstructions  which  herald  in  the  tormina  of  a  complete  miserere 
the  younger  the  patient,  and  thus  the  longer  the  natural  prospect  of 
active  life,  the  more  plain  are  the  indications  for  colotomy.  On  the  one 
hand,  certain  special  evils*  call  loudly  for  the  relief  which  the  operation 
may  give — viz.,  a  patulous  or  invaded  sphincter  allowing  of  involuntary 
escape  of  flatus  and  faeces  ;  multiple  fistulas  giving  rise  to  foul  sanious 
discharge,  keeping  the  patient  (perhaps  a  woman  of  scrupulous  cleanli- 
ness) in  a  constantly  filthy  condition,  and  leading  to  a  brawny,  painful 
condition  of  the  buttocks,  which  thus  readily  become  the  seat  of  cellu- 
litis and  its  allies ;  projection  of  the  growth  downwards  through  the 
anus,  leading  not  only  to  a  patulous  sphincter  and  its  consequent 
wretchedness,  but  also  to  irksome  or  painful  sitting. 

On  the  other  hand,  certain  conditions  contraindicate  the  operation — 
viz.,  exhaustion  of  strength,  evidence  of  secondary  deposits  in  the 
peritoneal  cavity,  liver,  lungs,  or  pleura,  extension  to  the  inguinal 
glands,  and  absence  of  much  pain  or  obstruction  from  first  to  last. 

It  has  been  too  much  taken  for  granted,  because  rectal  cancer  is  often 
a  disease  of  much  suffering,  and  because,  from  the  inefficiency  or  neglect 
of  treatment,  obstruction  does  occur,  that,  when  cancer  of  the  rectum  is 
diagnosed,  the  patient  has,  therefore,  agonising  pain  and  obstruction 
to  look  forward  to.  The  above  view  is  quite  incorrect.  In  a  few 
cases  cancer  of  the  large  intestine  may  run  its  course,  and  set  up  visceral 
deposits,  and  kill  the  patient  with  very  little  pain,  and  no  threatening  of 
obstruction!  whatever;  in  other  cases — and  they  form  a  considerable 
number,  and  wTould  be  still  more  numerous  if  efficient  treatment  were 
begun  early  and  persevered  with — careful  attention  to  diet,  regular 
use  of  laxatives,  daily  washing  out  of  the  bowel  with  warm  water  by  a 
soft  catheter  or  cesophagus-tube  passed  through  the  stricture,  followed 
by  the  injection  of  starch  and  laudanum,  or  a  suppository  of  cocaine, 
iodoform,  and  morphia,  will  give  great  comfort  for  the  rest  of  the  day, 
entirely  prevent  obstruction,  and  enable  the  patient  to  get  about  and  go 
to  business  almost  to  the  last. 

Other  ever  imj)ortant  points,  on  which  the  patient  or  the  friends, 
especially  if  in  a  better  rank  of  life,  will  frequently  expect  a  decided 
answTer,  are  the  amount  of  relief,  and  also  the  amount  of  annoyance, 
which  will  follow  the  formation  of  an  artificial  anus. 

The  amount  of  relief  given  will  depend  on  the  amount  of  pain  the 


*  To  quote  only  two  special  wretchednesses — e.g.,  when  a  lady  cannot  rise  from  her 
easy -chair  without  an  escape  of  flatus  or  feces  taking  place  from  a  powerless  sphincter  ; 
or  when  a  man  is  threatened  with  agonies  of  pain  from  the  carcinoma  eating  backwards 
and  involving  the  sacral  nerves,  and  causing  caries  of  the  sacrum  with  fistula?  and  foul 
discharge. 

t  In  a  few  cases  the  growth  may,  instead  of  projecting  into  and  obstructing  the  lumen 
of  the  bowel,  have  led  by  ulceration  to  enlargement  of  the  gut  into  a  cavern-like  space. 


112  OPERATIONS  ON  THE  ABDOMEN. 

patient  has,  the  degree  to  whieh  obstruction  is  threatening,  or  the 
presence  of  special  miseries  such  as  those  alluded  to  above.  Patients 
may  be  assured  that  any  continuous  pain  will  be  greatly  lessened  in 
severity,  if  not  entirely  removed  ;  that  defalcation  will  become  easy, 
painless,  and,  after  the  first  four  or  six  weeks,  limited  to  one  motion  a 
day,  save  when  diarrhcea  is  present;  and  that  the  distress  of  constant 
desire  to  go  to  stool,  and  tenesmus,  will  disappear.* 

The  other  part  of  the  question — the  amount  of  annoyance  following 
on  an  artificial  anus — must  be  honestly  met.  There  is  too  great  a 
tendency  amongst  winters  on  colotomy  to  teach  that  if  the  operation 
is  done  sufficiently  early,  and  if  its  immediate  risks  are  survived,  the 
relief  is  always  decided,  and  the  patient's  condition  always  a  most  satis- 
factoiy  one.  This  tendency  has  largely  arisen  from  colotomy  being  so 
often  performed  on  hospital  patients  whom  it  is  so  difficult  to  keep  long 
under  observation.  While  it  is  always  right  to  remember  that  the  dis- 
ease is  a  mortal  one,  and  that  if  a  fair  comparison  is  to  be  made,  it  must 
be  not  between  the  condition  with  an  artificial  anus  and  that  of  perfect 
health,  but  between  an  artificial  anus  and  a  bowel  with  incurable  cancer, 
the  patient's  after-condition  will  be  materially  affected  by  his  position  in 
life.  Where  a  patient's  remaining  days  are  easy,  where  he  can  continue 
to  be  careful  in  his  food  to  avoid  diarrhoea,  where  he  can  pay  regular 
attention  to  the  opening,  this  may  give  little  annoyance ;  and  it  is  also 
a  rule  that  the  greater  the  miseries  of  pain  and  frequent  and  difficult 
defalcation  from  which  the  patient  has  been  relieved  by  colotomy,  the 
more  easily  does  he  forget  any  annoyance  of  the  anus  in  his  relief  at 
what  he  has  escaped  from  in  the  past.  But,  on  the  other  hand,  where 
the  surroundings  of  the  patient  compel  him  to  try  and  work,  the  friction 
of  any  prolapsed  bowel  which  follows  on  movements  of  the  thigh  and 
groin,  the  difficulty  of  paying  attention  to  the  opening,  of  avoiding 
diarrhoea  from  unsuitable  food,  of  washing  out  the  lower  bowel — all 
these  may  mean  that  colotomy  has  only  enabled  the  patient  to  exchange 
a  life  of  miseries  for  one  of  annoyances — the  annoyances  of  the  opening 
for  the  miseries  of  the  disease;  annoyances  certainly  less  important,  but 
not  the  less  present  to  the  patient  because  the}r  were  unexpected.  And, 
as  I  have  said  before,  the  less  urgent  the  conditions  for  which  the 
colotomy  was  done,  the  less  the  patient  has  been  relieved  from,  the  more 
actively  will  the  annoyances  of  the  artificial  opening  be  present  to 
his  mind.  The  more  frequently  a  surgeon  performs  this  opera- 
tion, the  more  readily  will  he  admit  that  there  are  cases  in 
which  colotomy,  though  well  performed,  fails  to  give  the  expected 
amount  of  relief. 

Putting  aside  cases  where  the  operation  is  performed  too  late,  and 
where  the  local  mischief  has  been  allowed  to  become  too  advanced,  those 
where  secondary  deposits  exist,  cases  where  the  opening  has  been  too 
free,  or  where,  with  a  proper  opening,  a  constant  cough,  aided  by  a 
relaxed  condition  of  tissues,  tends  to  bring  about  a  worrying  prolapsus, 
— putting  aside  cases  in  which  the  opening  was  perhaps  originally  too 
small,  or  in  which  the  patient  does  not  take  the  trouble  to  keep  the 
opening  dilated  as  directed, — I  am  of  opinion  that  occasionally  cases  of 

*  I.e.,  if  the  opening  is  free,  if  there  be  a  good  "  spur,''  and  no  fteces  find  their  way 
into  the  bowel  below. 


COLOTOMY 


113 


failure  to  give  complete  relief  sire  met  with  after  an  operation  quite 
properly  carried  out.  While  I  cannot  give,  and  have  failed  to  meet, 
an  explanation  for  every  case,  I  think  the  following  are  bond  fide  causes, 
and  without  detracting  seriously  from  the  value  of  this  excellent  opera- 
tion, because  only  occasional,  I  feel  that  they  have  been  somewhat 
unduly  overlooked. 

Some  of  these  instances  of  incomplete  relief,  viz.,  persistent  passage 
of  motions  over  the  malignant  disease  and  teasing  diarrhoea  from  the 
artificial  and  natural  anus,  have  seemed  to  me  to  be  due — (a)  to  the 
lower  communication  with  the  bowel  being  too  patent,  sometimes  no 
doubt  accounted  for  by  the  fact  that  the  colon,  at  the  spot  where  it  has 
been  drawn  into  the  wound,  owing  to  the  shallowness  of  the  loin  or  the 
length  of  the  meso-colon,  is  scarcely  kinked  or  bent  at  all  :  this  leads  to 
escape  of  fasces  over  the  malignant  growth,  and  much  pain  and  teasing 
diarrhoea ;  (b)  to  persistence  of  the  growth  in  the  bowel  below,  causing 
a  profuse  sanious  discharge  ;  (c)  to  the  growth  extending  upwards 
towards  the  wound,  or  to  the  bowel  having  been  opened  only  just  above 
the  growth. 

The  question  of  the  value  (or  otherwise)  of  colotomy  as  a  preliminary 
to  excision  of  the  rectum  will  be  discussed  in  Chapter  XIV. 

(2)  Venereal  or  syphilitic  stricture  of  rectum,  in  which  previous 
treatment,  including  dilatation,  has  failed,  and  in  which  proctotomy*  is 
not  available. 

Much  of  what  has  been  written  above  of  colotomy  for  malignant 
disease  of  the  rectum  applies  to  the  operation  here  also.  There  is  one 
reason  for  resorting  to  it  earlier  which  may  occasionally  arise,  and  that 
is  where  the  patient  is  young,  and  colotomy  is  called  for  b}r  extensive 
ulceration,  it  is  possible  that  with  the  rest  given  by  the  operation 
the  above  condition  may  be  healed,  and  the  artificial  opening  closed 
later  on. 

(3)  Pelvic  tumours — e.g.,  enchondroma  or  sarcoma — pressing  on  the 
rectum. 

(4)  Results  of  pelvic  cellulitis  narrowing  the  rectum. f 

(5)  Vesicointestinal  fistula. 

Colotomy  is  performed  in  cases  of  communication  between  the  large 
intestine,  especially  the  rectum,  and  the  bladder,  to  prevent  the  passage 


*  Linear  division  of  a  non-malignant  stricture  posteriorly.  If  a  finger  cannot  be  passed 
through  the  stricture,  this  is  first  divided  with  a  probe-pointed  bistoury  to  admit  the  finger. 
Then  a  curved,  sharp-pointed  bistoury,  passed  through  the  stricture,  is  made  to  transfix 
the  bowel  beyond  the  stricture,  and  the  point  is  brought  out  close  to  the  tip  of  the  coccyx. 
The  parts  are  then  cleanly  divided  by  cutting  out  towards  the  anus  in  the  middle  line. 
Most  strict  antiseptic  precautions  are  necessary.  In  about  ten  days  the  use  of  bougies  is 
commenced. 

t  This,  though  rare,  is  occasionally  an  undoubted  indication  for  colotomy.  I  still  see 
from  time  to  time  a  woman  on  whom  Sir  Henry  Howse,  over  eighteen  years  ago,  performed 
colotomy  for  urgent  obstruction  due  to  the  contraction  of  the  bowel  brought  about  by 
pelvic  cellulitis.  More  lately  I  have  had  under  my  care  a  woman,  aged  23,  a  patient  of 
Dr.  Howell's,  of  Wandsworth,  on  whom  chronic  obstruction  had  been  brought  about  by  the 
same  cause,  dating  here  to  the  birth  of  an  illegitimate  child.  The  ring  of  contraction 
round  the  rectum  was  here  so  marked,  that  carelessness  in  diet  or  neglect  of  the  use  of 
bougies  will,  I  am  certain,  lead  to  colotomy  being  ultimately  called  for.  The  possibility 
of  the  mischief  in  these  ca-es  being  gummatous  must  always  be  remembered. 

S. — VOL.  II.  8 


H4  OPERATIONS  ON  THE  ABDOMEN. 

of  faeces  into  the  bladder,  with  its  results  of  cystitis,  agonising  obstruc- 
tion of  urine,  and  passage  of  flatus  from  the  urethra  without  notice  and 
beyond  control. 

Such  a  fistula  is  much  more  frequently  met  with  between  the  sigmoid 
or  rectum  and  the  bladder;  if  between  the  latter  and  the  rectum,  the 
communication  may  be  found  by  the  finger,  or  by  passing  a  duck-bill 
speculum,  or  by  the  aid  of  the  sigmoidoscope  and  injecting  coloured 
fluids  into  the  bladder.  Too  frequently  malignant  in  character,  it  is 
occasionally  of  a  simpler  nature — e.g.,  dysenteric,  &c, — and  so,  perhaps, 
curable.  Thus,  in  Mr.  Holmes's  case  (Med.-Chir.  Trans.,  vols.  xlix. 
and  1.)  the  ulceration  between  the  sigmoid  and  the  bladder  was  not  malig- 
nant, colotomy  for  fifteen  months  was  most  successful,  but  a  permanent 
cure  was  prevented  by  similar  ulceration  taking  place  between  the  caecum 
and  bladder,  which  caused  death.  Whether  the  cause  is  malignant 
disease  or  no,  the  life  which  lies  before  the  patient  is  scarcely  tolerable. 

The  opening  is  far  more  frequently  valvular  in  nature — i.e.,  while  it 
admits  of  the  passage  of  faeces  into  the  bladder,  urine  very  rarely  passes 
per  anum. 

(6)  Colotomy  (iliac)  is  usually  performed  on  the  left  side  in  cases  of 
malformation  of  the  rectum,  when  this  part  of  the  intestine  cannot  be 
found  by  a  dissection  in  the  perinseum.  It  has  been  disputed  in  these 
cases  whether,  after  an  unsuccessful  exploration  in  the  perinaeum,  an 
iliac  or  a  lumbar  colotomy  should  be  performed.  The  great  majority 
of  surgeons  have  preferred  the  former  operation,  following  here  Mr. 
Curling  (Diseases  of  the  Rectum,  p.  228).  This  surgeon  pointed  out 
that  the  lumbar  operation  was  contraindicated  on  the  following 
grounds: — (a)  The  death-rate  is  relatively  greater;  (/?)  the  kidney, 
varying  in  size  at  this  time  of  life,  may,  when  large,  overlap  the  colon  ; 
(y)  the  colon,  instead  of  being  distended  with  meconium,  as  might  be 
expected,  is  sometimes  contracted  and  very  hard  to  find  ;  (8)  in  addition 
to  the  irregularities  in  the  position  of  the  colon  which  have  already 
been  mentioned,  a  meso-colon  is  frequently  present.* 

To  these  reasons  may  be  added,  that  an  anterior  incision  allows  a 
thorough  exploration  to  be  made  ;  recently  three  cases  have  come  under 
my  notice  in  which  the  whole  of  the  large  intestine  was  represented 
by  a  fibrous  cord  with  a  very  minute  central  canal,  and  the  ileum  had 
to  be  opened. 

The  question  was  raised  by  M.  Huguierf  whether,  when  the  inguinal  operation  was 
going  to  be  performed,  the  right  side  should  not  be  chosen,  as  he  considered  that  on 
this  side  the  surgeon  was  more  certain  to  reach  some  part  of  the  large  intestine. 
M.  Giraldes,J  on  the  other  hand,  has  stated  that  all  the  inquiries  undertaken  to  elucidate 
this  subject  tend  to  show  clearly  that  the  surgeon  may  rely  on  nearly  always  finding 
the  sigmoid  in  the  left  groin.     "Numerous  anatomical  investigations,  together  with  the 

*  Mr.  Curling  (loc.  supra  cit.~)  gives  the  results  of  twenty  dissections  on  the  bodies  of 
infants,  both  operations  having  been  first  performed.  In  eighteen  out  of  the  twenty, 
Littre's  operation  was  found  easy,  whether  the  bowel  was  distended  or  no.  In  two,  this 
operation  failed,  as  the  colon  crossed  the  spine  to  run  down,  on  the  right  side,  into  the 
pelvis.  In  eight  out  of  the  twenty  subjects,  lumbar  colotomy  was  easily  performed,  without 
opening  the  peritonaeum.  In  six,  the  operation  was  "more  or  less  difficult,"  and,  as  Mr. 
Curling  remarks,  the  difficulties  would  have  been  increased  in  the  living.  In  six,  lumbar 
colotomy  was  impossible  owing  to  the  distinctness  and  looseness  of  the  meso-colon. 

t  Bull,  de  V Acad,  de  Med.,  torn.  xxiv.  p.  445. 

%  Led.  Clin,,  p.  121,  quoted  by  Mr.  Holmes  (DU.   of  Children,  p.  179). 


COLOTOMY.  115 

reoorda  <>f  those  of  Curling  and  Bourcart,  have  shown  me  thai  in  the  grc.it  majority  of 
In  the  foetus  and  newly-born  child  the  sigmoid  flexure  is  placed  on  the  left,  and  no1  on 
the  right.  In  t  34  autopsies  below  the  age  of  a  fortnight  I  found  the  sigmoid  flexure 
on  the  left  side  in  114;  in  50  cases  of  Littr6's  operation  which  I  have  collected  the 
operator  always  met  with  the  sigmoid  flexure  on  the  left  side;  in  30  post-mortem 
examinations  of  infants  operated  <>n  for  imperforation  the  intestine  was  always  found 
on  the  lil't  ;  in  100  examinations  of  new-born  children  Curling  found  the  sigmoid  flexure 
,m  the  left  side  83  times;  and  Bourcart,  who  made  prolonged  researches  in  order  to 
elucidate  this  question,  found  the  sigmoid  flexure  in  its  normal  position  117  times 
out  of  150." 

(7)  Tuberculous  disease  of  the  rectum  if  extensive  occasionally 
demands  a  temporary  colotomy;  the  rest  so  obtained  may  be  of  great 
value,  and  the  artificial  anus  may  be  closed  later  in  some  cases. 

(8)  Dysenteric  ulceration  and  stricture.  The  treatment  of  dysentery 
leading  to  stricture  is  rare ;  when  it  occurs,  ulceration  may  extend  so 
high  up  the  large  intestine  as  to  make  even  a  right-sided  colotomy  of 
doubtful  value.  A  case  of  colitis  (the  nature  of  this  is  not  explained) 
with  ulceration,  treated  by  inguinal  colotomy  and  local  treatment  of 
the  ulcerated  surfaces,  with  subsequent  closure  of  the  artificial  anus, 
is  recorded  by  Mr.  Mayo  Robson  (Clin.  Soc.  Trans.,  vol.  xxvi.  p.  213). 
In  patients  who  give  a  history  of  long-standing  dysentery  and  stricture, 
dysentery  is  often  the  result  and  not  the  cause  of  the  stricture. 

(9)  Annular  stricture  of  the  sigmoid  colon,  practically  always 
carcinomatous. 

(10)  Malignant  disease  of  the  large  intestine  higher  up — viz.,  in  the 
splenic  or  hepatic  flexures.  Here  colotomy  may  be  performed  as  a 
temporary  measure  preparatory  to  the  removal  of  the  growth  which  has 
caused  acute  obstruction. 

(11)  Membranous  colitis  and  ulcerative  colitis.  Mr.  Golding  Bird 
and  Dr.  Hale  White  have  described  three  cases  of  membranous  colitis 
in  which  right  lumbar  colotomy  was  performed,  and  one  case  of  chronic 
dysentery  in  which  csecostomy  was  employed  (Clin.  Soc.  Trans.  1896 
and  1899).  They  have  also  given  the  more  valuable  subsequent  histories 
of  these  cases  (Clin.  Soc.  Trans.,  1902). 

Case  i.  Female  jet.  30,  of  neurotic  temperament,  had  suffered  from  chronic  mucous  and 
membranous  colitis  for  ten  years.  The  right  lumbar  colotomy  was  performed,  and  a  spur 
soon  formed  so  that  no  faeces  entered  the  ascending  colon.  The  symptoms  all  disappeared, 
and  the  colotomy  was  easily  closed  after  five  weeks  ;  the  patient  remaining  quite  free  from 
symptoms  of  colitis  until  her  death,  two  months  later,  from  general  peritonitis  of  uncertain 
origin.     A  small  pelvic  tumour  existed,  which  may  have  contained  pus  and  ruptured. 

Case  ii.  Female  jet.  36  had  suffered  from  severe  membranous  colitis  for  twenty  years.  In 
May,  1896,  right  lumbar  colotomy  was  performed  in  two  stages,  and  the  patient  improved 
very  much  in  her  general  health,  but  she  still  passed  a  few  casts,  but  otherwise  she  had  not 
a  bad  symptom  when  in  May,  1897,  the  colotomy  was  easily  closed.  In  November,  1898,  she 
was  quite  well  and  leading  an  active  life,  but  had  to  take  aperients.  In  February,  1902, 
she  had  rheumatic  fever,  and  the  patient's  mother,  replying  to  an  inquiry,  stated  that  '"she 
has  to  admit  that  there  is  very  little  change  in  her  condition  compared  with  that  before 
operation,  and  she  could  not  candidly  say  that  there  is  a  perfect  cure."  "  The  general 
health  is  very  bad,  occasionally  swelling  attacks  (tympanites),  great  wasting  of  the  body  ; 
the  food  passes  through  undigested,  accompanied  by  casts  and  blood  occasionally.  .  .  .  There 
is  considerable  constipation."     The  relapse  began  in  December,  1898. 

Case  iii.  Female  jet.  31,  a  barmaid,  had  suffered  from  symptoms  of  severe  colitis  for 
eighteen  months,  passing  much  membrane.  In  March,  1898,  right  lumbar  colotomy  was  per- 
formed in  two  stages,  with  an  interval  of  five  days.     This  gave  great  relief.     A  weak  solution 

8—2 


u6  OPERATIONS   ON    THE   ABDOMEN. 

of  lysol  was  injected  Into  the  colon  on  two  occasions,  but  this  was  followed  each  time  by  a 
return  of  the  symptoms,  and  casts  were  passed  ;  the  same  thing  occurred  in  the  second 
month,  when,  owing  to  the  formation  of  a  keloid,  the  wound  contracted  and  sonic  fasces 
escaped  up  the  colon.  The  patient  left  the  hospital  after  four  months,  and  she  was  then  in 
excellent  health.  It  was  proposed  to  close  the  artificial  anus  aftor  a  year,  but  the  patient 
was  anxious  not  to  hurry  and  so  run  any  risk  of  a  relapse. 

No  difficulty  was  experienced  in  closing  the  artificial  anus  in  September,  1900,  two  and 
a  half  years  after  it  was  made. 

During  the  two  and  a  half  years  in  which  the  fistula  remained  open  the  patient  kept 
in  perfect  health,  resuming  her  business  as  a  barmaid  six  months  after  the  artificial  anus 
was  made,  and  subsequently  continuing  her  occupation  without  interruption.  She 
suffered  no  inconvenience  from  the  protective  apparatus  she  wore  over  the  opening. 
During  the  eighteen  months  that  have  now  elapsed  since  the  closure  of  the  wound  she 
has  remained  in  perfect  health,  following  her  usual  occupation.  She  was  taken  into 
Guy's  Hospital  in  November,  1901,  for  a  short  time,  and  all  the  motions  were  examined, 
and  found  to  be  perfectly  natural. 

Case  iv.  Male  vet.  35  had  suffered  from  symptoms  of  chronic  colitis  (probably  dysenteric) 
for  seven  years.  In  December,  1898,  the  caecum  was  opened  through  an  inguinal  incision, 
the  bowel  being  first  sewn  to  the  parietes  ;  it  did  not  allow  of  being  pulled  out  sufficiently 
to  pass  a  rod  or  anything  else  behind  it  ;  the  operation  was  performed  in  two  stages  with 
an  interval  of  five  days. 

Owing  mainly  to  the  fluidity  of  the  contents  of  the  bowel,  it  was  found  impossible  to 
prevent  a  little  motion  now  and  then  passing  into  the  colon  ;  but  after  the  external 
opening  had  been  somewhat  enlarged,  and  a  suitable  plug  fitted,  fasces  got  more  seldom 
into  the  colon  ;  but  throughout  the  case  up  to  the  time  of  the  man  leaving  the  hospital 
some  motion  would  escape  that  way  once  in  two  or  three  days.  To  try  to  prevent  this,  a 
Paul's  tube  was  inserted  into  the  ileo-caecal  valve,  which  was  easily  felt  opposite  the 
artificial  opening  in  the  caecum  ;  it,  however,  did  not  answer,  and  was  invariably  and 
quickly  extracted.  A  rubber  plug  attached  to  a  shield  so  made  as  to  block  the  ascending 
colon  as  far  as  possible  was  found  to  answer  best.  After  seven  weeks  the  patient  left  the 
hospital  to  return  to  work  much  improved  in  his  general  health  and  having  lost  all  his 
symptoms  of  colitis. 

During  the  summer  of  1899  he  worked  hard  as  an  artisan  at  Woolwich  Arsenal,  and  as 
he  continued  perfectly  well,  was  anxious  for  an  early  closure  of  the  wound.  Two 
attempts  were  therefore  made  during  1899,  but  neither  was  successful,  though  the  opening 
was  much  reduced  in  size.  Since  the  second  of  these  attempts  very  nearly  all  the  fasces 
have  passed  naturally  through  the  colon  and  rectum  in  a  perfectly  healthy  way,  only  a 
little  occasionally  coming  through  the  colotomy  wound.  A  third  and  last  attempt  was 
made  in  1901,  but  again  with  only  partial  success.  But  on  February  25,  1902,  he 
presented  himself  in  good  health,  and  reported  that  the  small  sinus  resulting  from  the 
last  operation  had  closed  by  itself.  It  will  be  noticed  that  he  has  remained  well  for 
two  and  a  half  years  after  the  passage  of  faeces  along  the  colon  has  been  re-established. 

Oilier  cases  may  be  very  briefly  mentioned. 

Case  v.  Messrs.  Keith  and  Simpson  (Mid.  Press,  July  24,  1896),  quoted  Trans.  Clin. 
Sue,  1899,  publish  an  account  of  an  apparently  right  colotomy  performed  in  June,  1894, 
on  a  woman  aet.  34,  with  four  years'  history  of  membranous  colitis.  The  wound  was  kept 
open  for  seven  months  and  then  closed.     A  perfect  cure  is  recorded. 

Case  vi.  Dr.  Lawrie,  of  Weymouth  (Brit.  Med.  Journ.,  November  5, 1898).  The  patient 
was  47,  and  had  a  history  of  membranous  colitis  for  eleven  years.  Caecotomy  was  per- 
formed in  January,  1897.  The  report  says  that  the  caecum  was  able  to  be  drawn  out  of  the 
wound  and  a  rod  to  be  passed  through  its  mesenttry.  The  wound  was  kept  open  seven 
months.      The  last  note  of  this  case  is  in  February,  1898,  and  a  cure  is  claimed. 

V.  Curl  mentions  several  cases  of  moderately  severe  dysentery  treated  by  caecostomy 
with  hopeful  results  {Ann.  of  Surg.  1906,  vol.  xliii.  p.  543). 

It  ma}r  be  concluded  from  these  cases  and  others,  that  right  lumbar 
colostomy  may  be  beneficial  in  the  treatment  of  chronic   colitis,  and 


<JOLOTOM\. 


117 


that  the  operation  is  better  than  caecostomy  because  the  diseased  colon 
is  granted  a  more  complete  rest;  the  discharges  are  more  solid  and  less 
frequent  owing  to  the  absorption  of  fluid  in  the  caecum.  The  skin 
around  the  fistula  is  less  apt  to  get  inflamed  ;  the  artificial  anus  is  far 
more  easily  (dosed,  but  it  is  not  so  accessible  for  the  necessary  but  less 
frequent  attentions  of  the  patient. 

The  absorption  of  water  and  some  nourishment  in  the  caecum  is  a 
distinct  gain  in  feeble  patients.  Mr.  Golding  Bird  believes  that  com- 
plete rest  to  the  colon  is  more  valuable  than  irrigation.  The  time  of 
closure  must  not  be  too  early,  certainly  not  under  six  months,  and 
probably  not  under  a  year  in  most  cases. 

Mr.  Golding  Bird  considers  that  colotomy  is  preferable  to  ileo-sig- 
moidostomy  in  these  cases  for  several  reasons  :  the  anastomosis  may 
not  be  above  the  disease,  which  may  extend  to  the  pelvic  colon  in  some 
cases,  and  the  faeces  in  time  regurgitate  into  the  diseased  colon  above 
and  set  up  more  trouble.  He  also  thought  that  diarrhoea  would 
probably  occur  ;  since  then  it  has  been  shown  that  diarrhoea  is  only 
temporary  and  rarely  troublesome  in  ileo-sigmoidostonry.  The  other 
alternatives  of  treatment  are  valvular  csecostomy  and  appendicostomy 
with  irrigation,  which  are  discussed  later  on  (vide  p.  141). 

The  writer  knows  of  one  case  of  membranous  colitis  for  which  the 
whole  of  the  diseased  colon  was  excised  ;  the  patient  died. 

Of  the  above  11  conditions,  the  first  five  will  usually  be  treated  by 
inguinal  colotomy,  this  operation  being  preferred  for  the  reasons  men- 
tioned below  (p.  126),  as  long  as  the  abdomen  is  undistended.  The 
operation  chosen  in  the  eighth  must  depend  on  the  height  to  which  the 
disease  has  extended.  In  the  ninth  the  surgeon  will  be  justified  in 
cutting  down  upon  the  sigmoid  colon,  with  the  intention  of  excising 
the  disease  if  possible,  or  opening  the  bowel  above  it,  and  if  the  sigmoid 
be  found  empty  to  enlarge  the  incision  sufficiently  to  allow  the  hand 
to  be  introduced  for  exploration.  It  is  not  easy,  however,  to  explore 
the  whole  abdomen  from  this  region.  In  the  last  two  it  will  be  needful 
to  open  the  colon  high  up.  It  will  be  well  to  discuss  here  the  difficulties 
which  often  arise  in  deciding  as  to — 

The  Site  of  the  Proposed  Colotomy. — In  the  above  cases,  espe- 
cially where  intestinal  obstruction  is  threatening  from  malignant  disease 
with  distension  and  tympanites,  the  surgeon,  particularly  if  the  history 
is  deficient  or  misleading,  may  be  in  doubt  as  to  the  site  of  the  disease, 
and  therefore  wdiere  to  operate.  It  is  quite  impossible  to  make  fixed 
rules  for  advice,  but  the  following  points  will  help  in  doubtful  cases. 
Before  specifying  them  I  would  call  attention  to  two  points  :  one,  that 
malignant  disease  quite  low  down — e.g.,  in  the  sigmoid — may,  by  a 
sudden  onset  of  obstruction,  simulate  an  acuter  condition  of  things 
higher  up,  the  patient  being  too  ill,  or  otherwise  unable,  to  give  an 
account  of  previous  threatening  and  finally  culminating  obstructions. 
Here  the  following  alternatives  lie  before  the  surgeon  :  (1)  to  explore 
the  site  of  obstruction  through  one  rectus  near  the  middle  line  :  this 
is  by  far  the  best  method  ;  (2)  to  cut  down  upon  the  sigmoid  flexure 
in  the  hope  that  the  obstruction  may  be  in  this  neighbourhood,  a  very 
common  place,  and  if  the  sigmoid  be  found  empty  to  enlarge  the 
incision  sufficiently  to  allow  the  hand  to  be  introduced  for  explora- 
tion ;   it  is  not  easy,  however,  to  explore  the  whole  abdomen  from 


n8  OPERATIONS  ON  THE  ABDOMEN. 

this  region,  and  the  risk  of  prolapse  of  the  colon  is  increased  by 
enlarging  the  incision  :  moreover,  another  incision  may  have  to  be 
made  to  open  the  colon  on  the  right  side  unless  an  ileo-sigmoidostom}'' 
be  performed  ;  (3)  to  perform  right  lumbar  colotomy,  so  as  to  make 
sure  of  relieving  any  obstruction  further  back — e.g.,  in  the  splenic  or 
hepatic  flexures.  Unless  it  be  certain  that  the  obstruction  is  in  the 
colon,  this  course  is  not  recommended,  for  the  ascending  colon  may 
be  found  to  be  empty,  as  in  a  patient  who  was  later  found  to  have  a 
gall  stone  in  the  ileum.  In  all  doubtful  cases  it  is  better  to  make 
the  incision  near  the  middle  line,  so  that  a  thorough  exploration  can 
be  made.  I  would  here  warn  my  junior  readers  on  two  or  three  points. 
If  they  decide  first  to  explore  by  abdominal  section,  and  find  a  growth 
in  the  colon,  descending  or  ascending,  they  should  not,  even  if  the 
meso-colon  admits  of  it,  bring  the  bowel  into  the  middle  line  and  open 
it.  Making  an  artificial  anus  in  the  colon  by  a  median  incision  is 
usually  a  matter  of  difficulty,  the  bowel  not  coming  sufficiently  up 
into  the  wound  (this  does  not  apply  to  the  transverse  colon),  thus  the 
skin  has  to  be  forced  down  to  it,  causing  tension  on  the  sutures,  giving 
wa}T  of  these  a  little  later,  and  either  disastrous  results  or  a  most 
unsatisfactory  opening.  Even  if  it  were  usually  easy  to  carry  out  the 
above  course,  I  do  not  consider  it  would  be  good  surgery,  as  such 
displacement  of  the  large  intestine  may  lead  to  acute  obstruction  of 
some  loop  of  the  small  intestine  later  on. 

I  also  advise  against  opening  the  caecum  if  this  can  be  avoided. 
Owing  to  the  more  liquid  nature  of  the  faeces  here  from  the  close 
proximity  of  the  small  intestine,  though  the  patient's  nutrition  will  not 
suffer,  the  skin  in  the  neighbourhood  of  the  artificial  anus  is  liable  to 
most  troublesome  excoriations  and  ulceration. 

In  cases  where  the  surgeon  is  in  doubt  as  to  the  exact  site  of  the 
disease,  but  suspects  from  the  age  of  his  patient,  duration  of  the  trouble, 
history  of  "indigestion"  with  unsatisfactory  action  of  the  bowels, 
number  of  attacks  of  threatening  obstruction,  &c,  that  the  mischief  is 
somewhere  in  the  large  intestine,  attention  to  some  of  the  following 
points  may  be  useful : 

(1)  The  proportionate  frequency  of  stricture  in  different  parts  of  the 
large  intestine.  The  frequency  of  disease  in  the  rectum  and  sigmoid 
flexure,  as  compared  with  any  other  part  of  the  large  intestine,  and, 
generally  speaking,  the  frequency  of  disease  in  the  left  side  of  the  arch 
formed  by  the  large  intestine,  as  compared  with  such  disease  in  the 
right  side,  are  well  known.* 

(2)  Examination  of  the  rectum.  It  must  be  remembered  that  a 
growth  in  the  rectum  may  not  be  discovered  by  the  usual  digital 
examination  made  with  the  patient  lying  down,  whereas  it  may  be 
felt  when  the  patient  is  in  the  sitting  attitude  and  straining  ;  this 
brings  more  than  another  inch  of  rectum  accessible  to  the  finger,  and 
when  an  annular  growth  exists  high  up,  it  often  becomes  intussuscepted 
into  the  ballooned  rectum  below,  and  may  be  felt  when  the  patient  sits 

*  Dr.  Fagge,  in  drawing  attention  to  this  fact  (Guy's  Hosp.  Reports,  1868,  p.  314), 
quoted  the  following  statistics  from  Dr.  Brinton  : — "  Of  100  cases,  4  are  in  the  cascum, 
10  in  the  ascending  colon,  n  in  the  transverse  colon,  14  in  the  descending  colon,  30  in 
the  sigmoid  flexure,  and  30  in  the  rectum."  The  statistics  of  Dr.  Fagge  and  M.  Duchaussoy 
confirm  the  above. 


COLOTOMV. 


119 


upon  one  buttock.  Occasionally  also  a  growth  of  the  pelvic  loop  of 
the  sigmoid  flexure  may  be  felt  through  the  anterior  wall  of  the  rectum. 
The  sigmoidoscope  may  reveal  a  growth  in  the  upper  part  of  the 
rectum  or  the  lower  part  of  the  sigmoid  colon. 

(3)  The  form  of  the  abdomen  may  help  to  valuable  conclusions.  Thus, 
Dr.  Fagge  (loc.  supra  cit.,  p.  319)  gives  a  case  of  cancer  of  the  hepatic 
flexure  in  which  it  was  observed  during  life  that  the  csecum  and 
ascending  colon  were  distended,  and  not  the  descending  colon.  Again, 
he  observes  that  when  the  rectum  or  the  sigmoid  flexure  is  the  seat 
of  obstruction  the  lumbar  regions  and  the  epigastrium  are  no  doubt 
generally  prominent,  and  the  course  of  the  colon  is  more  or  less  plainly 
marked  out.  That  these  conclusions  are  only  valuable  if  not  too 
implicitly  relied  upon  is  shown  by  the  fact  that  cancer  of  the  rectum 
may  be  present,  with  vomiting,  peristalsis,  and  borborygmi,  and  yet 
there  may  be  no  general  distension  of  the  abdomen,  no  filling  out  at 
all  of  its  sides;  on  the  other  hand,  a  prominent  epigastrium,  and  the 
appearance  of  a  large  horizontal  coil  of  intestine  here,  may  lead  to  the 
conclusion  that  the  transverse  colon  is  distended,  the  disease  being, 
nevertheless,  in  the  ileum,  a  distended  coil  of  which  has  rivalled  the 
colon  itself. 

A  patient  observation  of  the  abdomen  for  peristalsis,  which  may  be 
stimulated  by  flicking  the  abdominal  wall  with  a  wet  cold  towel,  may 
sometimes  enable  the  surgeon  to  localise  the  site  of  the  obstruction 
almost  accurately. 

(4)  A  symptom  of  some  value,  if  verified  by  the  medical  man  himself, 
is  the  fact  that  for  some  time  the  motions  have  been  narrow,  tape-like, 
broken  up,  abnormal  in  bulk,  shape,  and  length.  This  symptom  generally 
points  to  a  growth  in  the  rectum  or  sigmoid.  Certain  fallacies  diminish, 
however,  the  value  of  the  above — e.g.,  that  in  cases  of  stricture  high 
up,  as  in  the  upper  part  of  the  sigmoid  flexure,  there  is  probably  room 
for  the  fasces,  after  they  have  got  through  the  stricture,  to  collect, 
till  their  characteristic  form  is  given  them,  though  we  do  not  know 
how  far  irritation  of  the  intestine  and  formation  of  mucus  at  the  seat  of 
the  growth  may  interfere  with  this. 

(5)  The  frequent  passing  of  "blood  and  slime  "  also  generally  indicates 
a  growth  low  down  in  the  large  intestine.  When  the  symptom  is  only 
terminal  in  a  case  of  chronic  obstruction  it  probably  means  that  the 
growth  has  become  intussuscepted;  in  a  recent  case  this  sign,  associated 
with  pain  and  tenderness  and  dulness  in  the  left  flank,  enabled  the 
writer  to  conclude  that  an  intussusception  of  a  growth  at  the  splenic 
flexure  had  occurred. 

(6)  A  few  other  points — e.g.,  constant  arrest  of  borborygmi  at  one 
spot,  fixed  pain  at  one  spot,  as  in  the  right  hypochondrium — may  give 
useful  indications.  The  use  of  large  injections  is  mentioned  only  to  be 
condemned  as  unreliable  and  dangerous.  It  is  unreliable  because  some 
of  the  fluid  may  pass  through  the  stricture,  and  it  is  dangerous  for 
the  same  reason,  for  the  distended  colon,  especially  the  caecum,  may  be 
ruptured  from  the  increased  distension  of  the  intestine,  often  the  subject 
of  "  distension  ulcers."    Moreover,  it  is  painful  and  wastes  precious  time. 

The  distance  to  which  a  long  bougie  or  rectal  tube  ])asse8  is  of  very 
little  value,  and  needs  only  this  briefest  mention  here  because  the 
surgeon  is  still  sometimes  called  to  cases  in  which  he  is  assured  that 


120  OPERATIONS  ON  THE  ABDOMK.V 

the  obstruction  cannot  be  in  the  rectum  or  low  down  in  the  sigmoid 
flexure,  as  a  long  bougie  has  been  easily  passed  its  full  length.  This 
fallacy,  which  is  due  to  the  bougie  bending  on  itself,  is  more  frequent 
than  the  other  one  in  which  the  arrest  of  a  bougie  by  one  of  Houston's 
folds  misleads  into  the  belief  that  a  stricture  exists  low  down.  The 
sigmoidoscope  is  far  more  reliable,  and  it  is  practically  safe  unless  care- 
lessly passed  without  its  obturator.  If,  after  weighing  the  above,  the 
surgeon  is  still  in  doubt  as  to  the  exact  site  of  the  disease  of  the  large 
intestine,  he  should  not  hesitate  to  open  the  abdomen  near  the  middle 
line  and  explore  for  the  site  of  the  disease,  and  then  decide  on  the 
line  of  treatment  to  be  adopted. 

LUMBAR    OR    POSTERIOR    COLOTOMY. 

Though  this  operation  has  of  late  years  been  practically  replaced  by 
the  iliac  method,  it  deserves  attention  as  the  operation  first  largely 
employed,  and  as  one  that  may  still  be  resorted  to  under  certain  rare 
circumstances  of  difficulty.  A  right  lumbar  colotomy  may  sometimes 
be  performed  in  preference  to  appendicostomy  or  valvular  caecostomy 
in  the  treatment  of  cases  of  chronic  colitis  (vide  p.  115).  The  indica- 
tions for  colotomy  have  been  already  given  at  p.  no,  and  a  comparison 
of  the  lumbar  and  iliac  methods  will  be  found  below  at  p.  126. 

Landmarks  (Fig.  51). 

I.  The  lower  border  and  tip  of  the  last  rib.  2.  A  point  half  an  inch 
behind  the  centre  of  the  crest  of  the  ilium,  this  point  being  found  by 
accurate  measurement  along  the  crest  between  the  anterior  and  posterior 
superior  spines  ("W.  Allingham).  3.  A  line  drawn  vertically  up  from 
the  last-mentioned  point  to  the  last  rib.  This  gives,  with  sufficient 
correctness,  the  line  of  the  outer  edge  of  the  quadratus,  and  the  posi- 
tion of  a  normal  colon.  Owing  to  the  varying  length  of  the  last  rib, 
the  upper  end  of  this  line  may  meet  this  bone  at  its  tip,  or  at  a  spot  a 
varying  distance  in  front  of  or  behind  this  point.  It  is  well  to  dot  the 
ends  of  this  vertical  line  with  an  aniline  pencil.  The  dint  of  a  finger- 
nail, made  when  the  patient  has  been  brought  under  the  anaesthetic, 
will  mark  these  points  sufficiently  to  begin  with,  but  a  little  later,  in 
a  difficult  case,  the  surgeon  may  be  glad  of  having  taken  every  possible 
precaution. 

Incisions. 

I.  Vertical,  of  Callisen.  This  at  first  sight  is  the  best,  as  it  follows 
the  above  line,  and  thus  corresponds  anatomically  to  the  colon,  but  it 
has  the  disadvantage  of  giving  but  limited  space,  especially  in  a  fat  or 
deep-chested  patient ;  and,  if  prolonged  upwards,  so  as  to  give  all  the 
space  possible,  it  divides  the  intercostal  vessels  running  with  the  last 
dorsal  nerve,  and  gives  rise  to  troublesome  haemorrhage.  2.  Transverse, 
of  Amussat.  3.  Oblique,  of  Bryant,  modified  from  the  above.  One  of 
the  two  latter  is  usually  employed  ;  they  have  the  great  advantage  of 
being  readily  prolonged  when  more  room  is  required,  and  the  oblique 
incision  corresponds  better  with  the  course  of  the  nerves  and  vessels.* 
It  is  the  one  given  below. 

*  The  late  Mr.  Greig  Smith  (Abdom.  Surg.,  p.  396)  gave  the  following  practical 
hint  : — "  In   thin    patients,   and    particularly   in    women,    whose   iliac   crests   are  more 


MJMBAIl    COLOTOMV. 


121 


Operation  (Figs.  36 — 39). — The  patient  being  turned  on  to  his  side 
(most  usually  the  right),  with  a  firm  pillow  under  the  loin,  the  parts 
cleansed,  the  tip  of  the  last  rib  and  the  point  on  the  crest  of  the  ilium, 
as  given  above,  being  dotted  with  an  aniline  pencil,  an  incision  is 
made,  beginning  z\  to  3  inches  from  the  spine,  according  to  the  size 
of  the  erector  spinas  a  little  below  the  last  rib,  and  running  downwards 
and  forwards  for  31  to  4  inches  towards  the  anterior  superior  spine. 
The  centre  of  this  incision  should  hisect  the  line  given  above  as  the 
line  of  the  colon. 

The  first  cut  should  expose  the  muscles,  the  skin  in  the  posterior  half 
being  thick,  and  the  subcutaneous  fat  often  abundant.  The  next  may 
go  well  into  the  muscles,  the  remainder  of  which  should  then  be  care- 
fully divided  with  the  knife,  so  as  to  expose  the  fascia  lumborum  ; 
any  bleeding  vessels   being  now   secured,    this  fascia  is    pinched    up, 

Fig.  51. 
Peritoneum, 


Line  of  colon. 

Colon. 

Quadratus 

lumborum. 


Last  rib. 


Lumbar  colotomy.        , 

nicked,  and  slit  up  on  a  director.  Two  retractors  being  placed 
on  the  lips  of  the  wound,  the  fat  which  lies  around  the  kidney 
and  behind  the  fascia  lumborum  is  next  torn  through  and  pulled 
away  with  the  fingers.  If  the  bowel  is  distended,  it  will  bulge 
up  into  the  wound,  pushing  before  it  the  tranversalis  fascia,  and  the 
operation  can  be  readily  completed.  If,  on  the  other  hand,  the  bowel  is 
empty,  the  real  difficulties  of  the  operation  only  begin  at  this  stage. 
The  wound  being  well  opened,  the  kidney,  if  it  come  down  below  the  rib 
(as  it  occasionally  does,  especially  in  a  patient  breathing  heavily  under 
the  influence  of  an  anaesthetic),  being  kept  out  of  the  way  by  the 
finger  of  an  assistant,  the  intestine  is  sought  for  by  scratching  with  a 
director,  or  two  pairs  of  forceps,  through  the  transversalis  fascia 
(Fig.  51),  exactly  in  the  line  to  which  attention  has  been  already 
drawn.  Several  layers  of  cellular  tissue  may  be  met  with  here,  and  it 
is  now  that  most  of  the  difficulty  is  usually  met  with,  owing  to  the 


prominent  than  in  men,  there  is  a  tendency  for  the  upper  lip  of  the  wound  to  fall 
inwards,  while  the  lower  lip  protrudes.  This  may  be  obviated  by  careful  apposition, 
and  by  not  bringing  the  line  of  the  incision  too  close  to  the  ilium.'' 


122  OPERATIONS  ON  THE  ABDOMEN. 

operator  being  afraid  of  the  peritonaeum,  and  to  his  not  opening  the 
transversalis  fascia  with  sufficient  decision.  Unless  this  point  is 
attended  to,  the  colon  cannot  bulge  satisfactorily  or  be  drawn  up  into 
the  wound. 

When  this  has  been  done,  scybala  in  the  colon  will  in  many  cases 
be  felt ;  but  if  the  large  intestine  is  empty,  much  trouble  may  be  met 
with  in  detecting  it  and  getting  it  up  into  the  wound,  especially  if,  close 
b}7,  the  peritonaeum  is  bulging  up. 

At  this  stage  the  following  points  may  be  usefully  remembered  : — 

(a)  The  exact  position  of  the  line  of  the  colon  (p.  120).  (b)  The 
lower  end  of  the  kidney,  and  its  relation  to  the  colon,  (c)  The  outer 
edge  of  the  quadratus  lumborum  (p.  120).  ((/)  The  sensation  of  thick- 
ness as  given  to  the  fingers  in  pinching  up  the  colon,  thus  distinguishing 
large  from  small  intestine,  {e)  The  feel  of  scybala  if  present.  (/')  Seeing 
one  of  the  three  longitudinal  muscular  bands  which  distinguish  the 
colon.*  (g)  Inflation  with  air  or  injection  of  fluid. t  (/*)  Mr.  Bryant 
has  advised  rolling  the  patient  over  on  to  his  back  at  this  stage,  so  that 
the  colon  may  be  felt  to  fall  on  the  finger  inserted  deep  into  the 
wound. 

The  bowel  having  been  found,  its  posterior  surface  is  to  be  drawn 
well  up  into  the  wound.  This  is  one  of  the  weak  points  of  the  lumbar 
operation.  Owing  to  the  shortness  of  the  meso-colon  and  the  fixity 
of  the  bowel,  especially  when  distended,  it  is  very  difficult  to  get  the 
bowel  out  of  the  wound  sufficiently  to  make  a  satisfactory  "  spur." 
Unless  this  is  done,  there  is  a  risk  of  the  patient  having  a  faecal  fistula 
instead  of  an  artificial  anus.  If  the  case  is  not  an  urgent  one,  the  bowel, 
when  well  pulled  up,  may  be  retained  there  by  means  of  a  rod  passed 
beneath  it.  If  the  shortness  of  the  meso-colon  prevents  the  use  of  a 
straight  rod,  this  must  be  suitably  curved,  so  that  the  bowel  may  still 
be  kinked,  but  without  undue  tension.  The  margins  of  the  wound  are 
then  carefully  closed  with  salmon  gut  sutures,  and  a  few  fine  ones  may 
be  passed  between  the  bowel  itself  and  the  margins  of  the  wound. 
The  usual  antiseptic  dressings  are  then  applied,  iodoform  being  dusted 
over  the  bowel  and  wound.     These  dressings  will  probably  not  need 

*  Mr.  H.  Allingham  {Brit.  Med.  Juurn.,  April  28,  18S8)  seems  to  consider  it  very 
difficult  to  ensure  finding  one  of  these  bands  without  opening  the  peritoneal  cavity. 
While  I  should  be  the  last  to  make  light  of  the  difficulties  which  may  beset  this 
operation,  I  feel  sure  that  few  surgeons,  who  have  had  a  large  experience  of  colotomy, 
will  agree  that  the  above  step  is  needful,  especially  if  the  line  given  by  Mr.  Allingham's 
father  be  strictly  followed.  Where  the  operation  is  done  in  two  stages  the  peritoneum 
may  be  opened,  if  needful,  without  any  drawback.  But  where  the  bowel  must  be  opened 
at  once — and  this  will  be  the  rule  in  lumbar  colotomy —any  injury  to  the  peritoneum 
is  to  be  avoided.     The  aphorism  quoted  at  p.  61  is  to  be  remembered  here  also. 

f  Air  is  most  readily  made  use  of.  It  may  be  pumped  in  by  a  Higginson's  syringe, 
a  Lister's  hand-spray,  but,  best  of  all,  by  the  special  apparatus  described  by  Mr.  Lund 
{Lancet,  1883,  vol.  i.  p.  588),  which,  by  means  of  an  elastic  ring,  secures  air-tijdit 
contact  with  the  anus  while  air  is  being  pumped  in,  either  as  an  aid  in  colotomy 
or  as  a  means  of  reducing  an  intussusception.  In  some  cases  of  cancerous  disease 
of  the  rectum  it  will  be  very  difficult  to  introduce  any  nozzle  for  inflation  beyond  the 
disease.  In  the  summer  of  1885.  when  performing  colotomy  at  Guy's  Hospital  in  a 
patient  the  lower  part  of  whose  rectum  had  been  unsuccessfully  excised  at  another 
hospital,  I  found  it  impossible  to  introduce  any  nozzle  when  desirous  of  inflating  an 
empty  colon. 


li'muai;   COLOTOMY.  123 

changing  (ill  the  second  or  third  day,  when  the  operation  is  completed 
by  opening  the  bowel  with  a  tenotomy-knife,  or  sharp-pointed  pair  of 
scissors.  This  opening  may  be  a  small  crucial  one.  Very  little  but 
flatus  will  pass  at  the  time,  but  a  director  will  show  the  presence  of 
laces,  and  mild  aperients  may  he  given  as  soon  as  the  parts  are 
firmly  healed. 

The  method  of  performing  colotomy  by  two  stages  was  introduced 
at  Guy's  Hospital  by  some  of  my  senior  colleagues,  Mr.  Bryant,  Mr. 
Howse,  and  Mr.  Davies-Colley,  being  based  on  that  most  important 
modification  of  gastrostomy  which  Mr.  Howse  was  the  first  to  make  use 
of  in  this  country,  Mr.  Davies-Colley  bringing  before  the  Clinical 
Society,  in  1885  (Trans.,  vol.  xviii.  p.  204),  a  paper  on  "  Three  Cases 
of  Colotomy  with  Delayed  Opening  of  the  Intestine."  The  great 
advantages  of  this  two-stage  method  are  (1)  that  it  defers  the  opening 
of  the  bowel  till  this  is  sufficiently  adherent.  (2)  By  this  delayed  escape 
of  intestinal  contents  the  gravity  of  any  injury  to  the  peritonaeum  at 
the  time  of  the  operation  is  very  much  diminished.  (3)  The  second 
great  trouble  after  colotomy — that  of  burrowing  suppuration  up  and 
down  the  planes  of  cellular  tissue,  which  have  of  necessity  been  freely 
opened — is  done  away  with.  The  opening  of  the  intestine  being  delayed, 
primary  union,  to  a  very  large  extent,  can  be  secured,  especially  with 
the  aid  of  deeply-passed  sutures,  or  of  chromic  gut  ones  cut  short  and 
dropped  in,  and  dry  dressings. 

But,  nowadays,  under  the  conditions  in  which  lumbar  colotomy  is 
usually  resorted  to — viz.,  obstruction  and  distended  intestine — it  will 
be  necessary  to  complete  the  operation  at  one  stage.  Here  the  dis- 
tension, and  the  difficulties  consequent  upon  it,  are  best  met  by  tying 
in  a  Paul's  tube.  The  wound  having  been  closed  as  far  as  is  possible, 
the  intestine  is  drawn  out,  and  the  surrounding  parts  are  shut  off  with 
sterile  gauze ;  a  small  opening  is  then  made  in  the  clamped  intestine, 
the  tube  inserted  and  tied  in,  and  the  patient  turned  on  to  his  back 
while  the  chief  of  the  accumulation  in  the  intestine  is  allowed  to  run 
away  safely.  When  sufficient  relief  has  been  given,  the  bowel  may  be 
additionally  secured  by  some  sutures  between  it  and  the  lips  of  the 
wound.  The  wound  having  been  carefully  shut  off  with  dressings, 
the  faeces  are  collected  by  means  of  india-rubber  tubing  fitted  on  to 
the  tube,  soiling  of  the  dressings,  &c,  being  prevented  by  jaconet. 

Difficulties  in  Lumbar  Colotomy. 

1.  An  empty  bowel.*  This  has  been  already  alluded  to  (p.  121). 
2.  Mistaking  bulging  peritonaeum  for  colon,  and  opening  it.  This 
may  be  due  to  the  surgeon  forgetting  the  line  of  the  bowel,  and 
working  deeply  too  far  forwards ;  or  it  may  take  place  from  no  lault 
of  the  surgeon,  being  due  to  the  presence  of  a  meso-colon,  or  to  the 

*  It  is  noteworthy  that  the  intestine  may  be  found  empty  even  in  obstructions 
of  long  continuance.  Thus,  Mr.  Curling  (Diseases  of  the  lleetum,  p.  182)  writes  :  "In 
a  case  of  carcinomatous  stricture  of  the  rectum,  in  which  I  performed  colotomy  after 
a  month's  obstruction,  in  a  woman  aged  40,  not  only  was  the  colon  contracted,  but 
it  was  actually  compressed  against  the  spine  and  put  out  of  the  way  by  the  distended 
small  intestine,  so  that  it  was  impossible  to  reach  the  bowel  without  opening  the 
peritonaeum.  No  inflammation  or  unfavourable  symptom  resulted."  It  would  have 
been  interesting  to  know  whether  more  than  one  obstruction  did  not  exist  in  the  large 
intestine  in  this  case. 


124  OPERATIONS   OX    THE!    AliDOMEN. 

extremely  contracted  condition  of  the  colon.*  It  by  no  means  always 
causes  peritonitis.  When  this  accident  has  happened,  as  shown  by 
the  escape  of  a  little  serous  fluid,  the  appearance  of  a  coil  of  small 
intestine  or  of  omentum,  the  opening  should  be  at  once  taken  up 
with  dissecting-forceps  and  tied  round  with  carbolised  silk  or  chromic 
gut,  and  a  little  iodoform  rubbed  round  the  ligature.  If  the  opening 
be  larger,  it  must  be  closed  with  catgut  sutures.  3.  A  very  fat  loin. 
This  is  not  a  very  uncommon  source  of  difficulty  in  elderly  people  who 
require  colotomy.  It  must  be  met  by  a  very  free  incision  in  which  all 
the  tissues  are  cut  equally  throughout  (i.e.,  not  making  a  conical  wound 
deep  only  in  its  very  centre  ;  this  not  only  adds  to  the  difficulty  of 
finding  the  bowel,  but  also  of  retaining  it  in  situ  afterwards).  To  meet 
the  additional  tension  and  tendency  of  the  gut  to  drag  away  in  these 
cases,  it  must  be  more  carefully  secured  by  close  stitching,  especially 
if  it  is  necessary  to  do  the  operation  in  one  stage,  every  care  being 
taken  to  prevent  extravasation  of  faeces  into  the  surrounding  cellular 
tissue,  t  In  fat  people  the  surgeon  must  be  prepared  not  only  for 
much  subcutaneous  but  for  abundant  extra-peritonseal  fat  also,  coarse, 
and  difficult  to  dissect  in.  If,  in  such  a  case,  the  colon  is  contracted, 
there  are  few  more  difficult  operations.  4.  Presence  of  a  meso-colon. 
This  may  be  a  cause  of  much  difficulty  and  doubt,  and  render  opening 
of  the  peritonaeum  necessary.  Where  this  is  the  case,  the  surgeon 
should  always  defer  opening  the  colon  if  possible. 

Mr.  Jessop  {Brit.  Med.  Jour//.,  1879,  vol.  ii.  p.  614)  mentions  cases  in  which,  owing 
to  the  presence  of  the  above,  he  was  obliged  to  open  the  peritonaeal  cavity  and  incise 
the  gut  through  its  peritoneal  coat.  The  cut  edges  of  the  bowel,  brought  through  the 
opening  in  the  peritonajum,  were  stitched  to  the  skin  as  in  the  ordinary  operation. 
No  bad  effect  followed.  Mr.  Bennett  May  {Brit.  Med.  Joum.,  1882,  vol.  i.  p.  940), 
operating  on  the  right  side,  found  an  empty  colon,  "  and  it  was  only  by  keeping 
strictly  in  Allingham's  line,  and  patiently  searching  there  between  the  layers  of  a 
great  length  of  meso-colon,  that  the  intestine  was  reached,  collapsed  and  empty." 

5.  Abnormality  of  colon.  Every  surgeon  must  remember  cases  in 
which  the  descending  colon,  though  present,  was  displaced,  and  came 
down  in  the  middle  line.  Occasionally  part  of  the  large  intestine  is 
actually  absent. 

Mr.  Lockwood  {St.  Barthol.  Hosp.  Reports,  vol.  xxix.  p.  256)  mentions  three  cases 
in   which    the   colon   could   not    be   found  ;    in    two   its    absence    was   verified   at  the 

*  In  a  case  in  which,  owing  to  the  extreme  pain  during  defecation,  the  patient  had 
dreaded  any  action  of  the  bowels,  and  had  eaten  very  little,  the  colon  was  much 
contracted  and  lay  far  back.  In  trying  to  find  it,  I  opened  the  peritonaeum,  and 
omentum  protruded.  A  carbolised  sponge  was  kept  over  the  opening  while  the  colon 
was  found,  the  opening  then  tied  up  with  chromic  gut,  and  the  colon  not  opened 
for  four  days.  No  ill  result  followed.  As  in  supra-pubic  lithotomy,  the  peritonaeum 
may  give  way  during  vomiting.  Thus,  Dr.  Walters  {Brit.  Med.  Joum.,  1879,  vol.  i. 
p.  212)  was  stitching  the  colon  to  the  wound  when  "the  patient  retched  violently, 
causing  the  peritonaeum  to  give  way,  and  a  coil  of  intestine  to  protrude  from  the 
anterior  part  of  the  wound.  This  was  immediately  covered  with  warm  sponges, 
cleansed  from  the  faeculent  matter  it  had  acquired  by  contact  with  the  open  colon, 
and  returned."  When,  five  weeks  later,  the  patient  sank  from  exhaustion,  no  trace 
of  peritonitis  was  found  at  the  necropsy. 

t  As  much  of  the  wound  as  is  possible  should  be  closed  before  the  intestine  is 
opened. 


i.imi'.ai:   COLOTOMY,  125 

necropsy,  both  on  the  right  side.  One  of  these  cases  is  reported  fully.  The 
following  arc  the  main  points  : — Owing  to  el '-'.ruction  of  the  large  intestino,  the 
f  which  was  donbtfnl,  it  was  decided  to  cut  down  on  the  right  colon.  No  colon 
could  be  found,  and.  relief  being  imperatively  demanded,  the  peritonaeum  was  opened 
and  a  loop  of  small  intestine  drawn  outside  the  wound.  Death  occurred  four  hours 
after  the  operation,  and  at  the  necropsy  the  right  colon  was  quite  absent.*  the  caecum 
:  found  behind  the  live;- in  the  righl  hypochondrium,  the  large  intestine  extending 
from  this  to  the  splenic  flexure  in  the  usual  manner. 

6.  Malignant  disease  at  the  site  of  colotomy.  This  is  best  met  by 
performing  colectomy  in  appropriate  cases,  or  by  performing  colotomy 

on  the  opposite  side.  7.  The  kidney  may  be  embarrassingly  low. 
8.  The  peritonaeum  may  be  so  pushed  back  by  ascitic  fluid  that  it  is 
impossible  to  open  the  gut  without  injuring  the  peritonaeum  (Pepper, 
Lancet,  vol.  i.,  iSSS,  p.  772).  9.  Cases  where  the  operation  has  to  be 
completed  at  once,  and  the  colon  is  much  distended  with  faeces,  will 
give  much  trouble  (p.  123). 

Troubles  which  may  be  met  with  after  Colotomy. 

1.  Too  large  an  opening  in  the  bowel.  This  may  lead  to  pro- 
lapse of  the  mucous  membrane.  If  this  take  place  to  a  large  extent 
it  is  a  great  nuisance  to  the  patient,  owing  to  the  moist,  excoriated, 
bleeding  surface  which  results,  difficult  to  keep  up  by  any  apparatus. 
Even  where  the  opening  has  been  small,  a  good  deal  of  prolapse 
may  take  place  if  there  is  much  cough  and  a  flaccid  condition  of  the 
side. 

2.  Too  small  an  opening  in  the  bowel.  This  is  of  much  less 
moment,  as  it  can  be  readily  dilated  by  tents.  Of  these,  laminaria  are 
much  the  most  efficient ;  two  should  be  inserted  at  a  time,  to  effect 
rapid  dilatation.  Then  the  opening  is  easily  kept  patent  by  the 
occasional  insertion  of  the  little  finger,  or  by  the  wearing  of  a  proper 
plug.     (See  also  p.  134.) 

3.  Teasing  descent  of  scybala  into  the  bowel  below  the  artificial  anus. 
This,  which  often  renders  a  colotomy  disappointing,  is  best  met  by 
bringing  the  colon  sufficiently  into  the  wound  at  first,  and  by  keeping 
patent  an  adequate  opening.  If  scybala  still  find  their  way  down,  the 
colon  may  be  washed  out  from  the  anus  or  the  wound.  If  these  fail,  the 
only  course,  and  one  not  devoid  of  risk,  is  to  open  up  the  wound,  to 
divide  the  bowel,  and  attach  the  upper  end  in  the  wound,  and  then  to 
displace  and  fix  the  lower  end  well  away  from  the  upper. 

Causes  of  Death  after  Colotomy. 

These  will  vary  somewhat  according  to  the  presence  of  obstruction  or 
no.  I.  Exhaustion,  especially  if  the  operation  has  been  deferred  too 
lone.  2.  Toxic  conditions  due  to  the  continued  distension  of  the 
intestines,  and  the  resulting  absorption  by  the  patient  of  poisonous 
material.  3.  Extravasation  of  fasces  and  burrowing  suppuration.  This 
is  especially  liable  to  happen  in  very  fat  patients,  in  whom  there  is  a 
difficulty  in  getting  the  colon  up  into  the  wound,  especially  if  the  bowel 
must  be  opened  at  once.     As  the  faeces  pump  out  under  high  pressure, 

*  Mr.  Lockwood  {Brit.  Med.  Journ,.,  1882,  vol.  ii.  p.  574)  explains  the  abnormalities 
of  the  large  intestine  by  the  fact  that,  during  its  development,  it  is  very  mobile;  the 
caecum  occupying  first  the  umbilical,  then  the  left,  next  the  right  hypochondrium,  and, 
finally,  the  right  iliac  region,  abnormalities  may  follow  its  arrest  at  any  part  of  its 
course. 


126  OPERATIONS   ON   THE   ABDOMEN. 

a  sufficiently*  free  opening  should  in  these  cases  be  made  into  the 
bowel  after  this  has  been  secured  as  carefully  as  possible. 

4.  Peritonitis.  This  may  be  due  to  the  operation  directly,  or  more 
indirectly  from  frecalor  purulent  retro-peritonreal  extravasation,  or  from 
septicaemia.  Often  it  is  not  due  to  the  operation,  but  to  the  want  of  it 
at  an  earlier  stage.  Thus,  the  distended  bowel  may  have  given  way  just 
above  the  obstruction  ;  often  it  is  that  weak  spot  the  caecum  which  is 
found  perforated  after  the  stress  of  distension.! 

5.  Septic  cellulitis,  erysipelas,  &c.  These  are  not  always  preventable 
in  an  exhausted  patient  where  it  has  been  necessaiy  to  open  the  bowel 
at  once. 

6.  Vomiting.  This  has  been  noticed  in  a  few  cases  to  occur  obstinately 
and  fatally  after  colotomy.  Mr.  Couper  (Brit.  Med.  Journ.,  1869,  vol.  ii. 
p.  557)  thinks  that  it  is  not  an  infrequent  cause  of  death,  and  suspects 
that  traction  on  the  bowel,  its  proximity  to  the  stomach,  and  the  fact 
that  both  receive  nerves  from  the  solar  plexus  will  account  for  this. 

7.  Broncho-pneumonia,  pleuritic  effusion,  especially  if  the  wound 
has  become  septic  in  an  exhausted  patient. 

INGUINAL,    ILIAC,    OR    ANTERIOR    COLOTOMY. 

Of  late  years  this  has  replaced  the  lumbar  operation  in  nearly  all 
cases  which  call  for  colotomy  (vide  supra,  p.  117). 

The  advantages  of  the  iliac  operation  are  chief]}' — (i.)  It  is  easier. 
Thus,  (a)  the  patient,  being  on  his  back,  takes  the  anaesthetic  better 
than  when  rolled  on  his  side  ;  (/?)  in  a  stout  patient,  especially,  the 
soft  parts  are  easier  to  divide,  and  the  resulting  wound  less  deep  and 
more  readily  dealt  with  than  one  in  the  loin  ;  (y)  the  bowel  is  more 
easily  reached,  and  with  less  disturbance  of  deep-lying  soft  parts ; 
(8)  there  is  no  risk  of  opening  small  intestine,  or  of  failing  through 
abnormality  of  the  colon,  (ii.)  The  peritonaeum  being  opened  of  set 
purpose,  the  surgeon  can  examine  the  site  and  extent  of  the  disease, 
(iii.)  The  shallower  wound  makes  it  much  easier  to  draw  out  the  intes- 
tine, and  make  a  satisfactoiw  angle  and  spur,  or  to  perform  colectomy, 
(iv.)  The  position  of  the  anus  renders  it  more  easily  accessible  for  the 
needful  attention. 

If  the  above  advantages  are  considered  separately,  I  think  there  is 
no  doubt  that  the  first  (and  this  is  the  most  important  one)  is  correct. 
Where  the  colon  is  distended,  the  lumbar  operation  is  an  easy  one  ;  but 
where  the  bowel  is  flaccid  and  lies  deeply  far  away  in  a  fat  patient,  the 

*  Not  needlessly  large,  for  fear  of  troublesome  prolapsus  later. 

f  The  following  reasons  have  been  given  in  explanation  of  this  well-known  fact — 
viz.,  the  proneness  of  the  caecum  to  give  way  under  the  stress  of  distension,  and  even 
when  at  some  distance  from  the  obstruction.  Dr.  Coupland  and  Mr.  Morris  (Brit.  Med. 
Journ.,  1S78)  attribute  it  to  the  cul-de-sac  nature  of  this  part  of  the  intestine  ;  its 
fixity  and  dependent  position  ;  its  being  the  place  where  two  currents  meet — viz.,  from 
the  ileum  and,  in  case  of  regurgitation,  from  the  colon  ;  and  the  pressure  to  which  it 
is  subjected  between  the  iliacus  and  the  abdominal  muscles.  Mr.  Lockwood  (St.  Bart. 
Hosp.  Reports,  vol.  xix.  p.  26)  thinks  that  the  explanation  lies  rather  in  the  peculiarity 
of  structure  of  the  cascum,  as  it  contains  a  very  large  amount  of  lymphoid  tissue,  and 
as  its  walls  are  not  strengthened  equally  with  other  parts  of  the  large  intestine  by 
encircling  bands. 


INC  (IN  Ah    (OLOTOMV. 


127 


operation,  in  spite  of  the  aids  given  :it  p.  120,  is  one  of  the  most 
difficult  in  all  surgery.  J  am  speaking  now  from  an  experience  of 
twenty-nine  cases  of  my  own  and  a  large  number  which  J  have  seen 
performed  by  my  colleagues.  Iliac  colotomy,  with  the  thinner  soft 
parts,  the  deliberate  opening  of  the  peritoneum,  and  the  more  acces- 
sible colon,  is  a  far  easier  and  simpler  operation.  The  second  advantage 
claimed — that  an  iliac  colotomy  enables  the  surgeon,  by  opening  the 
peritonseal  cavity,  to  examine  into  the  site  and  extent  of  the  disease — - 
will  be  found  an  important  one,  for  the  surgeon  can  decide  for  or 
against  the  possibility  of  the  removal  of  the  growth  at  a  second 
operation,  or  he  may  be  able  to  bring  the  growth  outside  the  abdomen 
and  excise  it  some  days  later  when  the  patient  has  recovered  from  the 
intestinal  obstruction.  The  third  advantage  is  an  important  one  in 
those  cases  where  a  deep  wound  loaded  with  fat  makes  it  very  difficult 
to  bring  up  and  anchor  a  lumbar  colon  satisfactorily.  On  the  fourth 
point,  on  which  much  stress  has  been  laid — that  an  artificial  anus  in 
front  is  placed  more  satisfactorily  for  the  patient's  needs  than  one  in 
the  lumbar  region — there  is  something  to  be  said  on  both  sides.  A 
patient  with  an  artificial  anus  in  front  can  clean  this,  adjust  the  pad, 
and  wash  out  the  bowel  below  far  more  comfortably.  If  the  motions 
have  been  allowed  to  become  constipated,  and,  in  order  to  get  relief, 
assistance  must  be  given  from  without — a  very  real  difficulty  sometimes, 
and  one  requiring  considerable  time  and  attention  on  the  patient's  part 
— this  can  be  done  very  much  more  easily  with  an  anus  in  the  iliac 
region.  On  the  other  hand,  the  passage  of  flatus  or  the  effluvium  of  a 
suddenly  escaped  motion  will  be  greater  annoyances  with  an  anus  placed 
in  front.  And  it  is  obvious  that  in  some  conditions  of  daily  life  a 
lumbar  opening  may  be  very  superior  to  one  in  front.  Thus,  at  one 
time  I  watched  for  seven  years  a  case  of  lumbar  colotomy  which  I 
performed  in  a  young  married  woman,  aged  20. 

The  disadvantages  of  iliac  colotomy  next  require  attention. 

1.  There  is  the  opening  of  the  peritonaeum.  AVhile  I  readily  allow 
that  antiseptic  details,  faithfully  followed,  have  gone  far  to  remove  the 
old  dread  of  the  peritonaeum,  the  risk  of  peritonitis  still  remains  con- 
siderable, especially  in  late  cases  when  the  bowel  is  distended,  friable, 
and  easily  torn  in  attempting  to  draw  it  into  the  wound  ;  faecal  extra- 
vasation is  then  difficult  to  guard  against.  Moreover,  in  these  late 
cases,  the  patient's  general  health  is  often  depressed  from  faecal 
intoxication  and  starvation,  and  his  power  of  repair  very  poor.  The 
peritonaeum,  too,  frequently  contains  serous  or  sanguineous  fluid,  and  is 
in  a  very  receptive  state  for  any  infection,  especially  when  the  bowel 
is  distended. 

2.  A  much  larger  amount  of  prolapsus  follows  this  than  the  lumbar 
operation.  Of  this  there  can  be  no  doubt  whatever.  It  must  be  so,  on 
anatomical  grounds,  viz.,  the  far  greater  mobility  of  the  sigmoid  colon, 
the  greater  laxity  of  the  soft  parts  in  the  groin  as  compared  with  those 
in  the  loin,  where  we  have  the  lumbar  fascia,  psoas,  and  kidney.  These 
points,  together  with  the  fact  that  in  walking,  standing,  and  sitting* 

*  "A  pad  and  bandage  which  is  satisfactorily  adjusted  with  the  patient  standing 
will  require  readjustment  with  the  patient  sitting.  ...  I  have  been  consulted  by 
several  subjects  of  iliac  colotomy  on  this  point,  and  found  their  grievance  to.  be  a  real 
ODe"  (Bryant,  Lancet,  1881,  vol.  ii.  p.  1215). 


128 


OPERATIONS  ON  THE  ABDOMEN. 


the  small  intestines  must  necessarily  tend  to  push  upon  and  protrude  an 
inguinal  artificial  anus,  all  explain  why  prolapsus  after  inguinal  is  so 
much  more  marked  than  after  lumbar  colotomy.  This  result,  if  the 
prolapsus  be  a  large  one,  causes  great  discomfort  to  the  patient, 
the  projecting,  moist,  readily  bleeding  mass  in  the  groin  interfering 
much  with  cleanliness  and  locomotion.  While  the  precautions  given 
later  will  serve  to  diminish  the  amount  of  prolapsus,  this  will  always 
give  more  trouble  here  than  in  the  lumbar  region  :  a  tendency  to 
large  prolapsus  there  is  quite  exceptional ;  with  iliac  colotomy  it  is 
common.  On  the  other  hand,  an  artificial  anus,  as  ojiposed  to  a 
faecal  fistula,  is  much  more  easily  secured  after  an  iliac  colotomy. 


^s> — 41 — Incision 


Site  of  incision  for  inguinal  colotomy. 

3.  Another  objection  to  iliac  colotomy,  and  one  which  I  thought 
would  be  found  a  real  one — that  for  disease  high  up  in  the  rectum,  or 
of  the  sigmoid  flexure,  an  iliac  opening  would  be  placed  too  near  the 
seat  of  mischief — does  not  seem  to  have  been  verified.  Rectal  cancer, 
for  which  iliac  colotomy  is  usually  performed,  very  rarely  extends  high 
enough  up  to  give  any  trouble.  If,  on  performing  the  iliac  operation, 
the  surgeon  comes  down  on  a  growth  in  the  sigmoid,  he  must  resect  it, 
or  make  an  opening  above  it,  or  perform  a  lumbar  colotomy. 

Operation. 

The  parts  having  been  duly  cleansed,  an  incision  2  or  2 J  inches  long 
is  made  2  inches  above  and  parallel  with  the  outer  part  of  Poupart's 
ligament  and  the  anterior  superior  spine  and  with  its  centre  above  the 
line  joining  this  bony  prominence  and  the  umbilicus.  There  are  three 
points  here  of  the  greatest  importance  from  their  bearing  on  the  chief 
drawback  of  this  operation,  prolapsus.     Mr.  Oipps  ("  Complications 


I.MJUINAL    COLOTOMY. 


I2Q 


arising  in  Inguinal  Colotoniy,"  Brit.  Med.Journ.,  Oct.  ig,  1895)  finds 
that  by  making  his  opening  in  the  abdominal  wall  somewhat  higher 
than  in  his  earlier  cases,  there  is  much  less  tendency  to  protrusion. 
He  now  makes  his  "incision  nearly  as  high  as  the  level  of  the  umbilicus, 
so  that  the  wall  of  the  lower  part  of  the  abdomen,  where  the  pressure 
is  greatest,  is  left  intact."  Another  point  to  be  insisted  on  is  that, 
wherever  the  opening  is  made,  it  should  he  as  small  as  possible.  The 
freer  the  incision,  the  weaker  the  abdominal  wall — already  naturally 
weak  here — and  the  more  certain  is  a  large  prolapsus  to  follow.  In  an 
ordinary  case  of  iliac  colotoniy  for  rectal  cancer,  the  operator  should 
endeavour  to  find  the  sigmoid  with  an  opening  admitting  one  finger  to 


Rod 


Descending- 
colon 


Inguinal  colotomy. 


explore  deeply,  if  need  be,  as  far  as  the  pelvic  brim,  and  hook  up  the 
sigmoid.  Lastly,  it  is  an  advantage  to  use  the  "gridiron  "  or  valvular 
incision  similar  to  that  which  McBurney  introduced  for  the  removal 
of  the  appendix.  The  risk  of  prolapse  is  much  diminished,  and  the 
control  obtained  over  the  artificial  anus  is  greater.  Carwardine  (Pract., 
vol.74,  1905,  p.  179)  cuts  across  the  fibres  of  the  external  oblique 
aponeurosis,  making  his  skin  incision  also  in  the  direction  of  the 
muscular  fibres  of  the  internal  oblique  and  transversalis.  He  states 
that  he  thus  avoids  the  contraction  of  the  orifice  that  is  liable  to  occur 
if  the  tendinous  fibres  are  merely  separated.  When  the  incision  is 
placed  as  high  as  advised  above,  the  tendinous  fibres  of  the  external 
oblique  are  not  seen.  More  oedema  of  the  prolapsed  loop  is  apt  to 
occur  when  muscular  separation  is  adopted  instead  of  division  of 
the  muscular  fibres,  but  this  soon  passes  off.  The  layers  of  the 
abdominal  wall  having  been  separated,  and  all  haemorrhage  arrested,  the 
s. — vol.  11.  9 


130  OPERATIONS  ON  THE  ABDOMEN. 

peritonaeum  is  then  raised,  and  slit  up  with  scissors  for  about  two-thirds 
of  the  wound  already  existing.  It  is  not  necessary  to  sew  the  parietal 
peritonaeum  to  the  skin  and  this  step  increases  the  tendency  to  pro- 
lapse. The  intestine  rapidly  adheres  to  the  muscular  wound.  The 
sigmoid  or  the  omentum  or  small  intestine  may  be  seen  in  the  wound. 
If  either  of  the  two  latter  present  (and  the  omentum  may  do  so  very 
persistently),  they  are  returned,  and  the  colon  sought  for  with  the 
finger.  It  is  usually  close  at  hand,  and  may  be  recognised  by  the 
scybala  which  it  contains,  or  by  its  appendices  epiploic®  and  longi- 
tudinal muscular  bands,  which  are  not  always  obvious  however.  In 
difficult  cases  the  bowel  will  be  found  by  searching  in  the  iliac  fossa, 
the  finger  being  passed  along  the  parietal  peritonaeum  from  without 
inwards,  until  the  sigmoid  is  encountered  attached  to  the  posterior 
wall ;  this  is  the  best  method.  Failing  this,  the  descending  colon  may 
be  traced  down  from  the  kidney.  It  is  well  to  remember  that  anterior 
colotomj'  is  not  always  the  easy  operation,  as  regards  finding  the  bowel, 
that  it  is  represented  to  be.  Mr.  Cripps  speaks  (loc.  supra  cit.)  of 
occasionally  having  had  great  difficulty  in  finding  the  bowel. 

In  one  case,  after  a  long  search,  he  was  unable  to  find  the  bowel ;  the  nurse  being 
directed  to  give  an  injection  of  water,  the  finger  near  the  brim  of  the  pelvis  then  felt  a 
piece  of  intestine,  which  had  before  been  overlooked,  becoming  distended,  and  the 
sigmoid,  which  was  lying  almost  over  in  the  right  iliac  region,  was  thus  detected.  In 
these  cases  of  difficulty  Mr.  Cripps  thinks  that  the  colon  will  almost  invariably  be  found 
nearer  the  middle  line  of  the  abdomen  than  where  the  operator  has  been  searching. 

In  a  case  of  Mr.  Cooper's,  reported  by  Dr.  Pennington,  of  Chicago  (Journ.  Amer.  Med. 
Assoc,  1893,  vol.  ii.  p.  773),  the  operator  having  failed  to  find  the  sigmoid,  water  was 
injected  into  the  rectum,  and  was  noticed  to  pass  into  the  right  iliac  fossa.  The  opening  in 
the  left  side  being  closed,  an  incision  was  made  in  the  right  inguinal  region,  where  the  gut — 
presumably  the  misplaced  sigmoid — was  readily  found.     The  patient  made  a  good  recovery. 

In  some  cases,  the  wound  may  have  to  be  enlarged  by  prolonging  the 
separation  of  the  two  deep  muscles  inward,  opening  the  rectus  sheath, 
and  drawing  the  rectus  inwards,  then  the  large  intestine  may  be  traced 
upwards  from  the  rectum,  if  necessaiy. 

The  bowel  being  found,  a  loop  of  it  is  drawn  up  into  the  wound.  In 
the  next  step  the  operator  should  carefully  follow  Mr.  Cripps  {Brit. 
Med.  Journ.,  1889,  vol.  i.  p.  771).  To  avoid  the  prolapse  which  is  cer- 
tain to  occur  if  loose  folds  of  the  sigmoid  remain  immediately  above  the 
opening,  this  surgeon  gently  draws  out  as  much  loose  bowel  as  will 
readily  come,  passing  it  in  again  at  the  lower  angle  as  it  is  drawn  out 
from  above.  In  this  way,  after  an  amount  varying  from  one  to  several 
inches  has  been  passed  through  the  fingers,  no  more  will  come.  As 
soon  as  the  descending  colon  is  found  in  this  way  to  be  nearly  taut,  a 
pair  of  dressing-forceps  is  pushed  through  the  meso-sigmoid  about  a 
quarter  of  an  inch  from  its  attachment  to  the  bowel,  and  a  straight 
piece  of  sterilised  gum  elastic  catheter  No.  10  or  12  caught  in  the 
forceps  and  drawn  through ;  a  glass  rod  or  a  vulcanite  one  suitably 
pointed  at  one  end  may  also  be  vised.  This  is  then  supported  outside 
the  abdominal  wall  at  either  end  by  antiseptic  gauze.  If  the  meso- 
sigmoid  is  thick  and  laden  with  fat,  a  nick  may  be  made  over  the  forceps 
and  rod,  any  vessel  being,  of  course,  avoided.  The  angles  of  the  wound 
may  be  closed  by  salmon-gut  sutures  if  necessary.  The  colon  is  covered 
with  aseptic  green  protective  to  prevent    adhesion  to  the    dressings. 


[NGUINAL   COLOTO.MY.  131 

The  wound  is  dressed  with  gauze  or  small  sterile  pads  arranged  all 
around  tho  bowel  so  that  the  latter  is  in  a  kind  of  box  and  is  not  liable 
to  be  damaged  by  the  firm  pressure  that  must  be  maintained  to  prevent 
protrusion  of  more  bowel*  through  the  wound.  This  danger  can  be 
avoided  by  applying  a  broad  band  of  strapping  firmly  all  round  the 
body  but  outside  the  dressings  (Davies-Colley).  The  bowel  may  be 
opened  by  a  transverse  incision  on  the  third  day.f  No  anaesthetic 
need  be  given  ;  if  the  patient  is  nervous,  a  10  per  cent,  solution  of 
cocaine  may  be  applied.  A  few  days  later  all  the  bowel  that  projects 
above  the  skin  is  cut  away  with  scissors,  Spencer  Wells's  forceps  being 
applied  to  each  bleeding  point. 

When  the  artificial  anus  is  only  required  as  a  temporary  measure  a 
longitudinal  incision  is  made  into  the  bowel,  for  this  leads  to  less 
gaping  and  is  easier  to  close. 

Some  surgeons  support  the  loop  of  bowel  outside  the  abdomen  by 
joining  the  edges  of  the  skin  through  a  rent  made  in  the  mesentery ; 
this  provides  a  splendid  spur,  for  the  two  openings  into  the  bowel 
ultimately  left  are  separated  by  a  bridge  of  skin. 

In  some  cases,  the  loop  of  the  intestine  cannot  be  drawn  out  of  the 
wound  and  fixed  by  means  of  a  rod  passing  through  the  mesentery,  the 
latter  being  too  short.  In  most  of  these  cases,  however,  the  bowel  can 
be  brought  well  up  into  the  wound  and  fixed  by  means  of  numerous 
sutures  passed  through  the  sero  muscular  coats  of  the  intestine  and  the 
margins  of  the  parietal  wound. 

All  sutures  should  be  removed  by  the  tenth  day,  or  earlier  if  any 
redness  is  present. 

When  the  projecting  loop  has  been  pared  down,  as  advised  above, 
two  openings  will  be  seen  separated  by  an  efficient  spur.  Through  the 
lower  of  these  the  rectum  can  be  washed  out,  and  the  removal  of  any 
faeces  lying  above  the  disease  facilitated.  Gradually,  usually  in  about 
a  month,  the  patients  will  begin  to  acquire  some  control  over  their 
artificial  opening,  but  it  will  not  be  till  several  months  after  the  opera- 
tion that  they  can  be  said  to  become  comfortable  in  this  respect,  and 
acquire  satisfactory  control  over,  and  management  of,  their  artificial 
anus.  And  for  the  rest  of  their  life  discharge  of  blood  and  slime  will 
occur  from  the  anus  with  frequency,  varying  according  to  the  rate  of 
growth  of  the  original  disease.  This  must  be  met  by  astringent  injec- 
tions and  suppositories.  Diarrhoea  must  be  treated  by  strict  attention 
to  diet,  and  by  astringents  ;  escape  of  offensive  flatus  or  fasces  from  the 
artificial  anus  (which  is  more  perceptible  to  the  patient  when  the  open- 
ing is  made  in  front)  may  be  met  by  the  use  of  charcoal,  a  teaspoonful 
being  given  twice  a  day,  or  the  following  may  be  taken  twice  a  day  in  a 
capsule  or  cachet,  viz.,  betol,  salol,  salicylate  of  bismuth,  of  each  gr.  v. 
(Mr.  C.  Heath,  Brit.  Med.  Journ.,  vol.  i.  1892,  p.  1243). 

Where  obstruction  is  present,  the  bowels  much  distended,  and  the 
sigmoid  requires  immediate  opening,  anterior  colotomy  may  still  be 
employed,  but  additional  care  must  be  taken  in  handling  the  intestines 

*  This  is  especially  needed  during  the  first  few  days.  Mr.  Cripps  insists  on  the 
nurse  sitting  by  the  bedside  to  apply  pressure  if  vomiting  occurs. 

t  Vomiting  and  distension  of  the  abdomen  are  indications  for  opening  the  bowel 
earlier  ;  it  is  safe  to  do  so  if  necessary  after  24  hours. 

9—2 


132 


OPERATIONS  ON  THE  ABDOMEN. 


Fig.  54. 


and  in  preventing  any  escape  of  fsecal  fluid  or  gas  into  the  peritoneal 
cavity. 

The  following  methods  may  be  adopted  : 

(a)  Extra  pains  may  be  taken  to  suture  the  bowel  accurately  to  the 
edges  of  the  wound,  and  the  line  of  suture  should  be  protected  by  care- 
ful gauze  packing.     The  gaseous  contents  of  the  bowel  may  then  be 
let  out  through  a  small  cannula  passed  obliquely  through  the  wall  of 
the  intestine  ;  this  may  afford  temporary  relief  in 
some  cases  until  adhesions  have  formed. 

(b)  Or  better,  some  form  of  enterostomy  tube 
may  be  inserted  to  conduct  the  thin  and  very 
virulent  fsecal  accumulation  to  a  receptacle  well 
away  from  the  wound.  A  portion  of  the  bowel 
is  emptied  and  gently  clamped,  and  the  tube 
introduced  without  contaminating  the  wound  if 
possible. 

A  Paul's  tube  may  be  tied  in  (Fig.  54). 
The  objection  which  has  been  raised  to  the 
method,  namely,  that  sloughing  and  loosening 
of  the  tube  take  place  too  rapidly,  may  be  met 
by  making  use  of  a  purse-string  suture  to  fix 
the  tube,  and  by  taking  care  not  to  tie  the  ligature 
tighter  than  is  absolutely  necessaiy.  See  also 
Enterostomy. 

Carwardine's  {loc.  cit.,  vide  Fig.  55)  enteros- 
tomy tube  may  be  used  ;  this  is  more  expensive  but  also  more  secure 
than  a  Paul's  tube,  and  it  does  not  become  detached  so  soon. 

A  much  simpler,  lighter  and  smaller  metal  tube  is  employed  by  the 
writer  (vide  Fig.  56).  The  thin  rubber  tubing  having  been  previously 
secured  to  the  outer  end  of  the  tubes  the  inner  extremity  is  secured  in 
the  bowel  by  a  purse-string  suture. 

Greig  Smith's  method  of  fixing  a  long  rubber  tube  in  the  intestine 
is  very  simple  and  nearly  always  practicable. 

Lilienthal's  (Aim.   of  Surg.,  Jan.  1906)   visceral  evacuator  prevents 


No.  1  is  for  the  large,  No.  2 
for  the  small,  intestine. 

The  lower  end  is  tied 
in,  the  upper  receives  the 
drainage-tube.     (Paul.) 


Fig.  55. 


Carwardine's  tube. 


leakage  but  is  somewhat  complicated,  large  and  rigid  for  use  in 
colotomy.  It  is  likely  to  be  of  more  value  for  the  temporary  drainage 
of  distended  intestine  during  an  operation  for  the  relief  of  acute 
obstruction  by  a  removable  cause  like  a  band. 

I  would  strongly  impress  on  my  younger  readers  the  need  of 
careful  attention  to  the  following  points  when  dealing  with  chronic 
obstruction   low  down   in  the    large    intestine    by   inguinal    colotomy. 


INGUINAL   COLOTOMY. 


133 


First,  the  sigmoid  is  difficult  to  find,  owing  to  the  tendency  of  the  small 
intestine,  much  distended,  to  crowd  out  of  the  wound.  It  is  very  easy, 
during  the  necessary  handling  of  such  intestine,  to  make  small  tears  in 
the  peritonaea]  coat.  In  meeting  the  above  difficulty  the  operator,  if  he 
cannot  find  the  sigmoid  quickly,  should  enlarge  the  wound  and  pack 
away  the  small  intestine  with  flat  sponges  attached  to  forceps.  The 
second  point  is  the  great  care  needed  in  suturing  a  distended  sigmoid 
when  it  is  brought  to  the  lips  of  the  wound,  it  being  now  very  easy  to 
perforate  the  mucous  coat,  and  thus  cause  an  escape  of  flatus  or  faeces 
before  the  peritonaea]  sac  is  shut  off. 

Madelung's  Modification  of  Colotomy. — This  has  been  largely  used, 
both  in  the  lumbar  and  inguinal  operation,  abroad.  In  this  country  it 
has  not  found  favour.  It  consists  in  draw- 
ing out  the  bowel  sufficiently,  packing  the 
wound  with  small  sponges  attached  to 
silk,  while  the  loop  of  intestine  (which, 
if  full,  should  be  emptied  as  far  as 
possible  by  squeezing  its  contents  up- 
wards) is  packed  around  with  tampons  of 
iodoform  gauze.  The  intestine  being 
clamped,  or  held  by  the  fingers  of  assist- 
ants, is  next  cut  across.  The  clamp  is 
then  removed  from  the  lower  end,  which  is 
emptied,  cleansed,  and  closed  by  careful 
suturing,  viz.,  one  continuous,  and  then 
others  by  Lemhert's  method,  causing 
efficient  inversion  of  the  sutured  extremity. 
This  end  is  then  dropped  back  into  the 
peritonaeal  cavity.  The  upper  end  is  now 
fixed  in  the  wound,  or  is  drained  by 
tying  a  glass  tube  in  it  to  which  india- 
rubber  is  attached,  by  the  method  of  Mr. 
Paul  (Fig.  54)  (Brit.  Med.  Joum.,  vol.  ii.  1891,  p.  118). 

The  above  method  has  never  been  much  used  in  this  country, 
for  the  following  reasons  : — 

1.  The  great  advantage  which  it  claims,  of  preventing  the  passage  of 
faeces  into  the  lower  part  of  the  bowel,  may  be  secured  by  much 
simpler  means,  viz.,  pulling  out  the  bowel  sufficiently  to  get  an  efficient 
spur,  and  cutting  away  the  intestine  afterwards. 

2.  It  has  inherent  grave  objections  : — 

(a)  It  has  happened  again  and  again  that  when  the  mesentery  is  long 
the  sigmoid  has,  unknown  to  the  operator,  become  twisted,  and  thus, 
when  it  is  drawn  up  into  the  wound,  the  upper  instead  of  the  lower  end 
may  be  closed  and  returned.  In  such  a  case  faecal  extravasation  through 
the  sutures  into  the  peritonaeal  cavity  must  occur.  Mr.  H.  Allingham 
states  (Brit.  Med.  Joum.,  1891,  vol.  ii.  p.  33J)  that  in  seven  of  his 
inguinal  colotomies  the  gut  must  have  been  thus  "  twisted,"  as  faeces 
came  away  through  the  lower  of  the  two  openings.  He  states  that  he 
knows  of  a  fatal  termination  from  this  cause  in  several  cases  in  which 
Madelung's  operation  had  been  adopted.  Mr.  Cripps  (ibid.,  p.  447)  has 
met  with  two  cases  in  which  what  he  believed  to  be  the  lower  end  of  the 
bowel  eventually  proved  to  be  the  upper.     Dr.  Landon,  of  Gottingen 


Enterostomy  tube. 


134  OPERATIONS  OX  THE  ABDOMEN. 

(Centr.  f.  Chir.,  Bd.  xxx.,  1891),  has  explained  the  above  fact  by  a 
necropsy. 

In  two  cases  of  inguinal  colotomy  in  the  Gottingen  clinic,  where  the  usual  practice 
is  to  divide  the  gut  and  to  stitch  the  two  open  ends  in  the  wound,  it  was  noticed  that 
fasces  always  discharged  from  the  lower  and  not  from  the  upper  opening,  although 
at  the  operation  the  lower  part  of  the  intestine  had  been  traced  towards  the  bladder, 
and  the  upper  in  the  reverse  direction.  In  one  of  these  cases,  which  terminated 
fatally,  the  necropsy  showed  that  the  sigmoid,  which  was  very  long  and  freely  movable, 
passed  upwards  and  outwards  as  far  as  the  splenic  flexure  of  the  colon,  and  then 
curved  downwards  and  towards  the  middle  line,  reaching  the  rectum  after  a  long 
and  tortuous  course. 

(b)  The  lower  end  of  the  bowel,  whatever  precautions  are  taken 
before  the  operation,  will  contain  some  faeces  above  the  site  of  the 
cancer  :  if  the  lower  end  of  the  bowel  be  sutured,  these  fasces  must 
cause  irritation  and  increased  discharge  ;  if  they  be  scybalous,  and  the 
bowel  above  the  stricture  thinned,  as  it  often  is,  they  may  bring  about 
fatal  ulceration,  (c)  Closing  the  lower  end  prevents  any  attempt  at 
washing  out  the  bowel  by  syringing  through  from  the  colotoury  opening 
to  the  anus  or  vice  versa,  and  so  diminishing  the  constant  tendency  to 
sanious  mucous  discharge,  which,  if  left  to  collect  above  the  cancer, 
hastens  its  growth  and  promotes  its  sloughing,  (d)  It  adds  to  the 
severity  of  an  operation  in  patients  who,  from  their  present  and  in 
view  of  their  future,  need  careful  handling.  This  is  true  of  inguinal 
colotomies  when  the  bowel  is  empty.  If  it  be  distended,  severing 
the  bowel  adds  greatly  to  the  difficulties  of  what  is  now  a  trying 
operation,  and  increases  the  risks  of  contamination  of  the  peritonaeum. 

This  modification  of  Madelung's  is,  I  think,  only  justifiable  when 
colotomy  is  performed  previously  to  removal  of  part  of  the  rectum  : 
even  under  these  circumstances  I  think  it  may  be  harmful,  by  pre- 
venting the  washing  out  of  the  intervening  bowel  which  may  add 
so  much  to  the  comfort  of  the  patient.  Any  surgeon  about  to  divide 
the  bowel  should  make  certain  of  the  lower  end  by  asking  an  assistant 
to  pass  from  below,  if  possible,  a  small  cesophagus-bougie. 

Hartwell  (Ann.  of  Surg.,  vol.  42,  1905,  p.  273),  in  performing 
colotom}-  as  a  preliminary  to  excision  of  the  rectum  brings  the  sigmoid 
into  the  wound  through  a  gridiron  incision  at  the  level  of  the  left 
anterior  superior  spine ;  he  then  divides  the  clamped  bowel  across  at  a 
distance  of  about  12  inches  from  the  anus.  The  distal  end  is  then 
fixed  at  the  lower  angle  of  the  wound.  The  proximal  end  is  protected  by 
gauze  and  drawn  upwards  and  inwards  between  the  rectus  muscle  and 
its  anterior  sheath  and  secured  in  a  median  vertical  incision  near  the 
middle  line.  Care  is  taken  not  to  damage  the  vessels  of  the  meso-sigmoid 
during  this  manoeuvre ;  the  mesentery  is  only  slit  enough  to  allow  the 
intestine  to  come  into  the  median  wound  without  tension.  Hartwell 
claims  that  this  method  gives  the  patient  more  control  than  airy  other. 
It  seems  to  me  unnecessarily  severe  and  moreover  it  is  not  practicable 
without  gravely  increasing  the  risk  where  the  sigmoid  is  distended  and 
friable  in  obstructive  cases. 

If  the  artificial  anus  contract  unduly,  it  must  be  dilated  with  lami- 
naria  tents  and  the  patient's  finger.  Mr.  Cripps  has  introduced  a  spring 
dilator  which  is  self-retaining,  and  which  can  be  worn  for  four  or  five 
hours    daily.     That    this    complication    is  one   to  be  watched    for   is 


tNGUINAL    COLOTOMY. 


135 


plain  from  this  passage  in  IMi*.  Cripps's  experience  (Brit.  Med.  Jowrn., 
vol.  ii.  1895,  p.  966) :  "  This  is  not  an  uncommon  sequence,  and,  if 
allowed,  will  destroy  the  whole  advantage  of  the  operation.  Too  small 
an  opening  means  a  constant  dribbling  of  faecal  matter,  the  motions 
never  getting  freely  and  completely  away.  These  contractions  do  not 
occur  where  the  original  opening  has  been  made  of  proper  size,  and 
where  all  the  wound  has  healed  by  first  intention,  but  occur  where  the 
angles  of  the  wound  have  failed  primarily  to  unite,  and  where  the 
granulations  gradually  become  converted  into  firm  contractile  tissue.  If 
the  angles  have  not  united  properly,  the  contraction  will  begin  about 
the  third  week;  and  if  at  this  time  a  little  spring  dilator  be  introduced 
and  worn  for  a  few  hours  daily  for  a  month,  the  tendency  to  undue 
contraction  will  be  obviated.  If  this  precaution  has  been  neglected, 
or  be  impracticable,  the  opening  can  readily  be  made  the  right  size 
by  passing  the  finger  into  the  bowel,   and  then    completely    cutting 


Fig.  57. 


1 


Glass 
cup 


Colotomy  belt.     (Pengelley,  Bailey  &  Co.) 

through  all  the  contractile  tissue  up  to  each  angle,  the  depth  of  the 
cut  exposing  the  wall  of  the  bowel.  The  bowel  is  now  freed  a  little 
on  either  side  of  the  incision,  and  a  curved  needle  and  silk  thread  is 
passed  through  its  edge,  and  through  the  tissues  and  skin  at  the  apex 
of  the  reopened  wound.  This  suture  is  tied,  bringing  the  gut  well  up  to 
the  angle.  A  couple  of  additional  sutures  may  be  necessary  at  the  sides." 
Colotomy  appliances. — Until  the  patient  has  gained  some  control  over 
the  artificial  anus,  or  has  learnt  how  to  manage  it,  a  dressing  of  lint 
smeared  with  some  simple  ointment  and  changed  as  often  as  may  be 
necessary  is  the  best  thing  for  the  patient.  Later  some  form  of  belt  or 
spring  truss  may  be  fitted.  A  belt  gives  more  general  support  and 
keeps  in  position  better  than  a  spring  truss.  Rubber  belts  sag  and 
rarely  fit ;  plugs  if  hollow  collapse  and  turn  sideways,  if  solid  (vulcanite) 
they  irritate  so  much  that  the  patient  discards  them  ;  if  made  of  rubber 
they  soon  perish.  The  apparatus  illustrated  in  the  figure  is  the  best 
of  many  that  I  have  tried.  It  consists  essentially  of  a  strong  glass 
cup,  held  in  position  by  a  firm  and  accurately  fitting   belt.     Faeces 


136  OPERATIONS  ON  THE  ABDOMEN. 

rarely  leak  from  the  cup,  which  is  air-tight  when  in  position.  For 
prolapsus  a  suitable  receptacle  can  be  made. 

Complications  and  Difficulties  in  Inguinal  Colotomy. — Many  of 
those  given  at  p.  124  are  common  to  the  inguinal  and  lumbar  operations. 
Some  more  specially  belonging  to  the  former  operation  will  be  given  here. 

I.  Difficulty  in  finding  the  bowel.  This  has  been  fully  entered  into 
at  p.  130.  It  is  well  to  remember  that  the  claim  so  strongly  put 
forward,  that  the  inguinal  is  an  operation  of  no  difficulty  as  compared 
with  the  lumbar,  is  not  always  correct.  2.  Absence  or  shortness 
of  mesentery.  I  will  here  quote  Mr.  Cripps  (Brit.  Med.  Journ., 
vol.  ii.  1895,  p.  966)  :  "  This  is  perhaps  the  most  unfortunate  and 
dangerous  complication  that  can  be  met  with,  and  to  this  cause,  with 
one  exception,  I  owe  all  my  fatal  cases.  In  the  great  majority 
of  cases  the  mesentery  of  the  sigmoid  flexure  is  amply  sufficient 
to  allow  of  the  bowel  being  well  drawn  up  in  the  wound,  and 
safely  fixed  without  tension ;  but  in  3  or  4  per  cent,  this  is  not  so, 
for  there  is  absolutely  no  mesentery,  the  bowel  being  bound  firmly 
back  against  the  posterior  parietes.  This  is  either  due  to  congenital 
deficiency,  or  to  malignant  disease  behind  the  colon  fixing  it  firmly. 
The  question  to  be  considered  is  as  to  what  should  be  done  after  the 
surgeon  has  opened  the  abdomen  and  met  with  one  of  these  cases.  I 
am  confident,  from  my  unfortunate  experience,  that  any  endeavour  to 
invert  the  skin  and  forcibly  drag  it  down  to  the  bowel  by  the  sutures 
is  a  fatal  mistake.  The  sutures  will  certainly  cut  through,  leaving  an 
open  peritonseal  cavity."  The  surgeon  should  avoid  mistaking  the 
fixed  descending  colon  for  the  sigmoid  by  tracing  the  bowel  down  into 
the  pelvis,  where  he  may  discover  a  pendulous  and  mobile  loop  of 
sigmoid  which  should  be  brought  into  the  wound  and  opened  if  the 
obstruction  be  below  it.  If  the  mesentery  is  really  too  short, 
Carwardine's  advice  may  be  followed,  and  the  mesentery  of  the  central 
part  of  the  selected  loop  tied  and  divided  ;  the  loop  can  then  be  retained 
in  the  wound  by  bringing  the  edges  of  the  skin  together  through  the 
mesenteric  gap.  Gangrene  of  the  loop  may  occur  if  the  mesentery  be 
subjected  to  much  tension,  or  if  its  vessels  be  divided  too  freely.  I 
would  suggest  another  means  of  meeting  this  difficulty,  which  I  adopted 
in  the  only  case  that  I  have  met  with  in  which  the  sigmoid  was  abso- 
lutely tied  down  in  the  iliac  fossa,  apparently  from  a  congenital  absence 
of  the  mesentery.  The  lower  part  of  the  incision  being  closed,  its  upper 
extremity  was  prolonged  backwards  into  the  lumbar  region,  where,  at  the 
junction  of  the  descending  and  sigmoid  colons,  the  bowel  was  sufficiently 
mobile  to  be  brought  up  into  the  wound.  This  course  will,  I  believe, 
always  be  found  feasible.  It  is  preferable  to  performing  a  right 
colotomy,  as  it  saves  two  wounds,  and  rolling  the  patient  over  on  to  a 
recently  made  wound,  while  it  removes  an  objection  inseparable  from  a 
right-sided  colotomy,  that  a  more  or  less  extensive  tract  of  bowel  is  left 
below  the  opening,  containing  faeces  which  it  is  not  easy  to  get  rid  of. 
Moreover  the  more  fluid  and  irritating  nature  of  the  faeces  make  a 
right  lumbar  colotomy  very  troublesome.  3.  Prolapsus.  The 
frequency  of  this  after  the  operation  has  been  explained  at  p.  127.  It 
may  be  met  (a)  by  making  the  wound  as  high  up  as  possible  (p.  129)  ; 
(b)  drawing  down  the  intestine  till  the  upper  end  is  tight  (Cripps),  and 
then  bringing  it  out  through  as  small  and  valvular  an  opening  as  possible ; 


INGUINAL   COLOTOMY.  137 

(c)  closing  this  opening  round  the  bowel,  and  the  bowel  to  the  edges  of 
the  wound,  as  securely  as  possible,  whether  a  rod  (p.  130)  has  been 
used  or  no  ;  (d)  keeping  the  patient  at  rest  until  the  parts  have  had 
full  time  to  consolidate  ;  (e)  treating  assiduously  any  such  causes  as 
constipation,  coughing,  straining  in  micturition,  &c. ;  (/)  trying  the 
effect,  as  early  as  may  be,  of  a  light  spring  truss  and  pad.  The  two 
following  complications  may  occur  during  vomiting  or  coughing. 
4.  Small  intestine  or  omentum  may  escape  between  the  piece  of 
sigmoid  which  has  been  drawn  out  and  the  edges  of  the  wound.  This 
accident  may  be  known  by  the  urgent  vomiting,  pain,  collapse,  and 
soakage  of  serum  into  the  dressings.  These  should  of  course  be  removed 
at  once,  the  small  intestine  cleansed  and  returned,  and  the  wound  made 
safe  by  additional  sutures.  This  accident  is  most  likely  to  occur  when 
a  large  wound  has  been  made,  an  insufficient  number  of  sutures  used, 
or  sufficient  support  has  not  been  provided  by  means  of  a  belt  of 
strapping  (p.  131).  Where  omentum  protrudes — a  much  rarer  compli- 
cation— it  may  be  left,  as  it  will  all  shrivel  away  gradually,  but 
additional  sutures  should  be  inserted  at  once.  .5.  A  rarer  accident,  of 
which  Mr.  Cripps  has  published  an  instance  (Brit.  Med.  Journ.,  vol.  ii. 
1895,  p.  967),  is  where  the  bowel  tears  away  from  its  attachments  and 
falls  back  into  the  peritonseal  cavity.  This  happened  on  the  seventh 
day  during  a  violent  fit  of  coughing. 

"  The  released  bowel  discharged  a  considerable  motion  into  the  peritoneal  cavity. 
Fortunately,  I  saw  the  case  about  an  hour  after  the  accident.  The  fascal  matter  was 
thoroughly  washed  out  from  the  abdomen,  and  the  detached  bowel  restitched.  The 
patient  recovered."  * 

6.  Strangulation  of  small  intestine  between  the  attached  sigmoid 
and  the  parietes.  An  instance  of  this  very  rare  accident  will  be  found 
recorded  by  Mr.  Cripps  (loc.  supra  cit.,  p.  967). 

A  patient  on  whom  inguinal  colotomy  had  been  performed  was  about  to  leave  the 
hospital  when  he  was  seized  with  symptoms  of  acute  obstruction,  the  pain  being 
referred  to  the  colotomy  opening.  After  vomiting  three  or  four  times  the  patient  said 
he  felt  something  slip  in  his  inside  ;  the  vomiting  ceased,  and  the  pain  suddenly  left 
him.  A  few  days  after,  feeling  quite  well,  he  was  discharged  from  the  hospital,  and 
was  re-admitted  ten  days  afterwards  in  a  dying  condition.  The  necropsy  showed  that 
a  loop  of  small  intestine  had  slipped  down  into  a  canal,  about  an  inch  long,  between  the 
attached  portion  of  the  gut  and  the  reflection  of  the  parietal  peritonaeum,  near  the 
anterior  superior  spine  From  this  canal  the  intestine  must  have  released  itself  at 
the  first  attack.  Mr.  Cripps  adds  that  prompt  abdominal  section  would  have  saved 
this  patient. 

Causes  of  Death  after  Anterior  Colotomy. — Many  of  these  will  be 
the  same  as  those  given  in  the  account  of  the  lumbar  operation  (p.  125), 
and  others,  more  peculiar  to  the  anterior  operation,  have  been  so  fully 
given  in  the  pages  just  preceding  that  there  is  no  need  to  repeat  them  here. 

*  Mr.  C.  Heath's  remarks  on  this  or  a  similar  case  (Brit.  Med.  Journ.,  vol.  i.  1892, 
p.  1243)  are  worth  the  attention  of  anyone  inclined  to  think  lightly  of  such  an  accident 
because  the  patient  recovered.  "  Of  course  we  hear  of  one  case  that  did  recover,  but  we 
do  not  hear  of  the  ninety-and-nine  cases  which  did  not."  The  writer  remembers  a  similar 
case,  which  terminated  fatally  although  the  peritoneum  was  cleansed  within  a  couple 
of  hours. 


I38  OPERATIONS   ON   THE   ABDOMEN. 

RIGHT    INGUINAL    COLOTOMY. 

MAKING    AN    ARTIFICIAL    ANUS    IN    THE    CJECUM. 

Tliis  operation  is  but  rarely  made  use  of.  One  objection  to  it  is  that, 
owing  to  the  proximity  of  the  small  intestines,  the  intestinal  contents 
are  likely  to  be  more  liquid,  and  thus  to  cause  more  trouble  afterwards. 
It  may  be  resorted  to  under  such  conditions  as  the  following : 

(1)  In  cases  of  acute  following  upon  a  chronic  obstruction  of  the 
ascending  colon  or  hepatic  flexure,  it  may  be  employed  as  a  temporary 
measure  to  save  the  patient  from  his  urgent  danger ;  later  the  growth 
may  be  removed  and  still  later  the  colostomy  may  be  closed  (Carwardine, 
Pract.  1905,  vol.  74,  p.  179).  If  during  an  exploration  in  the  middle 
line  the  growth  in  such  a  case  is  found  to  be  irremovable,  it  is  better 
to  perform  ileo-sigmoidostomy  and  thus  avoid  a  permanent  and  very 
troublesome  fsecal  fistula. 

(2)  In  certain  cases  of  volvulus  of  the  caecum,  in  which  the  bowel  is 
replaced,  yet  greatly  distended  and  damaged,  a  temporary  caecostomy 
may  be  also  wisely  done,  and  this  may  serve  to  fix  the  viscus  and  thus 
prevent  recurrence. 

(3)  As  a  temporary  measure  for  granting  complete  rest  or  allowing 
efficient  irrigation  of  the  large  intestine,  in  some  cases  of  colitis  or 
dysentery. 

It  is  possible  that  the  future  may  prove  appendicostomy  to  be 
preferable  to  caecostomy  for  some  or  all  the  above  three  conditions. 

A  permanent  crecostom}'  is  very  objectionable  on  account  of  the 
frequent  and  irritating  discharges,  which  often  induce  very  troublesome 
inflammation  and  even  ulceration  of  the  skin  of  the  abdomen. 

In  some  of  the  above  instances  the  primary  incision  will  be  over  the 
caecum,  and,  personally,  when  the  surgeon  has  been  exploring  the  site  of 
an  obstruction  through  an  incision  near  the  middle  line,  and  determines 
to  open  the  caecum,  I  think  it  would  be  wise  to  do  this  through  a 
second  incision  in  the  right  iliac  region,  as  I  consider  it  risky  to 
anchor  intestine  in  the  middle  line. 

Sir  F.  Treves  {Lancet,  vol.  ii.  1887,  p.  853)  published  a  very  successful 
case,  in  which  exploration  in  the  middle  line  detected  a  stricture  at  the 
termination  of  the  descending  colon.  As  the  caecum  was  enormously 
distended,  its  peritonseal  coat  having  given  way  at  several  spots,  he 
brought  the  caecum  into  the  wound  in  the  linea  alba,  bringing  all  the 
most  damaged  part  of  the  wound,  which  was  united  round  it.  A 
puncture  of  the  caecum  through  one  of  the  rents  allowed  an  immense 
amount  of  gas  to  escape.  Fortunately  no  faeces  were  seen.  The  hole 
in  the  bowel  was  clamped,  and  the  wound  dressed  with  iodoform. 
When  the  bowel  was  opened  on  the  fifth  day  a  large  quantity  of  faecal 
matter  escaped.     Six  months  later  the  patient  was  in  excellent  health. 

On  the  other  hand,  the  case  of  Mr.  Cripps,  which  I  quoted  at  p.  137, 
shows  how  ver}'  small  a  space  between  anchored  bowel  and  the  parietes 
may  be  sufficient  to  bring  about  a  fatal  strangulation. 

Operation. 

In  some  cases  the  surgeon  may  experience  considerable  difficulty  in 
getting  the  caecum  satisfactorily  into  the  wound  from  congenital  or 
acquired  adhesions  to  the  iliac  fossa. 


ivminai,  COLOTOMY. 

The  caecum  is  exposed  through  the  "gridiron"  incision  used  for 
removing  the  appendix.  A  pari  of  the  anterior  wall  or  lower  pole  of  the 
(■.•renin  is  then  lixed  to  the  parietal  peritonaeum  by  a  circle  of  con- 
tinuous catgul  suture,  [f  immediate  drainage  be  imperative  one  of  the 
enterostomy  tubes  described  on  p.  132  is  then  introduced.  When  the 
operation  is  performed  for  colitis,  there  is  no  need  to  open  the  bowel 
at  once,  and  an  incision  may  he  made  into  the  csecum  after  the 
lapse  of  24  or  48  hours,  when  peritonaeal  adhesions  will  have  formed. 
Curl  (.1////.  <>/'  S11  r<!,,  April,  1906,  p.  543)  employs  this  method  for  the 
treatment  oi'  dysentery  by  irrigation.  He  prevents  closure  of  the 
muscular  wound  by  anchoring  the  csecum  by  silk  sutures  to  the  four 
corners  formed  where  the  oblique  muscles  decussate. 

Gibson  (Boston  Med.  and  Surg.  Journ.,  Sept.  25,  1902)  recommends 
the  application  of  Kader's  method  of  gastrostomy  for  making  a  valvular 
opening  into  the  csecum  for  the  treatment  of  various  forms  of  chronic 
colitis  by  irrigation.  It  is  claimed  that  little  or  no  leakage  occurs 
after  this  operation,  and  that  the  fistula  soon  closes  on  withdrawing 
the  catheter. 

MAKING    AN    ARTIFICIAL    ANUS    IN    THE    TRANSVERSE 

COLON. 

This  may  be  performed  as  a  temporary  measure  when  a  removable 
growth  of  the  splenic  flexure,  or  descending  colon  is  discovered  during 
an  exploratory  laparotomy  for  acute  following  upon  chronic  intestinal 
obstruction.  Under  these  circumstances  it  is  far  safer  to  perform  a 
temporary  colostomy  than  to  be  too  ambitious  and  to  attempt  a 
primary  resection.  When  the  intestines  have  been  emptied  of  their 
virulent  contents,  and  the  patient  has  recovered  from  his  immediate 
danger  of  death,  the  growth  may  be  resected,  an  end  to  end  anastomosis 
performed,  and  the  colostomy  closed  or  allowed  to  close  later. 

When  the  cause  of  the  obstruction  is  found  to  be  a  removable  growth 
of  the  transverse  colon,  it  ma}r  be  possible  to  bring  the  loop  of  bowel 
containing  the  growth  outside  the  abdomen  and  to  fix  it  there  by 
means  of  a  glass  rod  through  the  meso-colon  or  by  sutures.  The 
surgeon  having  protected  the  abdominal  cavity  by  careful  gauze 
packing,  may  then  be  content  to  merely  relieve  the  obstruction  by 
tying  an  enterostomy  tube  in  the  proximal  limb  of  the  loop.  Later  he 
can  resect  the  growth  and  close  the  artificial  anus,  or  the  growth  may 
be  immediately  removed  and  Paul's  tubes  tied  in  the  two  limbs  of  the 
loop.  The  contiguous  peritonseal  coats  of  the  two  stumps  of  intestine 
may  be  sutured  together  to  pave  the  way  for  the  subsequent  closure  of 
the  artificial  anus  (Bidwell,  Brit.  Med.  Journ.,  vol.  i.  1902,  p.  322). 

An  artificial  anus  in  the  transverse  colon  is,  from  its  high  position,  more 
manageable  than  a  sigmoid  colotomy,  and  from  the  more  solid  character 
of  the  faeces,  it  is  greatly  superior  to  a  right  lumbar  or  caecal  fistula. 

Mr.  Bidwell  {he.  supra  cit.)  in  an  able  article  maintains  that 
"  colotomy  should  never  he  performed  for  any  growth  that  is  situated 
above  the  middle  of  the  sigmoid  flexure,  and  that  an  artificial  anus 
made  in  such  a  case  should  be  only  a  temporary  one  left  after  the 
removal  of  the  growth."  For  such  cases  ileo-sigmoidostomy  or  some 
other  suitable  form  of  ileo-colostomy  is  far  preferable  for  a  surgeon 


I40  OPERATIONS  ON  THE  ABDOMEN. 

skilled  in  abdominal  surgery.  In  skilled  hands  this  operation  is  only  a 
little  more  dangerous  than  colotomy,  even  when  the  obstruction  is 
complete,  but  for  those  less  experienced  and  without  the  advantages 
of  skilled  assistance,  colotomy  remains  the  safest  if  not  the  most 
brilliantly  successful  treatment. 

The  disadvantages,  and  constant  annoyances  of  a  colotomy  are  so 
great  and  so  well  known,  that  a  patient  may  reasonably  be  advised  to 
run  some  additional  risk  in  order  to  avoid  them  ;  thus  after  an  anas- 
tomosis a  man  may  be  able  to  lead  an  active  and  profitable  life  for  a 
considerable  time  without  becoming  unpleasant  to  his  neighbours,  which 
is  a  rare  thing  after  colotomy. 

APPENDIC  OSTOMY    (WEIR'S     OPERATION). 

This  operation  was  first  described  and  practised  by  Dr.  Weir,  of 
New  York  (New  York  Med.  Record,  Aug.  9,  1902).  He  was  perform- 
ing a  csecostomy  for  chronic  colitis  when  the  appendix  presented  itself 
just  at  the  right  moment,  and  Dr.  Weir  saw  and  took  immediate 
advantage  of  his  opportunity.  Recently  the  important  contributions 
of  Mr.  Keetley  (Brit.  Med.  Joum.,  vol.  ii.  1905,  p.  863)  and  Sir  W.  H. 
Bennett  (Lancet,  vol.  i.  1906,  p.  419)  have  brought  the  operation  into 
more  general  notice,  and  many  surgeons  are  now  giving  it  a  trial. 
Much  of  what  follows  is  derived  from  the  excellent  and  suggestive 
articles  written  by  the  authors  named  above.  The  following  are  the  chief 
conditions  and  objects  for  which  the  operation  has  been  recommended. 

Indications. 

(1)  For  the  introduction  of  irrigating  or  medicating  fluids  into  the 
caecum  and  colon  in  certain  cases  of  chronic  colitis  and  amaebic  dysentery. 

(2)  For  the  local  treatment  of  the  lower  ileum  in  some  cases  of 
enterica. 

(3)  For  the  introduction  of  fluids  into  the  caecum  in  a  few  cases  of 
obstinate  chronic  constipation. 

(4)  For  the  administration  of  foods  and  fluids  in  a  few  cases  of 
carcinoma  of  the  stomach,   &c. 

(5)  For  temporary  drainage  of  the  caecum  in  some  cases  of  intestinal 
obstruction,  also  for  temporary  drainage  and  fixation  in  some  cases  of 
ileo-caecal  intussusception  and  volvulus  of  the  caecum. 

(6)  For  the  relief  of  intestinal  distension  in  cases  of  peritonitis,  &c. 
These  indications  will  be  considered  more  fully  after  the  description 

of  the  operation. 

Operation. 

(a)  The  appendix  is  sought  through  the  usual  incision  employed 
for  its  removal,  the  aponeurotic  and  muscular  fibres  of  the  abdominal 
wall  being  separated,  and  the  peritonaeum  divided  sufficiently  to  admit 
two  fingers.  Adhesions  and  other  difficulties  may  cause  delay  and 
may  even  make  the  operation  a  serious  one,  so  that  it  is  not  to  be 
lightly  undertaken  under  gas  and  oxygen  or  local  anaesthesia  as 
recommended  by  some  writers. 

The  appendix  is  drawn  out  through  the  wound  so  that  the  caecum  is 
brought  into  contact  with  the  abdominal  wall,  and  two  fine  catgut 
sutures  are  passed  through  the  sero-muscular  coats  of  the  appendix 
and  the  parietal  peritonaeum,  and  tied  so  as  to  fix  the  appendix,  and 


APPENDICOSTOMY. 


Mi 


Fig.  58. 


Safety- 
pins 


Stitches 


Meso- 
appendix. 


close   the  peritoneal  wound   without   compressing  the   vessels  of  tho 
meso-appendix. 

Care  must  be  taken  not  to  damage  these  vessels  or  Bubject  them  to 
much  tension.  Curl  [Ann.  of  Surg.,  April,  1906,  p.  545)  mentions 
three  eases  in  which  the  appendix  sloughed  even  after  careful  handling. 

Sometimes  the  mesentery  is  so  short  that  it  has  to  be  tied  and  divided. 
When  there  is  no  need  for  immediately  opening  the  appendix,  Sir 
William  Bennett  retains  it  in  position  by  means  of  two  sterilised 
safety  pins  passed  through  the  sero-museular  coats  of  the  appendix, 
and  (dosing  the  abdominal  wound  beneath  the  pins.  After  twenty-four 
hours,  when  adhesions  have  formed,  the  appendix  may  be  cut  across  a 
quarter  of  an  inch  from  the  level  of  the  skin,  and  the  margins  of  the 
opening  sutured  to  the  edges  of  the  skin  ;  these  sutures  serve  to 
prevent  undue  retraction  of  the  appendix  during  healing.  If  the 
parietal  wound  be  carefully  closed  the  appendix  may  be  opened  at 
once,  if  necessary,  and  a  soft  rubber 
catheter  with  a  fine  flexible  stilette  can 
then  be  inserted  for  the  introduction  of 
fluids. 

(b)  During  an  exploratory  laparotomy, 
the  surgeon  may  decide  to  use  the 
appendix  as  a  temporary  spout  for  the 
escape  of  faeces  or  gas,  as  recommended 
by  Mr.  Keetley  (Brit.  Med.  J  own.,  vol.  ii. 
1905,  p.  863).  A  stab  wound  can  then 
be  carefully  made  in  the  abdominal  wall 
over  the  appendix,  which  can  be  drawn 
out  and  fixed  in  the  manner  described 
above.  If  necessary  the  lumen  can  be 
stretched  by  means  of  fine-bladed  for- 
ceps, or  by  bougies.  When  the  fistula 
has  served  its  purpose  it  may  be  closed 
most  easily  by  the  simple  method 
described  by  Mr.  Maunsell.  He  dissects 
away  the    mucous  lining  of  the  stump 

and  leaves  a  short  muscular  tube,  which  heals  in  a  few  days ;  thus  a 
laparotomy  is  avoided. 

Appendicostomy  is  usually  a  very  simple  operation,  but  it  cannot 
always  be  performed,  for  the  appendix  may  have  been  already  removed, 
or  be  so  tied  down  with  adhesions,  or  so  diseased  and  contracted  at  its 
base,  that  it  cannot  be  safely  used.  Mr.  Spencer  {Lancet,  March  12, 
1904)  found  the  appendix  so  adherent  that  he  had  to  perform  caecos- 
tomyin  one  case.  In  one  hundred  autopsies  at  St.  George's  Hospital, 
the  appendix  was  a  fibrous  cord  in  two  bodies,  and  in  two  others  the 
lumen  near  the  base  would  only  admit  a  small  bristle;  but  an  appen- 
dicostomy could  probably  have  been  performed  in  the  remaining 
ninety-six. 

(1)  Colitis  and  Dysentery. — As  an  alternative  for  csecostomy  and 
right  lumbar  colostomy  in  the  treatment  of  cases  of  colitis  suitable  for 
surgical  treatment,  appendicostomy  has  the  following  important  advan- 
tages :—  (1)  The  fistula  does  not  allow  any  leakage  of  fasces,  because  it 
is  controlled  by  a  sphincter  at  its  base,  and  more  or  less  protected  by  a 


Appendix 


Appendicostomy  (after  Sir  Wil- 
liam Bennett,  Lancet).  The  safety- 
pins  pass  through  the  peritoneal 
and  muscular  coats  only. 


142 


OPERATIONS  ON  THE  ABDOMEN. 


valve  of  mucous  membrane  on  its  csecal  aspect;  thus  the  very  troublesome 
irritation  of  the  skin,  which  is  often  associated  with  the  older  opera- 
tion, is  entirely  prevented.  (2)  The  saving  of  the  fluid  contents  of 
the  caecum  for  more  complete  absorption  in  the  large  intestine  may 
be  a  gain,  especially  in  very  feeble  subjects;  thus  Goddard  maintains 
that  about  10  per  cent,  of  the  fat,  for  instance,  is  absorbed  in  the  large 
intestine  {Lancet,  March  25,  1905,  p.  795).  (3)  The  appendicular 
fistula  is  very  easily  closed,  whereas  the  difficulties  of  closing  an 
opening  in  the  caecum  are  well  known. 

Gibson's  valvular  caecostomy  also  generally  guards  against  leakage, 
and  it  often  closes  easily  on  removing  the  tube  ;  it  is  probably  the 
best  procedure  to  adopt  when  it  is  found  to  be  impossible  to  perform 
an  appendicostomy. 

Whether  the  above  gains  compensate  for  the  lack  of  rest,  and  the 
irritation  of  the  inflamed  colon  by  the  faeces,  is  an  open  question,  only 
to  be  decided  by  time  and  experience. 

The  place  of  appendicostomy  and  irrigation  in  the  treatment  of 
colitis  is  as  yet  uncertain.  Mr.  Keetley  (loc.  supra  cit.)  gives  the 
following  results  of  nine  reported  cases.  No  death  had  occurred  as  a 
result  of  the  operation,  but  in  one  fatal  case  the  operation  was  only 
performed  when  the  patient  was  in  extremis.  None  of  the  patients 
were  any  worse  for  the  operation.  Seven  cases  were  entirely  successful, 
and  the  issue  of  the  last  case  remained  to  be  seen. 

Since  then  Gra}'  has  reported  two  cases  {Lancet,  vol.  i.  1906, 
p.  596). 

Case  i.  Male,  Eet.  30,  had  severe  ulcerative  colitis  which  had  resisted  all  treatment  by  the 
mouth  and  rectum  ;  his  condition  was  desperate,  but  appendicostomy  was  performed,  and 
the  colon  washed  out  with  various  antiseptic  solutions.  Improvement  occurred  for  three 
weeks,  but  a  week  later  the  patient  died,  and  advanced  ulceration  of  the  colon  and  lower 
end  of  the  ileum  was  found  at  the  autopsy. 

Case  ii.  Female,  jet.  22,  had  diarrhoea,  and  passed  extensive  casts ;  her  symptoms 
were  annoying  rather  than  serious.  Weak  solutions  of  argyrol  were  introduced  through 
the  appendix  for  three  weeks,  when  the  symptoms  subsided,  and  the  fistula  was  allowed 
to  close,  which  it  did  rapidly.     A  tendency  to  relapse  was  noticed  later. 

Morley  Willis  (Lancet,  vol.  i.  1906,  p.  1180)  reports  a  case  of  mucous  colitis  in  a 
female,  set.  32.  The  disease  had  lasted  for  two  years  ;  the  colon  was  irrigated  by  soap 
and  water,  introduced  through  the  appendix  ;  two  or  three  pints  were  used  at  a  time. 
Much  improvement  had  occurred  in  a  month. 

Stretton  {Lancet,  vol.  i.  1906,  p.  1833)  exhibited  one  case  and  read  notes  of  another 
before  the  Kidderminster  Medical  Society.  In  the  last  case  the  patient  was  able  to 
irrigate  her  colon  with  comfort  and  efficiency,  greatly  to  the  relief  of  her  chronic  colitis. 

Nearly  all  the  cases  recorded  had  not  been  under  observation  lono- 
enough  to  enable  us  to  arrive  at  any  conclusion  as  to  the  ultimate 
results.  Cases  have  been  claimed  as  cures  after  a  few  weeks  or 
months.  It  must  be  remembered  that  these  patients  must  remain 
well  for  several  years  before  the  results  crai  be  claimed  to  be  entirely 
successful.  Every  physician  knows  that  relapses  are  frequent  in 
colitis.  Hale  White  and  Golding  Bird  {Clin.  Soc.  Trans.,  1902) 
publish  a  case  of  a  relapse  of  mucous  colitis  after  two  years'  relief  from 
right  lumbar  colotomy.  It  is  extremely  probable  that  appendicostomy 
will  be  found  to  be  of  very  little  use  in  severe  cases  of  ulcerative  colitis 


AH'KX  I  >l<  OSTOMY.  i  |  | 

niul  severe  cases  of  dysentery  with  deep  ulceration.  It  is  likely  that 
the  operation  will  be  found  to  be  of  real  value  in  milder  cases  of 
colitis,  but  which  have  not  reacted  to  medical  treatment  by  the  mouth 
and  rectum,  but  care  must  be  taken  to  keep  the  fistula  open  until  all 
signs  of  the  disease  have  disappeared. 

Curl  concludes  "from  observation  of  eleven  cases  of  dysentery, 
that  in  intermediate  cases  in  which  there  is  still  a  reasonable 
amount  of  strength,  but  where  treatment  is  not  controlling  the 
dysentery,  the  operation  of  caecostomy  with  irrigation  of  the  colon 
with  quinine  solution  is  indicated.  Caecostomy  is  preferred  to  appen- 
dicostomy  because  of  less  sloughing  and  an  earlier  closure  of  the 
fistula.  A  rapid  improvement  usually  follows  the  beginning  of  the 
irrigation,  but  convalescence  is  slow,  and  at  times  difficulty  is 
experienced  in  closing  the  fistuhe.  The  after-treatment — irrigation, 
&c. — is  tedious,  and  the  patients  are  offensive  cases  to  have  in  a 
ward.  All  in  all  it  is  the  lesser  of  two  evils,  but  in  my  opinion 
it   saves   lives  in  selected   cases."     (Ann.  of  Surg.,   1906,  vol.   xliii. 

P-  543-) 

Curl  does  not  state  in  how  many  of  these  cases  he  performed  appen- 

dicostomy — presumably    a    minority    only  ;    it    is    surprising   to    read 

that  the  fistula  closed  more  rapidly  in  the  cascostomy  cases.     Quinine 

solution  was  the  irrigating  fluid  used  ;    in  eight  out  of  eleven  cases 

partial   or   complete   recovery  occurred ;   in   two,  as  demonstrated   by 

autopsy,  there  was  extensive  and  deep  ulceration,  and  also  nephritis. 

One    was    so    weak    that    cascostomy    was    performed    under    cocaine 

anaesthesia,  and  death  occurred  the  following  da}\ 

Many  kinds  of  irrigating  fluids  have  been  recommended,  such  as  :  normal  saline 
solution,  starch,  infusion  of  marshmallow,  oil,  lime  water.  Various  astringents,  such  as 
nitrate  of  silver  solution,  ipecacuanha  in  suspension,  glyco-thymolin,  argyrol,  liquid 
paraffin,  2  oz.  daily  (Ewart)  ;  quinine  solution  for  dysenteric  cases  (Curl). 

Dr.  Dawburn  (Ann.  of  Sure/.,  vol.  37,  p.  613)  used  potassium  permanganate  ^^ 
solution,  alternating  every  six  hours  with  the  same  amount  of  normal  saline  ;  about  ten 
pints  of  the  solutions,  at  a  temperature  of  1200  Fahr.,  being  used  at  a  time.  The  case 
was  one  of  dysentery,  and  was  much  improved  by  the  treatment,  but  the  cure  was  not 
complete  when  Dr.  Dawburn  presented  the  case  only  a  few  weeks  after  the  operation. 

Dr.  Ewart  (Lancet,  vol.  i.  p.  1511,  1906)  has  given  a  helpful  account  of  his  method  of 
irrigation.  A  No.  8  india-rubber  catheter  is  introduced  by  means  of  a  blunt-ended,  very 
pliable  copper  stilette  ;  it  is  apt  to  coil  in  the  cascum  unless  care  be  taken  to  pass  it 
upwards  as  well  as  backwards.  A  good  sized  rectal  tube  is  then  passed  to  conduct  the 
outflow  into  a  suitable  receptacle  by  the  side  of  the  bed.  Tubing  and  funnel  are  fixed  to 
the  catheter,  and  both  the  afferent  and  efferent  tubes  have  clips  attached,  and  also  a  piece 
of  glass  tubing  inserted.  By  elevation  and  depression  of  the  funnel  the  rate  of  the 
injection  can  be  regulated,  and  the  rate  of  the  outflow  and  amount  of  distension  of  the 
colon  (if  any  is  desirable)  can  be  controlled  by  means  of  the  clips.  Dr.  Ewart  has  used 
as  much  as  twenty  pints  in  one  irrigation. 

It  is  probable  that  the  hopeful  results  obtained  depend  more  upon 
the  careful  lavage  than  upon  any  particular  kind  of  chemical  solution 
used.  The  patient  should  not  complain  of  pain  during  the  irrigation 
unless  the  outflow  be  obstructed,  or  too  much  pressure  be  employed. 
The  patient  should  be  kept  supine  unless  the  fluid  does  not  run  well, 
when  he  may  be  turned  on  to  his  left  side  to  overcome  any  possible 
obstruction  at  the  hepatic  flexure  of  the  colon. 


i44  OPERATIONS  OX  THE  ABDOMEN. 

(2)  Enterica. — It  has  been  suggested  by  Dr.  Ewart  that  appendi- 
costomy  may  be  useful  for  gaining  access  to  the  ileum  through  the 
ileo-cffical  valve  for  the  application  of  direct  local  treatment  to  the 
diseased  intestine. 

Mr.  Keetley  (Lancet,  1906,  vol.  i.  p.  1023),  has  also  suggested  that  the 
toxic  and  irritating  contents  of  the  lower  ileum  may  be  drained  off  by 
a  tube  passed  through  the  appendix  and  the  ileo-csecal  valve  and 
retained  in  position.  Box  and  Eccles  have  pointed  out  that  much  of 
the  ulceration  of  the  lower  ileum  may  be  due  to  the  stasis  of  infected 
feeces  above  the  ileo-csecal  sphincter. 

Ewart  (Joe.  supra  cit.~)  has  been  able  to  pass  a  catheter  into  the  ileum  with  ease  in  a 
case  of  chronic  colitis  ;  he  had  already  gained  experience  on  the  cadaver.  It  is  note- 
worthy that  the  neck  of  the  appendix  has  a  fairly  constant  relation  to  the  orifice  of  the 
ileum,  however  much  the  tip  of  the  former  may  vary  in  its  position.  Dr.  Ewart  and  his 
assistants  used  a  soft  rubber  catheter,  containing  a  very  pliable  copper  wire  stilette,  which 
is  bent  into  a  loop  at  the  end  for  safety.  The  catheter  is  bent  at  an  angle  of  no  degrees. 
About  two  and  a  half  inches  from  its  extremity  it  is  passed  inwards,  downwards  and 
backwards.  The  catheter  may  be  known  to  have  entered  the  ileum  by  the  greater  length 
(up  to  nine  inches)  introduced,  by  the  subjective  sensations  of  the  patient,  and  Dr.  Ewart 
had  skiagrams  taken  showing  the  stilette  to  have  reached  the  brim  of  the  pelvis  on  the 
left  side. 

Systematic  Lavage  of  the  Lower  Ileum. — Ewart  and  Aylen  state  that  they  were 
able  to  irrigate  about  a  foot  or  two  of  the  small  intestine.  After  a  preliminary  cleansing 
irrigation  they  passed  a  No.  2  gum  elastic  catheter  into  the  ileum,  and  a  No.  6  instrument 
is  passed  into  the  caecum,  where  it  acts  as  a  draw-off  for  the  fluid  returning  from  the 
ileum.     Medicating  fluids  may  thus  be  applied  to  the  ulcerated  intestine  low  down. 

So  far  no  case  of  typhoid  has  been  recorded  in  which  this  mode  of  treatment  has  been 
employed,  and  it  does  not  seem  to  me  to  be  a  hopeful  procedure  for  the  following  reasons. 

It  is  not  free  of  danger  ;  the  diseased  intestine  may  be  perforated  by  the  tube  or 
haemorrhage  induced  ;  without  special  experience  it  is  not  easy  to  pass  the  tube  into  the 
ileum,  and  the  latter  cannot  be  emptied  by  any  system  of  irrigation  yet  invented  ;  it  is 
not  even  claimed  that  more  than  a  foot  or  two  can  be  washed  out.  It  may  also  be 
remembered  that  the  bacillus  of  typhoid  fever  is  not  limited  to  the  intestinal  contents, 
but  flourishes  in  the  walls  of  the  bowel  and  in  the  mesenteric  glands.  Mr.  Keetley  believes 
that  appendicostomy  would  be  of  value  in  typhoid  fever  chiefly  by  providing  a  means 
for  keeping  "  the  large  intestine  well  and  frequently  washed  clear  of  fasces  polluted  with 
discharges  from  the  ulcerations,  and  to  substitute  for  these  discharges  abundance  of  water 
or  neutral  saline  solution." 

Mr.  Keetley  is  more  in  favour  of  enterostomy  and  makes  the  following  remarks,  which 
seem  to  me  to  be  too  optimistic.  i;  With  a  laparotomy  the  ileum  could  be  opened  a  yard 
above  the  ileo-caecal  valve.  Two  principal  techniques  are  available  :  (1)  resembling  that 
of  a  sigmoid  colotomy,  and  (2)  resembling  that  of  a  Witzel's  gastrostomy.  With  the  former 
the  last  yard  of  the  ilium  and  the  whole  of  the  large  intestine  could  be  placed  at  rest,  no 
faeces  passing  through,  but  only  the  warm  weak  saline  or  silver  solutions  prescribed  by 
the  phvsician.  With  the  latter  much,  if  not  all,  the  faeces  would  still  pass  on  to  the 
rectum  and  natural  anus.  Medication  would  be  easy,  but  rest  would  not  be  secured.  The 
first  technique  would  be  the  quicker  to  do,  while  the  anatomical  result  of  the  second 
technique  would  be  simpler  to  undo  when  the  patient  had  recovered.  But  resection  of  a 
portion  of  small  intestine  for  the  purpose  of  closing  such  an  enterostomy  opening  as  this 
which  we  are  discussing  should,  in  competent  hands,  be  a  very  safe  procedure,  because 
(a)  it  would  be  of  small  intestine,  not  large,  and  (b)  there  would  be  no  embarrassing 
adhesionTsuch  as  often  complicate  faecal  fistulae  which  have  been  caused  by  tubercle, 
by  appendicitis,  or  by  other  diseases  attended  by  peritonitis." 

The  surgical  treatment  of  typhoid  fever  is  certainly  worthy  of 
consideration,  for  if  surgery  can  be  shown  to  do  anything  to  lessen  the 


APPENDICOSTOMY.  145 

mortality  (about  10 — 15  per  cent.))  and  diminish  the  dangerous  and 
troublesome  complications  of  this  disease,  it  will  render  welcome  aid  to 

the  physician  as  well  :is  to  the  patient.  It  will  not  he  easy  to 
determine  the  indications  and  the  time  for  surgical  interference  in  any 
given  cast'. 

(3)  Chronic  Constipation. — Mr.  Murray  (Brit.  Med.  Joiirn.,  yol.  i. 
1905,  p.  1299)  first  suggested  appendicostomy  as  a  treatment  of  intrac- 
table cases  of  chronic  constipation.  Since  then  Mr.  Keetley  (Brit. 
Med.  Journ.,  vol.  ii.  1905,  p.  863)  has  tried  the  operation. 

A  girl  of  15  suffered  from  severe  chronic  constipation.  At  the  time  of  the  operation 
the  bowels  had  not  been  opened  for  3  weeks,  and  the  patient  was  vomiting.  Median 
laparotomy  disclosed  a  pendulous  transverse  colon  reaching  to  the  pubis,  but  there  was 
no  other  abnormality.  The  appendix  was  brought  out  through  a  button-hole  incision. 
and  the  median  incision  closed  ;  the  appendix  then  slipped  back  and  had  to  be  brought 
out  again  and  fixed.  Four  days  later  the  superfluous  part  of  the  appendix  and  its  mesentery 
were  removed  without  causing  any  pain.  The  ligature  which  secured  the  vessels  of  the 
meso-appendix  was  also  used  to  retain  a  soft  tube  inserted  in  the  fistula.  A  saline  injection 
was  given,  and  later  some  3ij  of  mist,  alba,  and  a  pint  of  saline.  These  were  very  efficacious, 
and  lately  an  injection  of  water  alone  procures  a  daily  evacuation.  The  patient  herself 
passes  a  No.  10  catheter.     No  leakage  occurs,  and  the  patient's  health  has  much  improved. 

It  remains  to  be  seen  whether  this  treatment  may  be  proved  by 
more  experience  to  be  of  real  and  permanent  use  in  the  treatment  of 
those  rare  cases  of  constipation  which  ai'e  not  amenable  to  medical 
treatment.  It  is  certainly  worthy  of  trial  in  preference  to  such  drastic 
measures  as  ileo-sigmoidostomy  and  extensive  colectomy. 

(4)  Ileo-Csecal  Intussusception. — Mr.  Keetley  (loc.  supra  cit.)  per- 
formed appendicostomy  after  reducing  an  intussusception  of  the  lower 
end  of  the  ileum,  caecum  and  appendix  in  an  infant  aged  one  year  and 
ten  months.  The  reduction  was  performed  through  an  incision  in  the 
right  rectus,  and  then  the  appendix  6^  inches  long  was  pulled  out 
through  a  button-hole  incision  made  over  it,  and  the  end  was  cut  off 
and  the  stump  fixed.  5\iij  of  normal  saline  were  injected  at  6  p.m., 
and  the  bowels  were  moved  at  7  p.m.  and  9.45  p.m.  The  stump  of 
the  appendix  was  removed  15  days  later,  but  its  site  was  fixed  to  the 
wound. 

The  operation  was  performed  for  several  reasons  :  for  the  relief  of 
gaseous  distension,  the  administration  of  fluids  which  acted  partly  as 
aperients,  and  fixation  of  the  bowel  with  a  view  of  preventing 
recurrence. 

The  appendix  would  probably  be  of  even  more  service  in  cases  of 
primary  esecal  intussusception. 

(5)  Volvulus  of  the  Caecum. — The  following  interesting  case  recorded 
by  Mr.  Maunsell  is  probably  the  first  in  which  appendicostomy  has 
been  tried  for  volvulus,  and  it  is  certainly  encouraging. 

Female,  ast.  77,  subject  to  chronic  constipation.  Volvulus  of  the  caecum  was  discovered 
in  the  pelvis  on  exploration  ;  the  greatly  distended  caecum  was  deflated  and  then  withdrawn 
and  uncoiled,  and  the  puncture  closed.  The  appendix  was  Drought  out  through  a  stab 
wound  at  the  outer  border  of  the  right  rectus.  Some  vessels  of  the  meso-appendix  had  to 
be  tied ;  the  appendix  was  fixed  by  two  sutures  and  its  distal  end  amputated.  The  fistula 
was  dilated  with  sinus  forceps  and  a  gum  elastic  catheter  tied  and  leftinfor  4  days.  From 
the  first  gas  and  some  fluid  faeces  escaped  from  the  opening  and  the  abdomen  kept  flat. 
Later  the  mucous  membrane  lining  of  the  stump  was  excised  and  the  fistula  closed  in  a 

8. — VOL.  H.  10 


146 


OPERATIONS  ON  THE  ABDOMEN. 


few   days.     The   patient  did   very  well   although    some    suppuration   occurred    in  the 
exploratory  wound,  probably  due  to  soiling  during  deflatation. 

(6)  Intestinal  Obstruction. — In  1894,  Keetley  (Brit.  Med.  Joum., 
Nov.  17,  1894,  p.  1 155)  first  suggested  the  use  of  the  appendix 
as  a  spout  for  the  relief  of  intestinal  obstruction,  instead  of  caecal 
colostomy. 

In  1905,  the  same  surgeon  was  the  first  to  put  this  operation  to 
the  test,  and  the  following  account  is  taken  from  Mr.  Keetley's  paper 
(Lancet,  vol.  i.  1906,  p.  1023). 

"In  the  past  winter  I  have  had  the  opportunity  of  using  the  appen- 
dix as  a  spout  for  giving  egress  to  fseces  in  a  case  in  which  it  would 
otherwise  have  been  necessary  to  perform  a  ceecal  colotomy.  In  a  case 
under  the  care  of  Dr.  James  Crombie*  mentioned  by  me  in  a  former 
paper  appendicostomy  was  performed  partly  with  this  object.  In  all 
other  published  cases  of  appendicostomy  the  operation  has  been  per- 
formed wholly  for  the  purpose  of  admitting  the  injection  of  fluids  into 
the  large  intestine.  The  question  was,  Could  the  appendix  be  suffi- 
ciently dilated  ?  I  felt  almost  sure 
FlG*  59<  it  could  because  I  have  seen  it  so 

dilated  b}r  pus,  by  large  concretions, 
and  by  intussusception  of  the  ap- 
pendix. 
Caecum  x 

"  In  the  case  which  I  am  about  to  relate 
I  was  a  little  discouraged  at  first  by  finding 
a  very  slender  appendix,  one  that  seemed,  in 
fact,   atrophied.      Accordingly,    on    Decem- 
ber 21,   1905,   I  operated   in   the   following 
manner  so  as  to  be  prepared  for  possible  non- 
dilatability  of   the  appendix.      Drawing  an 
imaginary  oval  line  (0)  on  the  cascum  and 
around  the  base  of  the  appendix,  with  the 
latter  occupying  an  eccentric  position  in  the 
oval,  I  stitched  this  oval  line  to  the  margin 
Appendicfecostomy  (after  Keetley,  Lan-    of  the  parietal  peritonaeum  near  the  lower 
cet).     The  caecum  and  appendix  are  secured   angle  of  the  wound.     (See  illustration.)     I 
to  the  abdominal  wall,  ready  for  opening   then  brought  the  appendix  obliquely  through 
extra-peritoneally.  the  substance  of  the  abdominal  wall  in  the 

parietal  incision  which  was  otherwise  closed 
by  sutures  in  layers.  The  wall  was  very  thin,  the  patient  being  emaciated,  with  very 
little  muscle  and  no  fat.  I  intended,  if  I  found  the  appendix  not  sufficiently  dilatable, 
to  cut  its  mucous  membrane  with  a  bistoury  or  hernia  knife  in  such  a  manner  that  if  the 
appendix  split  open  it  would  give  way  in  the  line  A,  B.  The  result  would,  of  course,  be 
the  performance  of  what  might  be  termed  an  '  appendicaecostoiny ' — i.e.,  an  opening  partly 
in  the  appendix  and  partly  in  the  caecum,  but  altogether  outside  thestitched-off  peritonaeal 
cavity,  though  overlapped  by  skin  and  fascia.  However,  the  next  day  I  had  no  difficulty 
in  stretching  this  appendix  to  the  size  of  a  small  rectal  tube,  and  for  three  months  the 
fasces  passed  through  it,  the  intestinal  obstruction,  which  was  due  to  a  large  malignant 
growth  obstructing  the  transverse  colon,  being,  completely  relieved.  The  patient  had 
carcinoma  of  the  stomach  with  some  infection  of  the  general  peritonaeum  (malignant 
nodules  were  seen  on  the  peritonaeum  and  adhesions  were  felt  matting  the  parts  together 
above,  and  to  the  left  of,  the  umbilicus  and  beneath  the  left  rib  cartilages).     Within  48 


Appendix 


Brit,  Med,  Joum. ,  vol.  ii.  1905,  p.  863. 


A  lM'KNDK  OSTOMY. 


T47 


hours  the  greatly  distended  abdomen  had  emptied  itself  through  the  appendix,  assisted 
by  warm  water  enemata.  More  recently  sonic  fasces  have  passed  per  rectum.  This 
patient's  abdomen  was  explored  last  summer  and  the  carcinoma  of  the  stomacfa  was 
found  but  was  too  advanced  for  removal.  A  friend  of  mine  performed  a  jejunostomy  by 
Mayo  Rolison's  method  but  as  the  patient  could  still  take  food  by  the  mouth  she  allowed 
the  jejunostomy  opening  to  close.  I  reopened  it  on  the  morning  of  thedayon  which  I 
performed  the  appendicostomy,  and  she  was,  to  a  great  extent,  nourished  by  what  passed 
between  the  jejunostomy  and  the  appendicostomy.  Still  she  tooksome  food  by  the  mouth, 
both  solid  and  liquid,  and  efforts  were  made  to  keep  the  large  intestine  properly  supplied 
with  water  eithei  by  the  rectum  or  through  the  appendix.  The  nurse  found  it  most  con- 
venient to  keep  both  the  appendicostomy  and  the  jejunostomy  tubes  permanently  in  situ, 
as  the  patient  complained  when  they  were  replaced.  Some  cutaneous  irritation  compli- 
cated the  jejunostomy  opening  but  none  the  appendicostomy.  There  was  no  excoriation 
whatever,  such  as  is  apt  to  occur  with  ordinary  cascal  fistulas. 

•'  This  patient  was,  and  remained,  under  Dr.  J.  A.  Shaw-Mackenzie's  trypsin  treatment. 
Having  regard  to  the  advanced  stage  of  the  case  she  held  her  own  in  a  marvellous  way 
and  she  was  free  from  pain  except  what  was  attributable  to  distension  by  ascites.  Death 
came,  from  exhaustion,  three  and  a  half  months  after  the  appendicostomy.  (I  have 
mentioned  that  the  peritonaeum  was  found  to  be  affected  at  the  time  of  operation.  In 
February  I  drew  off  150  ounces  of  ascitic  fluid.) 

'•  This  is,  so  far  as  I  know,  the  first  case  in  which  the  appendix  has  been  continuously 
used  as  a  spout  through  which  to  evacuate  faces.  It  was  for  this  purpose  that  I  sug- 
gested that  the  appendix  should  be  used  at  a  debate  on  ca»cal  colotomy  at  the  Medical 
Society  of  London  11  years  ago."* 

It  is  probable  that  appendicostomy  will  replace  cascostomy  for  the 
relief  of  at  least  some  cases  of  intestinal  obstruction  due  to  stricture 
of  the  colon.  The  growth  may  be  removed  later  and  the  appendicular 
fistula  easily  closed  when  the  channel  has  been  firmly  re-established. 
The  appendix  should  be  carefully  but  thoroughly  dilated  in  order  to 
provide  free  drainage.  It  must  be  remembered  however  that  with  only 
a  fistula  out  of  the  efficum,  faeces  passing  over  the  line  of  suture  may 
interfere  with  proper  union.  An  artificial  anus  is  more  satisfactory 
in  this  respect  although  far  more  troublesome  to  close.  Ileo-sigmoid- 
ostomy  is  more  satisfactory  except  that  it  is  more  risky  for  most 
surgeons.  For  cases  of  irremovable  growth  of  the  colon,  some  form 
of  ileo-colostomy  is  far  preferable  if  the  surgeon  is  experienced  and 
the  patient's  condition  not  too  serious.  Mr.  Keetley's  case  shows  how 
very  useful  appendicostomy  may  be  even  in  late  cases  ;  but  it  may  not 
always  be  so  easy  to  find  and  especially  to  dilate  the  appendix  as  in 
this  case. 

I  have  recently  performed  appendicostomy  for  the  relief  of  intestinal  obstruction  due 
to  irremovable  growth  of  the  ascending  colon.  There  were  miliary  growths  in  the  peri- 
tonaeum, and  some  larger  secondary  masses  in  the  pelvis,  so  that  ileo-sigmoidostomy  was 
not  practicable,  even  if  the  patient's  condition  had  been  better.  In  right  lumbar  colostomy 
the  opening  would  be  too  near  the  growth,  and  appendicostomy  was  preferred  to  cascos- 
tomy,  because  it  could  be  performed  more  quickly  and  without  any  risk  of  infecting  the 
exploratory  wound  near  the  middle  line,  which  was  covered  with  a  sealed  dressing.  A 
large  amount  of  fasces  escaped  from  the  appendix  when  it  was  opened  after  12  hours,  and 
the  patient  was  greatly  relieved.  The  dilated  appendix  did  not  give  a  free  enough  vent 
however,  for  the  old  lady  complained  of  colicky  pains  occasionally,  and  she  died  after 
three  weeks  from  a  perforation  of  a  stercoral  ulcer  in  the  lower  end  of  the  ileum,  although 
the  fistula  had  seemed  to  act  well.     The  patient  was  in  a  very  bad  condition  when  she 

*  The  Lancet,  November  17,  1894,  p.  1155. 

10 — 2 


148  OPERATIONS  ON  THE  ABDOMEN. 

wa?  admitted,  and  it  is  quite  possible  that  the  ileum  was  ulcerated  then  and  that  a  perfora- 
tion would  hare  occurred  even  if  a  freer  opening  had  been  made  into  the  caecum.  I  think 
that  this  case  illustrates  a  real  danger,  however. 

Id   cases  of  severe  intestinal  distension  embarrassing  the  breathing 

and  leading  to  paralytic  distension  of  the  intestine  if  unrelieved, 
appendicostomy  may  prove  to  be  a  simple  way  of  giving  great  relief; 
especially  is  this  likely  to  be  so  in  some  cases  of  general  suppurative 
peritonitis,  and  some  cases  of  intestinal  obstruction  after  removal  of 
the  cause. 


CHAPTER  IV. 
OPERATIONS  ON  THE  KIDNEY  AND  URETER. 

NEPHROTOMY  —  NEPHEO-LITHOTOMY  — NEPHRECTOMY  — 
NEPHRORRAPHY- OPERATIONS   ON    THE    URETER. 

Before  undertaking  an  operation  upon  any  of  the  urinary  organs 
the  surgeon  should,  of  course,  ascertain  the  state  of  the  general  health 
of  the  patient,  and  he  should  also  endeavour  to  gain  all  the  information 
he  can  about  the  condition  and  functional  capacity  of  each  one  of  the 
urinary  organs.  It  is  especially  important  before  operating  upon  one 
kidney  to  know  the  state  and  working  capacity  of  the  other.  By  means 
of  more  comprehensive  examinations  the  surgeon  may  hope  to  make 
more  accurate  diagnoses,  and  to  avoid  useless  and  incomplete  opera- 
tit)!)  s.  Armed  with  a  full  knowledge  of  the  value  of  the  other  kidney, 
the  surgeon  can  more  easily  decide  upon  the  extent  of  the  operative 
treatment  permissible  in  a  given  case,  as  well  as  the  nature  of  the  prog- 
nosis that  may  be  given.  On  the  other  hand,  valuable  time  must  not 
be  wasted  on  useless  investigations,  and  vexatious  and  dangerous  ones 
must  not  be  undertaken  unless  they  are  likely  to  lead  to  valuable  con- 
clusions. In  addition  to  the  valuable  information  to  be  obtained  from 
the  history,  symptoms,  physical  signs,  chemical,  microscopical,  and 
bacteriological  examinations  of  the  urine,  the  catheter  and  the  sound, 
there  are  other  means  which  may  provide  even  more  useful  knowledge 
in  some  cases.  The  cystoscope,  the  segregator,  skiagraphy,  the  estima- 
tion of  the  urea  in  the  separated  urines,  and  eryoscopy  may  complete  the 
diagnosis  made  by  the  older  methods,  which  are  sometimes  quite 
sufficient  if  well  considered. 

The  surgeon  must  decide  which  of  these  comparatively  new  methods 
of  investigation  to  use  and  rely  upon  in  any  given  case.  Some  of  them 
require  special  skill,  and  the  value  of  some  of  them  is  as  yet  uncertain. 
It  is  well  to  remember  that  we  cannot  afford  to  reject  reliable  informa- 
tion obtained  from  any  source,  new  or  old,  and  that  correct  conclusions 
are  generally  arrived  at  from  a  careful  consideration  of  all  the  available 
evidence  without  attaching  undue  weight  to  any  one  sign  or  symptom. 
It  may  be  wise,  therefore,  to  make  some  remarks  here  upon  the  possible 
value  and  place  of  these  most  recent  aids  to  diagnosis. 

A.  The  cystoscope. — Used  by  a  surgeon  who  is  accustomed  to  it,  and 
capable  of  interpreting  what  he.  sees,  as  well  as  conscious  of  its  limita- 
tions, the  cystoscope  renders  invaluable  aid  in  the  diagnosis  of  the 
various  diseases  of  the  bladder,  and  a  full  consideration  of  the  instru- 
ment will  be  found  in  the  section  of  this  book  referring  to  these 
diseases, 


150  OPERATIONS  ON  THE  ABDOMEN. 

It  may  also  be  very  useful  in  helping  the  surgeon  to  decide  in  cases 
of  difficulty  of  diagnosis  between  renal  and  vesical  disease ;  thus  the 
source  of  a  hematuria  of  doubtful  origin  may  be  proved  to  be  a  villous 
tumour  near  one  ureter.  It  may  also  help  us  to  decide  which  kidney 
is  affected,  for  a  skilful  observer  may  see  blood  or  pus  exuding  from 
one  ureter  or  he  may  observe  an  ulcerated,  retracted  or  dilated  ureteral 
orifice,  indicative  of  the  side  of  the  renal  disease.  Cystoscopic  ureteral 
catheterisation  besides  being  a  very  difficult,  tedious  procedure,  not 
free  of  danger  even  in  practised  hands,  is  no  longer  necessary  for 
the  separation  of  the  urines  for  diagnostic  purposes,  for  the  segregator 
provides  us  with  a  far  simpler  and  safer  means  of  attaining  this  desirable 
object.  Further,  the  ureteral  catheter  may  give  very  misleading  results, 
for  the  instrument  may  get  blocked,  or  its  orifice  be  obstructed  by 
mucous  membrane,  and  it  is  quite  common  for  the  ureter  to  bleed  a 
little  from  slight  injury  to  the  mucous  membrane  inflicted  during  the 
introduction  of  the  instrument ;  this  may  easily  lead  to  error.  The 
danger  of  infecting  a  healthy  kidney  from  a  diseased  bladder  has  been 
referred  to.  Even  Kelly's  far  safer  and  comparatively  simple  direct 
method  of  catheterising  the  female  ureter  is  not  so  easy  as  segregation, 
and  the  former  disturbs  the  patient  and  the  bladder  more. 

B.  The  Value  of  the  X-Bays  in  the  Diagnosis  of  Urinary  Diseases. 
— The  X-rays  are  capable  of  giving  invaluable  aid  in  the  diagnosis  of 
urinary  diseases,  but  for  reliable  results  a  skilled  radiographer,  who  has 
devoted  much  time  and  care  to  this  method  of  investigation,  is  essential. 
He  should  also  have  a  knowledge  of  anatomy  and  clinical  experience  to 
guide  him  in  his  work  and  guard  him  against  mistakes.  The  evidence 
obtained  by  this  means  is  not  to  be  taken  alone,  but  should  be  carefully 
weighed  in  conjunction  with  other  facts,  for  by  itself  it  may  be  mis- 
leading like  all  other  solitaiy  signs.  Mr.  Shenton  (Lancet,  vol.  ii.  1906, 
p.  719)  in  an  able  article  upon  this  subject  rightly  lays  great  stress  upon 
the  importance  of  screen  examinations,  and  points  out  that  the  value 
of  photographs  is  comparative!}7  small,  and  to  be  taken  as  records  of 
the  objects  seen  upon  the  screen,  and  for  future  reference. 

In  comparing  the  two  methods  Mr.  Shenton  makes  the  following 
important  remarks : — 

"  '  The  smaller  the  diaphragm  the  better  the  skiagram,'  would  be  a 
true  maxim  if  it  were  borne  in  mind  that  the  actual  image  does  not 
become  smaller,  and  therefore  the  diaphragm  must  be  sufficiently  large 
to  include  the  object  examined.  We  have  no  method  of  reducing  the 
size  of  our  image  as  in  photography,  for  the  X-rays  cannot  be  refracted, 
reflected,  or  influenced  in  any  such  way.  Now  it  would  be  very 
laborious  and  well-nigh  impossible  to  take  a  quantity  of  little  skiagrams 
about  one  and  a  half  inches  in  diameter  all  over  the  urinary  areas,  and 
it  is,  therefore,  to  the  screen  that  we  must  turn  for  assistance.  In  a 
screen  examination  it  is  possible  to  examine  the  patient  in  a  series  of 
small  areas  and  in  this  lies  one  of  the  superiorities  of  screening  over 
photography.  Moreover,  the  amount  of  movement  constantly  present 
in  the  abdomen,  whatever  precautions  are  taken,  such  as  holding  the 
breath,  fixing  the  kidney  with  compressors,  &c,  makes  photography 
in  small  areas  often  of  little  use,  whereas  the  slight  movement  upon 
the  screen  is  a  positive  help  in  the  detection  of  a  foreign  body. 

"  Upon  discerning  the  slightest  suspicion  of  a  foreign  body  the  patient 


OPERATIONS   ON   THE    KIDNEY   AND    UKETEI!.  i5I 

is  told  to  take  a  deep  breath.  This  is  done  for  two  reasons :  first,  a 
moving  body  is  often  easier  to  detect  than  one  remaining  stationary; 
and  secondly,  the  relative  movements  of  this  object  and  surrounding 
organs  bear  an  important  relation  to  one  another.  For  example,  if,  as 
is  usually  possible,  one  edge  or  part  of  the  kidney  is  observable,  note 
whether  the  movement  of  this  and  the  foreign  body  are  coincident.  If 
they  move  as  one  the  inference  is  in  favour  of  the  object  being  a  stone 
in  the  kidney,  and  if  the  relative  movements  do  not  coincide  it  is 
extremely  probable  that  the  contrary  is  the  case.  Contract  the  dia- 
phragm upon  this  suspicious  object  and  try  to  make  out  its  outline. 
Renal  stones  have  often  such  characteristic  shapes  that  this  may  be 
valuable  evidence.  Systematic  search  is  made  in  this  manner  in  renal, 
ureteric,  and  bladder  regions,  being  careful  to  look  up  as  high  as  the 
last  two  ribs,  and  while  in  this  position  make  the  patient  breathe 
deeply,  for  I  have  several  times  in  this  manner  driven  a  stone  from  its 
lurking  place  behind  a  rib.  The  kidney  is  a  more  movable  organ 
than  is  usually  described  and  normally  moves  appreciably  with  respira* 
tion.  When  examining  over  the  bladder  region  pressure  on  the  screen 
should  be  made  as  this  much  improves  the  screen  picture.  In  this 
region  the  sacrum  must  be  remembered,  but  its  extreme  symmetry 
prevents  it  being  mistaken  for  calculus  material ;  also,  in  the  event  of 
finding  calculus  in  this  region  remember  the  possibility  of  its  being 
in  the  lower  ends  of  the  ureters.  I  have  found  calculi  in  both  ureters 
at  the  same  time  and  from  the  comparison  of  their  appearances  have 
been  able  to  give  their  composition ;  in  one  case  this  was  oxalate  of 
lime  in  the  right  and  phosphatic  material  in  the  left." 

"  When  examining  a  photograph,  it  should  be  generally  understood 
that  if  a  skiagram,  particularly  of  the  lumbar  regions,  possesses  great 
pictorial  beauty,  a  clear  spine  with  a  few  well-defined  and  clear-cut  ribs, 
it  is  usually  inadequate  so  far  as  diagnostic  value  is  concerned.  Pale 
stones,  such  as  phosphatic  calculi,  and  little  stones  will  not  appear,  and 
to  show  these  it  is  essential  to  get  a  dull  grey  image  which,  from  a 
pictorial  point  of  view,  is  unattractive." 

"  In  speaking  of  the  screen  in  the  diagnosis  of  urinary  calculus  I  am 
not  putting  forward  an  untried  theory,  but  one  which  a  very  large 
series  of  cases  has  proved  to  be  sound  and  practical.  It  has  reduced 
the  inaccuracies  of  this  branch  of  radiography  to  a  minimum,  and 
where  failures  do  occur  they  are  usually  traceable  to  inability  to  carry 
out  the  method  I  have  described  completely.  In  the  work  I  have  done 
for  St.  Peter's  Hospital  and  which,  owing  to  the  kindness  of  Mr.  S. 
Allen,  I  have  been  able  to  check  as  to  accuracy,  there  has  not  been  an 
X-ray  report  that  has  been  proved  incorrect  since  this  system  of  strict 
screen  examination  was  substituted  for  the  former  photographic  method.'' 

An  incomplete  X-ray  examination  is  of  no  great  value,  and  may  be 
very  misleading.  Before  undertaking  a  nephrolithotomy  for  instance, 
it  is  not  enough  to  know  that  there  is  a  stone  in  one  kidney  without 
ascertaining  the  condition  of  the  corresponding  ureter  and  that  of  the 
opposite  kidney  and  its  duct.  To  gain  this  knowledge  a  complete 
examination  of  both  sides  is  necessary  in  addition  to  an  estimation  of 
the  urea  in  the  separated  urines.  Failure  to  take  this  precaution  may 
lead  to  an  unwise  or  incomplete  operation. 

When  a  stone  is  discovered  in  the  bladder,  it  is  more  than  likely 


152  OPERATIONS  ON  THE  ABDOMEN. 

that  there  is  another  at  its  source  in  one  kidney  or  in  the  corresponding 
ureter,  therefore  a  screen  examination  of  these  organs  should  he  made. 
An  elderly  man  was  greatly  relieved  by  the  removal  of  a  stone  from 
his  bladder,  but  within  a  year  another  vesical  calculus  had  to  be 
removed,  and  soon  afterwards  the  patient  died  from  uraemia  and  sup- 
purative nephritis  ;  then  it  was  discovered  that  both  kidneys  contained 
several  stones,  although  the  patient  had  never  complained  of  any  renal 
symptoms. 

It  can  be  safely  stated  that  with  proper  precautions  radiography  is 
free  of  danger  to  the  patient,  and  on  this  account  as  well  as  that  of 
accuracy,  it  compares  very  favourably  with  other  methods  of  investiga- 
tion, such  as  cystoscopy,  segregation,  and  especially  ureteral  cathe- 
terisation  ;  it  is  also  more  universally  applicable,  for  cystitis,  stricture, 
or  enlargement  of  the  prostate  may  limit  the  application  of  one  or  more 
of  these  methods. 

That  the  evidence  obtained  from  radiography  has  become  more  and 
more  accurate  in  the  last  few  years  must  be  the  experience  of  every 
surgeon  who  is  fortunate  enough  to  secure  the  services  of  an 
experienced  and  capable  radiographer,  and  the  following  remarks  from 
an  excellent  paper  by  Dr.  Leonard,  of  Philadelphia  (Lancet,  vol.  i.  1905, 
p.  1632)  are  well  worth  quoting  upon  this  point : — 

"  This  claim  of  accuracy  for  the  negative  or  exclusion  diagnosis  is 
borne  out  by  the  statistics  of  the  cases  examined  by  myself.  There 
have  been  but  four  cases  in  which  calculi  have  been  found  on  operation 
or  passed  in  the  series  of  330  cases  examined  since  I  claimed  equal 
accuracy  for  the  negative  and  positive  diagnosis,  and  the  negative 
diagnosis  has  been  confirmed  by  operation  forty-seven  times.  There 
have  been  six  other  cases  in  which  the  surgeon  failed  to  find  a  small 
calculus  detected  by  the  Rontgen-ray  or  in  which  only  a  mass  of 
cretaceous  substance  was  found  in  the  pelvis  of  the  kidney.  It  is 
probable  that  half  the  errors  were  due  to  defective  operating,  a  delay 
after  the  examination  sufficient  for  the  calculus  to  pass,  or  its  escape 
during  the  operation." 

"...  The  total  amount  of  error  in  both  the  positive  and  negative 
diagnosis  is  less  than  3  per  cent,  of  the  330  cases  examined.  This  is 
a  percentage  of  error  that  compares  very  favourably  with  any  other 
method,  or  all  other  methods  of  diagnosis,  including  exploratory 
nephrotomy." 

"  The  effect  of  the  greater  accuracy  in  the  diagnosis  of  calculous 
conditions  by  this  method  upon  surgical  procedures  has  been  to  render 
a  complete  operation  with  the  minimum  of  surgical  interference 
impossible  without  the  comprehensive  diagnosis  which  it  affords.  It 
has  also  decreased  the  necessity  for  operation  by  furnishing  valuable 
indications  for  a  conservative  expectant  line  of  treatment  that  is  fully 
justified  by  results  already  obtained.  The  value  and  wisdom  of  such 
a  course  of  treatment  in  selected  cases  of  ureteral  lithiasis  has  been 
demonstrated  by  the  passage  and  recovery  of  calculi  in  26  cases  without 
operation.  In  addition  to  rendering  the  operation  complete  this 
method  has  localised  the  operative  intervention,  making  it  unnecessary 
to  explore  the  other  kidney  or  the  ureter  when  only  the  kidney  is  the 
seat  of  calculous  disease.  The  value  peculiar  to  this  method  of 
diagnosis   and  the  accuracy  claimed  for  it  can  only  be  secured  by  a 


OPERATIONS   ON   THE    KIDNEY   AND    URETER.  153 

technique  capable  of  making  an  accurate  negative  as  well  as  positive 
diagnosis.  Such  technique  cannot  be  obtained  without  careful  study 
and  must  be  fortified  by  a  clinical  experience  that  renders  the  operator 
capable  of  translating  the  diagnosis  accurately  from  a  radiographic 
plate  in  which  he  recognises  the  features  essential  to  the  establishment 
of  the  diagnosis.  Infallibility  is  not  claimed  for  this  method  but  a 
greater  amount  of  accuracy  has  been  established  than  is  possible  by 
other  methods.  Even  such  accuracy  cannot  be  expected  unless  the 
operator  has  acquired  a  technique  and  clinical  experience  that  warrant 
a  belief  in  his  accuracy.  The  great  difficulty  is  that  the  surgeon 
expects  equal  accuracy  from  every  operator  and  condemns  the  method 
because  his  clinical  experience  has  brought  him  in  contact  with  an 
operator  who  is  unfitted  to  employ  it  accurately." 

"  The  early  period  at  which  this  method  of  diagnosis  can  determine 
the  presence  or  absence  of  lithiasis  is  of  the  utmost  importance,  for 
when  the  symptoms  have  become  sufficiently  obvious  to  make  it 
possible  to  recognise  the  condition  pathological  changes  are  often 
far  enough  advanced  seriously  to  affect  the  functional  efficiency  of  the 
kidney." 

Very  small  calculi  may  not  be  discovered  by  means  of  the  Rontgen- 
rays,  and  therefore  a  negative  result  is  not  always  final.  Uratic  stones 
are  also  difficult  to  see,  but  calculi  formed  of  urates  or  uric  acid  only 
are  very  rare,  some  phosphate  or  oxalate  being  practically  always 
present  in  sufficient  quantity  to  give  a  shadow.  Henry  Morris 
(Lancet,  vol.  ii.  1906,  p.  141)  has  shown  that  xanthin  and  cystin 
calculi  are  discoverable  by  means  of  the  X-rays.  Quite  small  oxalate 
and  phosphatic  stones  are  opaque  and  easihy  shown. 

Cretaceous  mesenteric  glands,  phleboliths  within  the  pelvic  veins, 
atheromatous  plates  in  the  walls  of  the  arteries,  ossifying  pelvic  liga- 
ments and  tendons,  and  sc}Tbala  in  the  colon  have  all  been  mistaken 
for  calculi,  but  with  greater  knowledge  and  experience  these  mistakes 
are  becoming  quite  rare,  but  the  possibility  of  their  occurrence  should 
be  remembered.  In  cases  of  doubt  it  is  well  to  have  two  examinations, 
and  it  is  always  wise  to  give  a  purgative  on  the  day  before  an  examination 
is  made,  so  that  fsecal  concretions  may  not  mislead  the  radiographer. 

Hurry  Fenwick  {Brit.  Med.  Journ.,  June  17,  1905)  passes  an 
opaque  ureteric  bougie  in  order  to  avoid  such  errors ;  this  procedure 
is  very  difficult  in  the  male,  and  not  devoid  of  danger  in  either  sex,  but 
with  these  reservations  it  may  be  found  useful  in  some  cases. 

The  X-rays  may  give  some  information  in  other  renal  diseases; 
sometimes  the  kidney  may  be  seen  to  be  enlarged,  for  instance,  or 
unduly  fixed,  suggesting  a  growth. 

Negative  radiographic  results  should  not  be  allowed  to  prevent  or 
defer  renal  explorations  which  are  strongly  indicated  by  other  evidence  ; 
this  is  especially  true  of  unilateral  hematuria  of  unknown  cause  ;  delay 
in  a  case  of  this  kind  may  allow  a  renal  growth  to  become  irremovable. 

C.  The  segregator  or  separator  (Luys). — This  may  render  valuable 
aid  by  enabling  us  to  collect  the  urines  from  the  two  ureters  separately. 

(a)  Blood  or  pus  may  come  from  one  side  only  indicating  the  side  of 
the  disease. 

(6)  The  percentage  of  the  urea  coming  from  each  kidney  may  be 
estimated,  and  thus  the  diseased  organ  may  be  determined  and  roughly 


154  OPERATIONS  OX  THE  ABDOMEN. 

the  comparative  value  of  the  two  kidneys,  supposing  both  to  be 
diseased,  as  proved  by  the  discharge  of  morbid  urine  from  both  ureters. 
The  freezing  points  of  the  separated  urines  may  also  be  obtained. 

(c)  Similarly  the  amount  of  sugar  coming  from  each  kidney  in  the 
Phloridzin  test  may  be  determined,  and  also  the  amount,  time  of 
onset,  and  duration  of  the  elimination  of  chromogen  in  the  methy- 
lene blue  test.  Urine  of  different  degrees  of  colour  may  flow  from 
the  two  tubes. 

(d)  It  may  enable  the  surgeon  to  distinguish  between  renal  and  other 
enlargements  as  shown  by  Bickersteth  (vide  infra). 

(e)  It  may  help  us  to  find  out  whether  unilateral,  primary  or  idiopathic 
nephritis  really  ever  occurs. 

It  must  be  remembered,  however,  that  a  certain  amount  of  skill  and 
a  knowledge  of  anatomy  are  required  in  the  use  of  the  instrument, 
which  may  be  very  misleading  if  carelessly  handled  ;  thus  a  case  has 
been  recorded  in  which  urine  came  from  both  tubes  although  the  patient 
only  possessed  one  kidney ;  it  is  easy  to  understand  that  a  slight 
relaxation  of  pressure  on  the  bladder  base  may  allow  urine  to  pass  the 
india-rubber  diaphragm  from  one  side  to  the  other.  The  instrument 
is  not  reliable  unless  the  bladder  has  been  seen  to  be  free  of  disease 
by  cystoscopy,  for,  as  pointed  out  by  Fenwick  (Med.  Annual,  1905,  p.  36), 
villous  growth,  carcinoma,  encysted  stone  or  inflamed  pouch  may  each 
add  morbid  products  to  the  urine  of  one  side  only,  and  this  would 
lead  to  serious  error.  It  cannot  be  relied  upon  in  cases  of  enlarged 
prostate  owing  to  the  irregularity  of  the  bladder  base,  and  it  should 
not  be  used  in  cases  of  contracted  bladder  due  to  carcinoma  or  late 
tuberculosis,  and  it  cannot  be  used  in  cases  of  urethral  stricture  until 
the  stricture  has  been  dilated.  Luys  first  described  his  valuable  inven- 
tion in  October,  1901,  and  demonstrated  its  use  before  the  International 
Medical  Congress  at  Madrid  in  1903.  Bickersteth  introduced  the  instru- 
ment into  England  and  wrote  a  valuable  paper  on  the  subject  with  refe- 
rences and  an  account  of  cases  {Lancet,  March  26, 1904).  The  instrument 
is  best  sterilised  by  boiling,  which  does  not  spoil  the  india-rubber  if  not 
continued  too  long.  The  genitalia  are  thoroughly  cleansed  and 
anaBsthetised  by  the  injection  of  a  5  per  cent,  solution  of  cocaine  into 
the  urethra  and  "  milking  "  it  backwards  into  the  deep  urethra  in  the 
male,  or  by  placing  some  cotton  wool  soaked  in  the  cocaine  solution 
between  the  labia  in  the  female.  A  general  anesthetic  is  very  rarely 
necessary  and  is  not  an  advantage.  Before  making  these  preparations 
the  patient  should  drink  about  a  pint  of  water,  tea  or  Contrexeville 
water.  Some  contrivance  must  be  made  for  sitting  the  patient  up 
and  providing  him  with  a  back  rest  during  the  separation  ;  this  attitude 
is  essential  for  complete  success.  Mr.  Bickersteth's  account  of  the 
introduction  and  use  of  the  instrument  is  so  good  that  I  make  use  of 
it  verbatim. 

"  The  first  step  of  the  actual  procedure  is  to  pass  a  catheter  and  to 
draw  off  and  to  set  on  one  side  the  specimen  of  the  "mixed  urines" 
thus  obtained.  Next,  the  bladder  is  washed  out  and  upon  the  careful- 
ness and  thoroughness  with  which  this  is  done  much  will  depend.  It 
is  essential  that  the  bladder  should  be  thoroughly  clean  and  if  each  of 
the  last  two  or  three  "  washings"  is  collected  in  a  clean  urine  glass 
and  the  fluid  is  seen  to  come  back  perfectly  clear  the  surgeon  may  feel 


OPERATIONS    ON    TIIK    K  1 1  >N  I'.V    AM>    UBETEE. 


J55 


satisfied  that  so  far  he  has  done  his  work  well.  Then  about  two  ounces 
of  fluid  are  injected  into  the  bladder  and  all  is  now  ready  for  intro- 
ducing the  "  separator."  As  ;i  rule  the  instrument  slides  easily  and 
smoothly  int..  the  female  bladder  without  any  difficulty  at  all;  in  the 
male  a  little  difficulty  may  at  first  be  found.  The  curves  of  Dr.  Luys's 
separator,  designed  solely  with  the  object  of  making  the  instrument 
tit  closely  and  naturally  against  the  floor  and  neck  of  the  bladder — and 
which  at  first  sight  may  perhaps  strike  an  observer  as  peculiar — are, 
after  all,  only  a  little  shorter  and  sharper  than  those  of  the  French 
"  bougies  de  r>eiiique,"  in  which  very  similar  curves  are  selected  as 
being  most  suitable  for  the  ordinary  instruments  used  in  the  treatment 
of  stricture.  These  curves,  when  once  the  surgeon  is  used  to  them, 
do  not  cause  any  difficulty  in  getting  the  point  of  the  separator  well 
into  the  bladder,  but  it  must  be  admitted  that  at  and  beyond  this  point 
when  it  is  required  to  pass  the  whole  curved  part  of  the  instrument 
right  on  into  the  bladder  itself  a  little  difficulty  may  certainly  be  met 
with  until  by  practice  the  operator  has  learnt  how  to  do  it.     As  soon 


Fig.  60. 


Luys'  segregator.     (Down's  catalogue.) 


as  the  curved  part  has  been  passed  fairly  into  the  bladder,  the  back  rest 
is  raised  and  the  patient  is  placed  in  the  sitting  position.  Then  by 
turning  the  screw  at  the  end  of  the  handle  the  rubber  partition  is  raised 
and  the  injected  fluid  is  allowed  to  run  off  by  the  two  catheter  tubes,  the 
ends  of  which  have  been  closed  by  our  fingers  during  the  foregoing  mani- 
pulations. This  not  only  shows  that  the  catheter  eyes  have  not  become 
blocked  by  urethral  mucous,  &c.,but  by  filling  the  catheters  themselves  it 
starts  what  seems  to  be  a  syphon  action  and  allows  the  urine  to  flow 
off  from  the  bladder  as  fast  as  it  enters  it  from  the  ureters.  In  order 
that  the  curve  of  the  instrument  may  press  with  sufficient  firmness 
upon  the  floor  of  the  bladder  to  make  the  partition  water-tight  and 
the  "  separation  "  trustworthy  only  one  thing  more  is  now  necessary, 
the  surgeon  must  raise  the  handle  a  little,  and  while  doing  this  at  the 
same  time  draw  the  whole  instrument  gently  forwards  towards  him  ; 
it  must  always  be  remembered  that  the  most  gentle  pressure  suffices 
for  this  and  that  no  force  at  all  is  either  necessary  or  permissible.  At 
this  stage  patience  is  required,  the  surgeon  must  not  put  the  collecting 
tubes  under  the  catheters  at  once  but  must  wait ;  he  may  have  to  wait 
three  or  four  minutes,  or  even  longer  sometimes,  until  the  last  drops 
of  the  injected  fluid  have  come  away  and  urine  itself  begins  to  flow. 
When  all  is  going  well  the  manner  in  which  the  urine  flows  from  the 
catheter  tubes  is  always  most  striking  and  characteristic,     It  comes 


i56 


OPERATIONS  ON  THE  ABDOMEN. 


with  the  greatest  regularity,  four  or  five  drops  at  a  time,  then  a  pause 
for  an  appreciable  interval,  and  after  this  another  group  of  drops. 
Each  of  these  groups  of  drops  represents  an  "  overflow  "  from  the  little 
pool  of  urine  in  the  bladder  in  which  the  other  end  of  the  catheter  tube 
is  lying  and  these  periodic  overflows  of  course  correspond  with  the 
rhythmically  recurring  jets  by  which  the  urine  normally  escapes  from 
the  ureter  into  the  bladder.  When  once  the  operator  is  satisfied  that 
all  the  injected  fluid  has  run  off  and  that  urine  is  now  coming  he  may 
place  the  collecting  tubes  in  position  ;  in  about  twenty  minutes  he  will 
probably  have  collected  about  six  cubic  centimetres  in  each  tube  and 
the  tubes  will  be  full.     They  can  then  be  replaced  by  a  fresh  pair  of 


Segregator  passed 

into  proper 

position. 

Elastic  membrane  :  this  also  extends  for  a  little  distance  below 
and  behind  the  metal  blades. 

After  Luys  and  Vale.     (Ann.  of  Sun/.) 

empty  tubes  and  in  this  way  a  second,  and  if  necessary  even  a  third, 
pair  of  specimens  can  be  obtained." 

Figs.  60,  61,  and  62  illustrate  the  segregator  and  its  use.  Care 
must  be  taken  to  see  that  the  instrument  is  in  proper  working  order 
before  introducing  it,  for  if  the  india-rubber  lose  its  elasticity,  it  may 
not  pull  the  chain  well  into  the  concavity  of  tbe  instrument,  and  then 
the  cogs  may  still  be  standing  up  when  the  instrument  is  withdrawn, 
and  the  urethra  may  thus  be  damaged. 

The  two  following  cases  of  Bickersteth  illustrate  very  well  the  use 
of  the  segregator  in  the  diagnosis  of  renal  tumours  from  others  in  their 
vicinity  and  vice  versa. 

Case  4. — Large  tumour  in  the  right  loin  simulating  hydronephrosis.  The  patient,  a 
man,  aged  49  years,  gave  a  history  of  nine  months'  uneasiness  and  discomfort  from  a 
gradually  increasing  swelling  in  the  right  side.  This  had  now  reached  a  very  large  size  ; 
it  seemed  to  be  fluid  but  it  was  very  tense  ;  it  could  be  pushed  forward  from  the  loin.  It 
was  unhesitatingly  taken  for  a  hydronephrosis  and  an  operation  through  the  loin  was 


OPERATIONS    ONT    THE    KIDNEY     WD    [JKKTKIt. 


157 


decided  upon.  On  Feb.  2nd,  1904,  the  separator  was  applied,  the  instrumenl  being  kepi  in 
for  thirty  minutes,  six  cubic  cenl  imet  res  of  urine  lowed  from  the  right  tube  ;  it  whs  . 
of  good  colour,  with  Blight  deposit  of  mucous  and  lithates.  On  cryoscopic  examination 
the  freezing  poinl  was  found  to  be— 2-0°  C.  Two  and  a  half  cubic  centimetres  of  urine 
flowed  from  the  lefl  tube  ;  it  was  very  pale,  with  practically  no  deposit.  On  cryoscopic 
examination  the  freezing  poinl  was  found  to  be  —  io°C.  This  altogether  unexpected  and 
surprising  resull  led  to  a  postponement  of  the  operation  and  to  a  reconsideration  of  the 
whole  case.  A  second  application  of  the  separator  on  the  third  confirmed  the  results 
Obtained  on  the  previous  day  and  gave  two  specimens  exactly  similar  both  in  character 
and  quantity  to  those  already  described,  except  that  one  grain  of  methylene  bine  bavin": 
been  given  hypodcrmically  a  quarter  of  an  hour  beforehand  both  specimens  alike  were 
beginning  to  show  traces  of  colour.  At  the  operation,  which  was  performed  on  Feb.  5th 
(anterior  incision),  the  swelling  proved  to  be  a  large  pancreatic  cyst.  The  right  kidney 
was  normal. 

CASE  5. — The  patient,  a  man,  aged  40  years,  was  admitted  into  the  Royal  Infirmary, 
Liverpool,  on  Oct,  27th,  1903,  complaining  of  severe  pain  in  the  left  side,  especially  about 

Fig.  62. 


Bladder. 


Segregator. 


Triangular 
ligament. 


The  segregator  imperfectly  introduced.     (After  Luys  and  Vale.) 

the  tip  of  the  twelfth  rib,  of  a  dull  aching  character,  but  sometimes  paroxysmal,  radiating 
down  to  the  left  groin  but  not  extending  to  the  testicle.  The  pain  was  almost  always 
relieved  by  the  patient  lying  flat  down  on  his  back.  He  had  been  suffering  like  this  for 
two  years  and  was  getting  worse.  "  The  left  kidney  was  felt  to  be  much  enlarged." 
Under  the  very  natural  impression  that  this  was  probably  a  case  of  calculous  pyelitis 
with  a  blocked  ureter  it  was  decided  to  cut  down  into  the  left  loin  and  to  explore  this 
kidney.  Examination  of  the  mixed  urines  showed  them  to  be  of  specific  gravity  1017, 
acid,  clear,  pale  amber  in  colour,  with  no  deposit,  albumin,  or  sugar.  On  Nov.  18th  the 
separator  was  applied.  My  note  reads  :  "  Instrument  passed  easily  and  was  kept  in  for 
thirty  minutes.  Urine  flowed  at  normal  rate  and  in  equal  quantity  from  both  kidneys. 
The  urine  is  normal,  quite  healthy,  and  apparently  exactly  the  same  on  one  side  as  on  the 
other."  Unfortunately,  the  findings  of  the  instrument  were  in  this  case  disregarded.  It 
was  one  of  my  earlier  cases,  and  as  I  had  not  at  that  time  acquired  my  present  degree  of 
confidence  in  the  method  I  could  scarcely  expect  to  convince  others  of  its  trustworthiness. 
On  Nov.  24th  operation  was  performed.  An  incision  into  the  left  loin  showed  an  aneurysm 
displacing  the  kidney.  The  mistake  was  quickly  recognised  before  any  apparent  harm  had 
been  done  and  the  wound  was  closed.     The  wound  healed  and  all  seemed  to  be  going  well, 


158  OPERATIONS   OX   THE   ABDOMEN. 

but  about  ten  days  later  this  patient  died  without  warning  and  with  absolute  suddenness.  A 
post-mortem  examination  revealed  the  condition  to  be  aneurysm  of  the  abdominal  aorta 
which  had  ruptured  into  the  left  pleura. 

Mr.  Bruce  Clarke  (Lancet,  Jan.  7,  1905,  p.  5)  and  many  others 
have  published  interesting  cases  showing  the  undoubted  value  of  the 
segregator,  which  is  now  in  constant  use  in  most  of  the  London  hospitals. 
The  following  is  one  of  Mr.  Bruce  Clarke's  cases. 

"  One  more  instance  of  the  use  of  this  instrument.  The  patient  in  question  was  passing 
pus  from  time  to  time  with  her  urine  but  the  symptoms  though  pointing  to  the  right 
lumbar  region  were  not  sufficiently  marked  to  make  it  absolutely  certain  which  of  the  two 
kidneys  was  affected.  She  had  been  examined  by  means  of  a  cystoscope  but  the  urine,  even 
after  the  bladder  had  been  washed  out,  was  too  opaque  to  make  the  diagnosis  a  matter  of 
certainty.  The  separator  was  introduced,  three  grains  of  methylene  blue  in  a  pill  having 
been  previously  administered.  The  result  was  a  striking  one.  The  left  kidney  secreted 
urine  naturally.  It  came  away  rapidly  and  evenly  and  was  deeply  stained  with  the 
methylene  blue  and  healthy  in  character.  A  few  drops  of  urine,  opaque  and  purulent  in 
appearance,  passed  from  the  right  side  shortly  after  the  separator  was  introduced.  No  more 
passed  for  nearly  half  an  hour,  when  more  fluid  of  the  same  character  was  voided.  It  was 
tested  for  urea  and  found  to  contain  less  than  \  per  cent.  The  diagnosis  was  consequently 
placed  beyond  doubt  and  the  right  kidney  was  removed  a  few  days  later.  It  was  little 
more  than  a  bag  of  pus  and  contained  some  caseous  material  as  well.  The  upper  part  of 
the  ureter  was  much  thickened  and  was  removed  at  the  same  time.  A  good  recovery 
resulted." 

The  Determination  of  the  Functional  Capacity  of  the  Kidney. — 
Ashton  Berg  (Ann.  of  Surg.,  May,  1906,  p.  724),  has  contributed  an 
able  discussion  upon  this  important  subject,  and  much  of  what  follows 
has  been  derived  from  his  paper. 

He  points  out  that  the  problem  is  a  threefold  one  ;  we  want  to 
discover  the  amount  of :  (a)  The  combined  work  of  the  kidneys;  (b) 
the  individual  work  of  each ;  and  (c)  the  probable  amount  of  work 
that  each  is  capable  of  doing  if  its  fellow  is  excised  or  seriously  damaged. 

(a)  The  combined  work  is  estimated  from  (i.)  the  cryoscopic  index  of 
the  blood,  and  (ii.)  the  amount  of  urea  discharged  in  24  hours. 

(b)  The  individual  work  is  determined  from  (i.)  the  percentage  of  urea 
in  the  individual  urines,  (ii.)  the  amount  of  sugar  and  chromogen  in 
each  urine  after  an  injection  of  Phloridzin  and  methylene  blue,  (iii.)  and 
the  cryoscopic  index  of  each  urine. 

(c)  The  potential  functional  power  of  each  kidney  cannot  be 
estimated  with  any  degree  of  accuracy  from  the  results  of  (a)  and  (b). 

D.  Cryoscopy. — Koranyi  was  the  originator  of  this  method  of 
investigation  which  aims  towards  estimating  the  functional  capacity 
of  the  kidneys  by  means  of  determinations  of  the  freezing  points  of 
the  blood  and  urine. 

Kiimmel,  Rovsing  and  others  have  written  much  upon  this  subject 
("  German  Surg.  Congress,"  1905;  Lancet,  vol.  i.  1905,  p.  1536). 

(i.)  The  cryoscopic  index  of  the  blood. — The  freezing  point  of  normal 
blood  is  from  0*56°  to  o*6o°  C.  below  that  of  distilled  water  ;  when  the 
solids  increase  from  deficient  renal  excretion  the  freezing  point  falls 
below  0'6o°  C,  and  it  also  falls  in  certain  diseases  accompanied  by 
deficient  oxidation  such  as  large  abdominal  tumours,  cardiac  and 
respiratoiy  insufficiency,  &c. 

In  severe  anaemia  the  blood  is  so  thin  that  considerable  retention  of 


OPERATIONS   ON    THE    KIDNEY   AND    URETER.  159 

potential  urinary  excretions  may  occur  without  a  fall  of  the  freezing 
point  below  o  6o°  ('. 

Dr.  Berg  concludes  that  "  the  cryoscopic  index  of  the  blood  merely 
indicates  the  work  that  is  being  done  by  the  renal  organs  :  it  teaches 
us  nothing  of  the  health  or  disease  of  the  kidneys,  for  three-fourths  of 
the  total  kidney-tissue  may  be  destroyed  and  yet  the  remaining  one- 
fourth  will  be  sufficient  to  maintain  the  normal  molecular  concentration 
of  the  blood;  nor  does  it  afford  an  indication  of  their  potential 
functionating  power.  Only  in  connection  with  the  health  or  disease  of 
the  individual  organs  can  the  freezing  point  of  the  blood  be  considered 
as  a  help  in  this  respect." 

"  (a)  A  normal  cryoscopic  index  of  the  blood  when  there  is  one  healthy 
and  one  diseased  kidney  would  indicate  a  potentially  sufficient  func- 
tional capacity  of  the  sound  organ,  and  would  warrant  us  in  doing  a 
nephrectomy. 

"  (b)  An  abnormally  low  cryoscopic  index  of  the  blood  when  there  is 
one  healthy  and  one  diseased  kidney  does  not  indicate  potential 
insufficiency  of  the  former  for  the  function  of  this  organ  may  be  only 
temporarily  impaired  by  the  diseased  fellow  organ.  In  such  a  case 
nephrectomy  may  nevertheless  be  done  safely. 

"  (c)  A  normal  cryoscopic  index  of  the  blood  when  there  is  one  slightly 
diseased  and  one  extensively  diseased  organ  would  usually  point  to  a 
potentially  sufficient  functional  capacity  of  the  less  diseased  organ,  and 
would  allow  of  our  doing  a  nephrectomy  or  other  operation  upon  the  more 
affected  kidney. 

"  (d)  A  normal  cryoscopic  index  of  the  blood  when  there  is  more  or 
less  extensive  affection  of  both  kidneys  does  not  mean  a  potentially 
sufficient  functional  capacity  of  these  organs,  and  does  not  permit  of  our 
removing  one  or  even  of  incisively  attacking  either  organ. 

"  (e)  An  abnormally  low  cryoscopic  index  of  the  blood  with  more  or 
less  extensive  disease  of  both  kidneys  indicates  their  potential  insuffi- 
ciency and  strongly  speaks  against  the  advisability  of  doing  any  operation 
upon  them." 

From  the  above  it  is  clear  that  too  much  reliance  must  not  be  placed 
in  this  one  source  of  information,  and  to  reject  all  patients  with  a 
freezing  point  of  the  blood  below  0.600  C.  as  unsuitable  for  nephrectomy 
or  major  operation  is  absurd.  Dr.  Berg  has  performed  nephrectomy 
when  the  freezing  point  has  been  as  low  as  0*65°  C.  and  0.670  C,  and 
the  patients  have  recovered. 

(ii.)  The  cryoscopic  index  of  the  combined  urines  is  of  far  less  value,  because  the  freezing 
point  of  the  urine  normally  varies  from  1.20  to  2.20  C.  below  that  of  distilled  water  ;  this  is 
due  to  variations  in  the  circulation,  nervous  influence  and  especially  the  amount  of  fluid 
partaken.  If  the  freezing  point  falls  below  i°  C.  under  normal  conditions,  renal  excretion 
may  be  assumed  to  be  deficient. 

A  comparison  of  the  freezing  points  of  the  separated  urines  may  however  be  valuable, 
and  may  indicate  the  proportion  of  the  work  done,  and  with  less  certainty  the  comparative 
amount  of  renal  tissue  in  the  two  kidneys. 

E.  Estimation  of  the  average  total  amount  of  urea  passed  in  the 
24  hours  is  of  value ;  it  should  be  about  350  to  400  grains  in  a  healthy 
person  in  bed  on  farinaceous  diet,  if  it  is  below  300  grains  renal  insuffi- 
ciency may  be  assumed.  Mr.  Clement  Lucas  many  years  ago,  relying 
upon  this  test,  refrained  from  removing  a  seriously  damaged  tuberculous 


160  OPERATIONS  OX  THE  ABDOMEN. 

kidney.  The  patient  died  of  diphtheria  and  was  found  to  have  only  one 
kidney.  A  comparison  of  the  percentage  of  urea  in  the  separated  urines 
is  of  more  value  for  it  enables  us  to  tell  which  is  the  diseased  or  the 
most  diseased  of  the  two  kidneys.  Rosving  relies  upon  this  and  a  care- 
ful examination  of  the  separated  urines,  and  he  "  maintains  that  a 
kidney  which  secretes  healthy  urine  containing  a  normal  percentage  of 
urea  is  functionally  sufficient  and  may  be  relied  upon  to  satisfactorily 
perform  the  full  work  of  the  body." 

The  Methylene  blue  test. — The  bladder  being  empty  and  the  segregator  or  ureteral 
catheters  introduced  a  sterilised  solution  of  0-05  grm.  of  methylene  blue  may  be  injected 
beneath  the  skin  of  the  flank.  The  urines  from  the  two  ureters  may  soon  differ  in  colour. 
The  time  of  onset,  the  rapidity  and  duration  of  the  elimination  by  each  kidney  should  be 
estimated,  and  from  these  data  the  comparative  functional  capacity  of  the  two  kidneys 
may  be  inferred. 

The  Phloridzin  test. — Phloridzin  (o-oo5  grm.)  is  injected  subcutaneously  and  the 
amounts  of  sugar  appearing  in  the  separated  urines  is  estimated,  and  from  a  comparison  of 
these  amounts  the  functional  activity  of  each  kidney  may  be  inferred. 

These  tests  are  of  little  value  in  determining  the  potential  functional  capacity  of  the 
kidneys,  except  when  the  state  of  the  kidneys  as  regards  presence  or  absence  of  disease  is 
known  from  other  sources,  such  as  a  thorough  examination  of  the  separated  urines. 

In  conclusion  it  may  be  stated  that  valuable  information  may  be 
obtained  by  a  careful,  skilful  and  combined  study  of 

(1)  The  cryoscopic  index  of  the  blood. 

(2)  The  percentage  of  urea  in  the  separated  urines. 

(3)  The  chemical,  microscopical  and  bacteriological  examination  of 
the  separated  urines. 

(4)  A  comparison  of  the  freezing  points  of  the  separated  urines. 

(5)  The  average  total  amount  of  urea  passed  in  the  24  hours. 

(6)  Rate  of  excretion  of  methylene  blue  and  sugar  in  the  methylene 
blue  and  Phloridzin  tests. 

The  urines  should  be  separated  by  means  of  the  segregator  and 
not  by  ureteral  catheterisation,  which  Berg,  Rosving  and  others 
recommend. 

The  following  case  may  serve  to  show  the  value  of  some  of  the  modern  methods  of 
diagnosis  of  urinary  diseases.  A  middle-aged  man  was  admitted  into  Guy's  Hospital, 
under  the  care  of  Sir  Cooper  Perry,  suffering  from  attacks  of  hematuria.  The  bleeding 
was  profuse  and  painless  but  it  lasted  only  for  a  few  hours  at  a  time.  In  the  intervals 
the  urine  was  healthy.  There  were  no  abnormal  physical  signs  in  the  loins  or  along  the 
course  of  the  ureters  :  there  was  some  dull  pain  over  the  sacrum.  A  radiographic  examina- 
tion was  negative.  On  examining  with  the  cystoscope  I  proved  the  absence  of  villous  or 
other  growth  of  the  bladder,  and  found  the  bladder  to  be  normal  except  for  a  slight 
enlargement  of  the  right  ureteral  orifice  and  some  congestion  around  it.  The  patient 
never  had  an  attack  of  bleeding  when  in  the  hospital,  although  he  was  encouraged  to  take 
exercise,  and  to  go  up  and  down  stairs  ;  and  bimanual  pressure  in  the  loins  failed  to  send  any 
blood  down  the  ureters  during  cystoscopic  examination.  Later  the  man  returned,  bring- 
ing with  him  a  ureteral  cast,  and  now  he  had  a  slight  varicocele  on  the  right  side. 

The  segregator  was  introduced,  and  the  urine  issuing  from  the  right  side  was  paler 
than  that  from  the  left,  and  the  former  contained  2-3  per  cent,  of  urea,  while  the  latter 
only  had  1*3  per  cent.  Control  examinations  gave  similar  results.  The  centrifugalised 
right  urine  showed  crenated  red  blood  corpuscles  and  large  round  cells  of  growth,  whereas 
the  left  urine  was  normal.  Cryoscopic  examination  of  the  separated  urines  by  Dr.  Bell 
Walker  confirmed  the  conclusion  that  the  right  kidney  was  doing  much  less  work  than 
the  left.  The  total  amount  of  urea  was  satisfactory.  A  diagnosis  of  malignant  growth  of 
the  right  kidney  was  made  with  confidence,  and  this  was  proved  upon  exposing  the  kidney, 


NEPHROTOMY.  161 

which  was  fairly  fixed  and  hidden  high  up  in  front  of  the  ribs.  The  kidney  was  removed 
without  hesitation,  for  it  was  known  thai  the  other  one  was  normal  in  function.  The 
patient  unfortunately  died  from  Lobar  pneumonia  of  the  left  lung  a  few  days  later.  There 
were  no  secondary  growths  anywhere. 

NEPHROTOMY. 

Indications. — The  following  are  the  principal  conditions  which 
demand  this  operation  : — 

i.  Pyonephrosis  and  Abscess  of  the  Kidney. — When  due  to  tuber- 
culous disease,  and  the  tumour  is  large,  or  the  patient  is  not  in  a 
condition  to  stand  primary  nephrectomy,  nephrotomy  should  be  per- 
formed as  a  preliminary  measure ;  when,  however,  there  is  evidence 
of  disease  of  the  opposite  kidney  or  of  other  viscera,  nephrotomy 
alone  is  available.  The  results,  however,  when  a  secondary  nephrec- 
tomy cannot  be  performed  are,  as  might  be  expected,  extremely 
unsatisfactory.  Otto  Ramsay,  of  Baltimore  (Ann.  of  Surg.,  vol.  ii. 
1900,  pp.  461  et  seq.),  gives  the  results  of  fifty-five  cases.  Of 
these,  four  at  the  most,  and  probably  two  only,  can  be  considered  as 
cured. 

When  the  abscess  is  due  to  calculi,  these  will  be  removed  and  the 
cavity  drained,  except  in  special  cases  where  nephrectomy  is  indicated 
(vide  infra,  p.  180). 

In  a  few  rare  instances  pyonephrosis  may  be  due  to  a  stricture  of 
the  ureter.  An  example  of  this  condition  is  referred  to  below  under 
the  Surgery  of  the  Ureter  (vide  p.  254). 

ii.  Hydronephrosis. — If  the  kidney  has  been  entirely  destroyed,  and 
the  size  of  the  tumour  prevents  removal,  incision  and  drainage  should 
be  employed  either  as  a  method  of  cure  or  as  a  preliminary  to  a 
secondary  nephrectomy. 

iii.  As  an  exploratory  operation  for  diagnostic  purposes  for  certain 
obscure  renal  symptoms.  Some  of  the  conditions  that  have  been 
found  are  mentioned  below  under  Nephrolithotomy  (vide  p.  166)  ;  in 
others  a  calculus  will  be  found.  In  others  again,  particularly  where  the 
only  symptom  is  haematuria,  the  exploration  may  have  a  negative  result. 

Hurry  Fenwick  (Brit.  Med.  Journ.,  vol.  i.  1900,  p.  248),  however, 
records  two  striking  cases  of  operation  for  unilateral  painless  renal 
haematuria. 

In  the  first  case,  a  young  lady,  aged  18,  had  suffered  from^  attacks 
of  haematuria  for  five  years,  causing  marked  anaemia.  With  the 
cystoscope  the  blood  was  seen  to  come  from  the  left  ureter.  At 
the  operation  the  left  kidney  was  brought  out  on  to  the  loin,  the 
pelvis  incised  and  illuminated  with  electric  light.  It  was  then  seen 
that  one  of  the  renal  papillae  was  of  a  bright  red  colour,  and  appeared 
to  be  villous  on  the  surface.  The  papilla  and  half  the  pyramid  were 
removed  with  a  Volkmann's  spoon.  No  haematuria  has  occurred  since 
the  operation. 

In  the  second  case  there  had  been  alarming  haematuria  for  a  fort- 
night, producing  profound  anaemia.  The  blood  was  seen  to  come 
from  the  left  ureter.  The  operation  was  similar  to  that  performed  in 
the  first  case,  as  was  also  the  condition  found.  This  case  was  likewise 
completely  cured. 

s. — vol.  11.  11 


162  OPERATIONS  ON  THE  ABDOMEN. 

iv.  Anuria. — This  will  be  dealt  with  later  (vide  p.  190). 

v.  Nephritis. — Dr.  Alfred  Pousson  read  a  paper  on  the  surgical 
treatment  of  nephritis  at  the  International  Congress  of  Medicine  at 
Lisbon,  April,  1906  (Lancet,  vol.  i.  1906,  p.  1202).  The  following 
summary  of  his  views  is  taken  from  the  Lancet. 

"  Four  operations  have  been  suggested  for  acute  nephritis — namely,  nephrectomy, 
total  or  partial,  nephrotomy,  and  decapsulation.  Nephrotomy  acts  by  relieving  tension 
and  by  local  bleeding.  Decapsulation  only  reduces  the  compression  of  the  kidney.  The 
mortality  of  all  forms  of  surgical  interference  is  only  i5"4  per  cent,  and  the  patients  who 
have  survived  the  operation  have  done  well.  This  mortality  justifies  surgical  intervention 
in  acute  nephritis,  but  only  in  severe  cases  which  have  failed  to  respond  to  medical  treat- 
ment. Acute  nephritis  is  often  unilateral  and  the  affected  side  can  generally  be  diagnosed, 
especially  by  means  of  cystoscopy  and  separation  of  the  urines  of  the  two  kidneys.  In 
cases  where  both  kidneys  are  affected  the  treatment  of  one  often  relieves  the  other. 
Nephrotomy  is  the  operation  of  choice  for  acute  nephritis.  Nephrectomy  should  be  reserved 
for  cases  where  there  are  severe  lesions  limited  to  a  single  kidney.  Decapsulation  is  much 
inferior  to  incision  of  the  kidney.  In  chronic  nephritis  surgical  intervention  can  do  much 
but  it  should  only  be  employed  where  medical  treatment  can  do  no  more.  Nephrotomy  is 
less  dangerous  than  decapsulation  and  it  should  be  preferred.  It  is  difficult  to  speak  with 
certainty,  but  decapsulation  seems  to  be  the  only  operation  which  gives  a  hope  of  a  radical 
cure  of  chronic  nephritis,  but  it  is  best  to  combine  with  it  a  unilateral  nephrotomy." 

I  do  not  recommend  any  of  the  above  procedures,  which  are  highly 
experimental ;  the  results  that  have  been  published  so  far  are  certainly 
no  better  than  those  obtained  by  the  far  safer  medical  treatment.  The 
same  remarks  apply  to  the  Treatment  of  eclampsia  by  nephrotomy 
introduced  by  Edebohls  and  advocated  by  Chamberland  and  Pousson 
in  a  paper  read  before  the  Paris  Academy  of  Medicine,  April  3rd, 
1906. 

Operation. — As  this  is  identical  with  the  first  stages  of  a  nephro- 
lithotomjr  the  reader  is  referred  to  the  description  of  that  operation 
(vide  p.  172). 

NEPHRO-LITHOTOMY. 

The  following  are  the  chief  symptoms  and  conditions  justifying 
nephro-lithotomy : — 

1.  Continued  Hematuria,  or  Passage  of  Blood. — I  may  at  once  be 
criticised  for  putting  this  first ;  and,  indeed,  it  is  somewhat  difficult 
to  decide  which  symptom  of  renal  calculus  is  clinically  the  most 
important.*  On  the  whole,  I  am  inclined  to  agree  with  an  old  friend, 
G-.  A.  Wright,  of  Manchester  (Med.  Chron.,  March,  1887,  p.  463), 
who  considers  "renal  hematuria  as  the  only  single  symptom  of 
anything  like  cardinal  importance,"  if  without  evidence  of  nephritis. 

A  few  words  as  to  the  character  of  the  haematuria  of  renal  calculus 
and  the  fallacies  which  must  be  borne  in  mind.  It  is  a  haematuria 
of  long  standing,  often  repeated,  frequently  increased  by  exercise  or 
jolting,  rarely  profuse,  and  never  producing  anaemia,  as  in  growth  of 
the  kidney.     Always  intimately  mixed  with  the  urine,  the  tint  varies 

*  Being  convinced  of  the  frequency  of  errors  of  diagnosis  in  renal  calculus,  I  have 
dealt  with  these  fully.  I  may  also  refer  my  readers  to  my  paper,  Brit.  Med.  Journ., 
1890,  vol.  i.  p.  117. 


NEPHRO-LITHOTOMY.  L6  ; 

from  a  bright  or  deep  iv<l  (which    I   think  are  rare)  to  a  smoky  or 
porter-like  colour. 

Fallacies:  (a)  Hematuria  may  be  absent  from  first  to  lust.  This, 
an  undoubted  fact,  is  one  very  difficult  of  explanation.  Jt  was  the 
case  with  the  smaller  calculus  (Fig.  63).  And  this  is  the  more 
extraordinary  as  the  stone  is  covered  with  minute  crystalline  spicules, 
a  condition  which  would  have  appeared  certain  to  lead  to  oozing 
from  the  inflamed  mucous  membrane  of  the  pelvis  in  which  the 
stone  lay.  The  only  explanation  that  I  can  give  is  that  at  the 
operation  I  found  the  abdominal  muscles  extremely  rigid  ;  even  when 
the  patient  was  fully  anaesthetised,  they  gave  the  impression  to  the 
scalpel  of  cutting  through  tissues  frozen  by  ether.  Now,  if  it  is  fair 
to  suppose  that  on  the  other  side  of  the  kidney  the  quadratus  and 
psoas  were  as  firmly  contracted,  the  kidney  and  the  stone  in  its 
pelvis  may  have  been  so  firmly  held  that  no  irritation  by  the  calculus 
could  take  place,  and  thus  no  hematuria,  (b)  Another  fallacy  is  that 
the  hematuria  of  calculus  may  be  only  temporary,  present  for  a  while 
and  then  ceasing  altogether.  This  occurs,  though  rarely,  when  a  small 
renal  calculus  becomes  encysted,  (c)  The  value  of  hematuria,  though 
only  occasional,  is  shown  by  a  case  of  Dr.  Owen  Rees',  to  which 
Mr.  Morris  has  drawn  attention. 

It  was  that  of  a  young  lady  with  lumbar  pains  and  frequent  micturition,  which 
were  both  put  down  to  the  hysteria  that  was  markedly  present.  After  a  while, 
hematuria  was  found  to  be  present  on  several  occasions,  and  eventually,  after  death, 
a  mulberry  calculus  was  found  in  one  kidney. 

Other  fallacies  are  presented  by  the  host  of  kidney  conditions 
which  may  give  rise  to  hematuria — namely,  (1)  the  passage  of  uric 
acid  crystals  ;  (2)  tubercular  kidney  ;  (3)  granular  kidney  ;  (4)  growths  ; 
(5)   increased  intra-renal  pressure,  &c.     To  these  I  shall  refer  later. 

2.  Pain  and  Tenderness,  Lumbar  and  elsewhere. — (a)  Fixed  Lumbar 
Pain. — Characters  :  Generally  dull,  gnawing,  pricking,  or  aching,  in- 
creased usually  by  exercise,  twisting  from  side  to  side,  or  flexing  the 
body.*  Sometimes  it  is  relieved  by  pressure  of  the  hand,  leading  to 
thickening  and  vascularity  of  the  parts  when  they  are  incised  at  the 
operation.  (b)  Radiating  Pain,  for  example,  in  the  testis,f  region 
of  the  small  sciatic  nerve,  calf,  foot,  or  in  the  intestine  simulating 
colic.  It  is  easy  to  see  how  readily  the  pain  of  a  renal  calculus, 
if  limited  to  distant  parts,  and  if  occurring  without  hematuria,  may 
mislead.  Another  point  with  regard  to  the  pain  of  renal  calculus  is 
the  frequency  of  nocturnal  exacerbations.  The  explanation  of  this  is 
doubtful,  whether,  as  Mr.  Morris  has  suggested,  from  the  passage  of 
flatus  in  the  colon,  at  this  time  over  a  stone  in  the  pelvis,  or,  as  I 
venture  to   think  more  probable,  as  accounting  for  stone  whether  in 

*  As  in  going  upstairs  ;  probably  from  the  pressure  on  the  kidney  by  the  contracting 
psoas  But  the  relation  of  the  pain  to  movement,  and  the  kind  of  movement  which  most 
induces  pain,  vary  greatly.  Thus  Mr.  Butlin's  patient  is  said  to  have  suffered  greatest 
pain  when  driving,  least  when  riding.     Prolonged  walking  seems  the  mosl  frequent  cause. 

t  In  a  case  of  Mr.  Butlin's  {Clin.  Soc.  Tranx.,  vol.  xv.  p.  113)  the  patient  sought  relief 
from  severe  neuralgia  of  the  right  testis,  which  was  generally  retracted  and  extremely 
tender.  Later  on  it  was  noticed  that  these  neuralgic  attacks  were  associated  with  some 
lumbar  pain  and  tenderness.  Complete  recovery  followed  after  the  removal  of  a  small, 
prickly,  calcium-oxalate  calculus  from  the  pelvis  of  the  right  kidney. 

II — 2 


164  OPERATIONS  ON  THE  ABDOMEN. 

the  pelvis  or  in  one  of  the  calyces,  to  the  concentration  of  the  urine, 
and  consequent  deposit  of  crystals,  which  takes  place  at  night,  is 
unsettled.     The  fact,  however,  is  undoubted. 

In  the  case  of  a  patient,  aged  58,  who  had  suffered  from  symptoms  of  renal  calculus 
for  thirty  years,  and  from  whose  left  kidney  I  removed  the  huge  calculus  (Fig.  63), 
the  pain  at  night  was  often  so  severe  as  to  drive  him  from  his  bed  into  his  garden  or 
the  streets  of  the  town  in  which  he  lived. 

(c)  Renal  Colic. — Very  acute  in  character,  radiating  from  the  loin, 
usually  downwards,  and  accompanied  often  by  rigors,  nausea,  vomiting, 
and  profuse  perspiration.  The  attacks  are  usually  recurrent,  and 
vary  greatly  in  severity. 

On  the  other  hand,  pain  is,  much  more  rarely,  absent. 

With  regard  to  tenderness,  Mr.  Jordan  Lloyd  (Pract.,  vol.  xxxix. 
p.  178),  in  a  paper  to  which  I  shall  have  again  to  refer,  writes 
thus :  "  I  attach  great  importance  to  the  evidence  to  be  obtained 
by  immediate  percussion  over  the  suspected  organ,  a  method  of 
investigation  which  has  not  received  that  amount  of  attention  to 
which  it  is  entitled.  It  is  best  practised  from  the  loin,  just  beneath 
the  space  between  the  tips  of  the  last  two  ribs,  and  should  be  made  in 
a  direction  upwards,  forwards,  and  slightly  inwards.  It  is  best  for  the 
patient  to  stand  upright  before  you.  The  blow  should  be  sharp  and 
decisive,  and  of  force  sufficient  to  affect  a  structure  situated  several 
inches  below  the  surface.  It  may  also  be  practised  from  the  front,  at 
a  point  midway  between  the  umbilicus  and  ninth  rib.  When  a  calculus 
is  present,  the  patient  will  complain  of  sharp,  stabbing  pain  at  the 
moment  of  percussion.  Other  conditions  doubtless  give  rise  to 
percussion  pain,  but  not  of  the  characteristic  stabbing  of  calculus." 

I  have  tried  the  percussion  test  of  Mr.  Lloyd  in  many  of  the  cases 
which  have  come  under  my  hands  for  nephrolithotomy  (table,  p.  188) 
since  his  paper  was  published.  In  three  the  tenderness  was  increased, 
but  in  one  only  was  there  any  "  characteristic  stabbing."  In  this, 
where  a  small  and  very  spiculated  oxalate  of  lime  calculus  occupied  the 
top  of  the  left  ureter,  the  patient  at  once  said,  "  You  stab  me  there." 
This  patient,  No.  5  in  the  table,  was  thin  and  spare.  Tenderness 
more  or  less  marked  will,  however,  be  usually  elicited  by  making  firm 
pressure  upon  the  kidney  between  the  two  hands,  one  placed  in  front 
and  one  behind  the  kidney. 

Mr.  Clement  Lucas  (Hunterian  Lecture,  1903 ;  Lancet,  vol.  i.  1903, 
p.  1148)  recommends  a  new  test,  which  he  calls  "the  stamping  test," 
which  "  sometimes  gives  the  most  remarkable  results.  The  patient 
supports  himself  by  resting  one  hand  on  some  firm  object,  then  is  told 
to  flex  the  thigh  on  the  suspected  side  as  high  as  possible.  The  psoas 
muscle  being  thus  strongly  flexed,  by  its  contracted  belly  presses  the 
kidney  forwards  and  outwards.  Next  the  patient  brings  the  limb 
suddenly  down,  stamping  the  heel  firmly  on  the  ground.  The  kidney 
in  this  way  suddenly  loses  its  muscular  support  and  is  caught,  as  it 
were,  unawares,  whilst  the  jar  carried  through  the  pelvis  and  spine  is 
communicated  to  it.  A  sudden  acute  pain  is  commonly  caused  by  this 
manoeuvre  when  a  calculus  is  present.  In  one  case  in  which  I  employed 
this  test  it  answered  only  too  well,  for  the  patient  was  immediately 
seized  with  acute  renal  colic  which  necessitated  his  being  put  to  bed, 


NEPHROLITHOTOMY.  165 

where  he  lay  for  some  hours  in  great  agony.  It  was  evident  that  a 
stone  had  been  displaced  from  a  calyx  and  had  fallen  over  the  outlet 
of  the  pelvis  whence  it  was  removed  by  operation  some  days  later." 

3.  Points  in  the  Precious  History. — Space  will  only  allow  of  my 
noticing  a  few  of  those  given  above,  namely,  lithiasis  and  oxaluria, 
history  of  previous  passage  of  a  stone,  history  of  previous  colic. 

The  history  of  long-standing  lithiasis  and  oxaluria  is  of  obvious 
importance,  from  the  fact  that  the  habitual  passage  of  crystals  or 
gravel  and  the  formation  of  a  calculus  lie  not  far  apart.  But  there 
is  another  point  which  has  not,  I  think,  received  sufficient  attention, 
and  that  is,  that  in  patients  who  have  habitually,  for  many  years, 
passed  uric  acid  and  oxalate  of  lime,  there  is  a  most  serious  risk 
that  the  minute  anatomy  of  their  kidneys  will  have  become  seriously 
damaged  by  the  constant  presence  of  the  above  crystals.  We  should 
all  be  agreed  as  to  the  damaging  effect  of  multiple  calculi  on  the 
secreting  tissue  of  the  kidney.  I  would  suggest  that  in  the  future 
the  results  on  the  kidney  of  the  daily  passage  of  crystals  of  uric 
acid  and  lime  oxalate  must  receive  sufficient  attention  before  patients 
at  all  advanced  in  life  are  submitted  to  nephrolithotomy.  Further- 
more, it  is  obvious  that  long-continued  lithiasis  and  oxaluria  will 
very  likely  have  led  to  the  formation  of  bilateral  stones. 

Under  the  heading  of  Ilenal  Colic,  I  would  point  out  that  the 
vomiting  and  nausea  which  are  thought  to  be  characteristic  of  the 
agony  of  a  descending  calculus  may  also  be  caused  by  a  stone  which 
is  distending  the  renal  pelvis,  but  has  not  yet  begun  to  make  its 
way  clown. 

4.  Frequency  of  Micturition. — The  co-existence  of  irritability  of  the 
bladder  with  renal  calculus  is  well  known,  and  may  be  explained  either 
by  nerve  disturbance,  or  by  the  blood  and  pus,  or  the  over- acid  urine 
which  often  accompanies  stone  in  the  kidney. 

A  point  with  regard  to  bladder  irritability  is  that  it  may  be  of  value 
in  making  the  most  difficult  diagnosis  between  a  calculous  and  a 
tubercular  kidney.  Thus,  if  a  patient  with  hematuria,  lumbar  pain, 
&c,  has  irritability  of  the  bladder  which  is  not  relieved  by  rest  in  bed, 
but  which  continues  by  night  as  well  as  by  day,  it  is  probable  that  this 
is  due  not  to  trouble  in  the  kidney  alone,  but  to  co-existing  ulceration 
of  the  bladder,  and  this  will  probably  be  confirmed  by  cystoscopic 
examination,  and  sometimes  by  examination  of  the  prostate  and 
vesicular  seminales  in  the  male,  and  by  digital  exploration  of  the 
bladder  in  the  female. 

5.  Pyuria,  especially  when  unilateral  in  origin. 

6.  Localising  evidence  obtained  by  the  X-rays,  the  segregator  and 
the  cystoscope  (vide  p.  150). 

7.  Failure  of  Previous  Treatment  to  give  Relief. — I  can  only  touch  on 
one  point  here — i.e.,  the  question  of  the  advisability  of  trying  to  exert 
any  solvent  action  on  a  calculus  in  the  kidney.  Whilst,  for  myself,  I 
attach  the  greatest  importance  to  the  use  of  large  quantities  of  water,  it 
is  rather  because  this,  by  washing  out  the  kidneys,  removes  collections 
of  crystals,  and  gets  the  patient  into  a  better  state  for  operation,  than 
because  I  believe  in  its  possessing  any  actively  solvent  action  upon  the 
calculus.  I  do  not  forget  that  Sir  W.  lloberts  has  proved  by  experi- 
ments on  calculi,  both  those  without  the  body  and  those  in  the  bladder, 


i66  OPERATIONS  ON  THE  ABDOMEN. 

that  urine  rendered   alkaline  by  fixed  alkali  has  a  distinctly  solvent 
action. 

Dr.  Ralfe  has  reported  (Path.  Soc.  Trans.,  vol.  xxxiii.  p.  206)  a  case  of  a  patient, 
aged  37,  who,  after  suffering  from  uric  acid  gravel  for  some  years,  had  a  violent  attack 
of  renal  colic,  with  profuse  hasniaturia,  no  calculus  or  gravel  being  discharged. 
Alkaline  treatment  was  at  once  resorted  to,  and  for  a  time  afforded  relief,  but  the 
patient  could  not  be  persuaded  to  continue  it  systematically.  He  was  then  ordered  to 
drink  copiously  of  soft  water  -filtered  rain-water.  Two  years  later  he  began  to  pass 
grit  and  scales  of  calculous  matter  with  his  urine  ;  and  shoitly  afterwards,  after  a 
severe  attack  of  colic,  he  passed  the  shell  of  what  had  evidently  been  a  solid  calculus.* 

But  it  must  be  remembered  that,  as  my  late  colleague  Dr.  Hilton 
Fagge  pointed  out  (Medicine,  vol.  ii.  pp.  373,  383),  such  solvent  treat- 
ment is  only  worth  trying  in  the  case  of  uric  acid  calculi.  He  at  the 
same  time  showed  that  the  greater  relative  frequency  of  lime  oxalate 
calculi  over  those  of  uric  acid,  especially  in  patients  after  early  adult 
life,  is  much  more  marked  than  is  generally  believed.  Moreover, 
as  Morris  {Huntcrian  Lectures,  1898)  points  out,  it  cannot  be  too 
strongly  urged  that,  in  the  presence  of  definite  symptoms  of  calculus, 
any  prolonged  course  of  palliative  treatment  is  to  be  deprecated,  for 
during  this  time  the  stone  may  be  steadily  but  slowly  destroying  the 
kidney,  and  so  valuable  time  will  be  lost. 

8.  Calculous  Anuria. — Exploration  of  the  kidney  in  this  extreme 
condition  is  urgently  called  for,  although  in  a  few  cases  recovery  has 
taken  place  without  operation.  Morris  (loc.  supra  cit.)  gives  two 
collections  of  cases,  those  operated  on  and  those  not  operated  on. 
Of  forty-eight  cases  not  operated  on,  ten,  or  20"8  per  cent.,  recovered  ; 
of  forty-nine  cases  operated  on,  twentj'-five,  or  51  per  cent.,  recovered. 
These  figures  speak  for  themselves. 

The  most  important  and  difficult  point  to  decide  is  the  question  as 
to  which  kidney  should  be  explored.  If  it  can  be  determined  which 
kidney  has  become  the  more  recently  affected,  this  should  be  chosen 
for  operation,  because  this  kidney  will  be  the  one  that  is  least  destroyed 
by  disease.  Apart  from  history,  abdominal  pain,  rigidity,  and  tender- 
ness may  help  to  clear  up  this  point.  This  subject  is  again  referred  to 
later,  p.  190. 

Conditions  which  may  simulate  Renal  Calculus. — Before  deciding 
to  operate  on  a  given  case,  it  must  be  borne  in  mind,  in  addition  to 
what  has  been  already  said,  that  many  other  diseases  may  give  rise  to 
the  same  symptoms  as  renal  calculus. 

So  closely  do  some  of  these  conditions  simulate  renal  calculus  that 
a  correct  diagnosis  can  onl}r  be  arrived  at  by  means  of  an  exploratory 

*  Dr.  Ralfe  (Diseases  of  the  Kidneys,  p.  523)  points  out  that  the  solvent  action  of 
distilled  water  is  due  to  several  influences.  In  the  first  place,  by  causing  a  low  specific 
gravity  of  the  urine,  it  induces  disintegration,  since  Itainey  has  shown,  experimentally, 
that  bodies  placed  in  solutions  of  different  density  to  those  in  which  they  were  formed 
undergo  molecular  disintegration.  Again,  chemical  analysis  has  shown  that  those  calculi 
that  undergo  spontaneous  disintegration  are  always  poor  in  inorganic  constituents  :  the 
use  of  soft  water  diminishes  the  supply  of  these,  even  if  it  does  not  actually  act  as  a 
solvent  on  those  forming  the  outer  crust  of  the  calculus,  and  so  increases  the  tendency  to 
disintegration.  Lastly,  soft  water  probably  diminishes  the  catarrh  of  the  urinary  passages, 
and  by  diminishing  the  swelling  of  the  mucous  membrane  allows  a  small  stone  to  pass 
which  was  before  obstructed. 


NEPHRO-LITHOTOMY.  1G7 

operation.  Morris  (loc.aupra  cit.)  gives  a  list  of  qo  Less  than  forty-four 
cases  occurring  in  his  own  practice  in  which  the  kidney  was  explored  for 

stone,  and  no  stone  found.  In  a  few  of  the  cases  a  calculus  was  passed 
soon  afterwards,  so  may  have  heen  lodged  in  the  ureter  at  the  time  of 
the  operation.  In  the  majority  of  the  cases,  however,  some  other  morbid 
condition  of  the  kidney  or  ureter  was  found  and  remedied.  So  that, 
although  no  stone  was  found  as  the  result  of  these  operations,  110  harm 
was  done  in  any  (for  none  were  fatal),  and  good  was  done  in  the 
majority.  Morris  says  :  "  It  is  certain  that  the  diagnosis  of  calculus, 
though  incorrect,  was  advantageous  to  the  patients,  for  the  very  reason 
that  it  led  to  the  exploration,  and  in  this  way  to  the  discovery  of  the 
true  cause  of  the  disease." 

These  conditions  simulating  calculus  must  now  be  severally  con- 
sidered. They  may  be  usefully  divided  into  two  groups — affections  of 
the  kidney  and  ureter,  and  diseases  of  other  organs. 

A.  Affections  of  the  kidney  and  ureter  which,  simulate  renal 
calculus. 

1.  Litldasis. — I  have  already  alluded  to  this  condition  as  one  which 
simulates  renal  calculus  by  the  hematuria  which  crystals  of  uric  acid 
may  cause.  Lumbar  and  testicular  pains  are  also  points  which  mere 
lithiasis  shares  with  renal  calculus.  The  diagnosis  will  not  be  difficult 
by  wTatching  the  result  of  treatment,  which  only  gives  relief  in  the  one, 
but  clears  up  the  other.     Exercise,  again,  is  a  test. 

2.  Tubercular  Kidney. — Lumbar  pain  and  tenderness,  frequent  mic- 
turition, hematuria,  are  all  common  to  tubercular  kidney  and  renal 
calculus.  The  chief  aids  in  the  diagnosis  appear  to  me  to  be  :  (a)  the 
pyuria;  (b)  careful  examination  of  the  urine;  (c)  early  pyrexia;  (d)  early 
exploration  of  the  kidney  ;  (e)  the  comparative  slightness  of  the  pain 
and  the  infrequency  of  radiating  pain  or  colic  ;  (/)  the  corresponding 
ureter  may  sometimes  be  felt  to  be  enlarged  and  tender  by  vaginal 
examination  (Clement  Lucas,  loc.  cit.). 

(a)  Pyuria. — This  is  usually  present  early  in  the  case  with  a  pro- 
portionate amount  of  albumen,  without  much  hematuria,  the  blood 
often  occurring  only  as  a  thin  layer  over  the  pus  at  the  bottom  of  the 
urine-glass,  or  as  small,  thready  clots.  With  all  the  pus  the  urine  is 
strongly  acid  at  first,  then  more  feebly  so,  but  often  remains  slightly 
acid  to  the  last,  {b)  Careful  examinations  of  the  urine. — The  sediment 
contains  caseous  matter,  and  sometimes  debris  of  connective  tissue  can 
be  made  out,  a  point  of  much  importance.  Finally,  there  is  the  bacillus 
tuberculosis.  While  I  am  well  aware  of  the  frequent  want  of  success 
in  demonstrating  the  presence  of  the  bacillus  in  urine  as  in  bone,  I 
may  add  that  it  was  found  in  six  out  of  the  thirteen  cases  in  which  I 
have  been  asked  to  explore  tubercular  kidneys.*     (c)  Pyrexia. — I  do 

*  I  may  point  out  here  that  bacteriology  will  help  the  surgeon  in  difficult  cases. 
My  colleague,  Dr.  Washbourn,  has  thus  cleared  up  two  obscure  cases  for  me.  One,  a 
delicate  woman  of  32,  with  a  tubercular  history,  was  sent  to  me  by  Dr.  Forty,  of  Wotton, 
in  Gloucestershire,  with  obstinate  cystitis  and  irritable  bladder.  The  endoscope  and 
digital  exploration  showed  swollen  and  hyper-vascular  mucous  membrane,  but  detected 
no  ulceration.  Wiping  over  the  mucous  membrane  with  a  solution  of  silver  nitrate 
(gr.  xl. — 3j)  was  followed  by  very  great  relief  lasting  over  two  months  on  two  occasions. 
At  my  request  Dr.  Washbourn  injected  some  of  the  pus  containing  urine  (in  which  no 
bacilli  could  be  found)  under  the  skin  of  a  guinea-pig.     No  result  apparently  followed,  but 


1 68  OPERATIONS  ON  THE  ABDOMEN. 

not  here  speak  of  the  hectic  which  accompanies  the  advanced  stage, 
but  of  the  pyrexia  which  may  be  an  important  factor  in  the  diagnosis 
much  earlier  in  the  case.  Often  intermittent  at  first,  and  liable  to  be 
overlooked  in  the  anorexia,  nausea,  and  debility  which  accompany  it, 
later  on,  and  too  late,  it  becomes  only  too  evident  and  confirmed. 
(d)  Early  exploration  of  the  kidney. — Morris  mentions  seven  cases  in 
which  tuberculous  foci  were  found  in  the  kidney  and  excised  ;  but  in 
three  of  these  secondary  nephrectomy  had  to  be  performed  later,  the 
other  four  remaining  well  for  from  two  and  a  half  to  four  and  a  half 
years.  In  one  case  three  separate  wedges  of  kidney  substance  were 
removed,  and  the  resulting  gaps  in  the  kidney  closed  by  sutures.  This 
matter  is  referred  to  later,  p.  216. 

3.  Hydronephrosis  due  to  stricture  of  the  ureter,  or  a  valvular 
obstruction  at  the  commencement  of  the  ureter.  Several  remarkable 
cases  of  this  nature  have  been  described,  notably  those  of  Morris  and 
Fenger.  These  will  be  referred  to  later,  pp.  250,  254.  Mr.  Bruce 
Clarke  has  also  published  {Lancet,  vol.  ii.  1891,  p.  984)  two  cases  of 
this  kind  in  which  the  cause  was  not  found.  The  first  was  perhaps 
an  early  stage  of  hydronephrosis,  and  the  pain  a  very  prominent 
feature,  dull  and  aching,  with  severer  attacks  ;  but,  as  it  was  found  at 
the  operation  that  "  the  kidney  pelvis  was  veiy  slightly  dilated,"  the 
case  is  not  decisive.  The  second  is  more  convincing.  The  kidney 
here  was  dilated  and  a  mere  shell,  no  cause  being  found.  There  was  a 
definite  history  of  several  attacks  of  renal  colic,  and  Mr.  Bruce  Clarke 
thought  that  these  had  probably  been  caused  by  kinking  of  the  ureter. 

4.  Slight  Pyelitis,  not  Tubercular. — This  condition  may,  by  hematuria, 
pus  in  the  urine,  lumbar  and  testicular  pain,  simulate  renal  calculus 
closely.  It  may  follow  a  gonorrhoea,  perhaps  a  previous  stone,  or  occur 
in  women  after  pregnancy;  perhaps,  as  Dr.  M.  Duncan  thought,  from 
some  parametritis  extending  up  the  psoas  to  the  peri-renal  fat  and  kidney. 

5.  Movable  Kidney,  especially  if  associated  with  neuralgia,  pyelitis, 
or  if  recurring  with  some  of  the  reflex  causes  of  nephralgia  to  be 
mentioned  below.  The  following  case  under  Mr.  Watson  Cheyne  (Brit. 
Med.  Journ.,  vol.  i.  1899,  p.  17),  in  which  there  was  severe  hematuria, 
caused  probably  by  congestion  due  to  kinking  of  the  renal  vessels,  is 
worthy  of  note  in  this  connection. 

A  woman,  aged  40,  had  a  fall,  hurting  her  back,  in  1885.  This  caused  great  pain 
and  hematuria,  the  urine  being  bright  red  in  colour.  This  continued  for  five  weeks, 
during  which  time  the  patient  was  confined  to  bed,  and  then  ceased.  There  was  no 
further  hematuria  for  ten  years,  although  pain  was  present  during  most  of  the  time. 
Severe  hsematuria  then  occurred  again,  and  again  stopped  after  a  time.  In  June,  1897,  severe 
hematuria  and  pain  came  on  again,  and  continued  till  November,  when  the  operation  was 
performed.  No  stone  was  present,  but  the  kidney  was  found  to  be  freely  movable.  The 
kidney  was  fixed,  with  the  result  that  hematuria  ceased  immediately  and  did  not  recur. 

6.  Ureteritis. — The  following  is  a  very  striking  instance  of  this  rare 
disease,  described  by  Israel  (Berl.  Klin.  Woch.,  xxvii.,  1893)  : 

A  young  man,  aged  28,  had  for  eight  years  suffered  from  a  urinary  affection  which 
began  with  frequency  of  micturition.     Soon  acute  attacks  of  pain  in  the  bladder  and  left 

when  the  animal  had  been  killed,  one  of  the  nearest  chain  of  glands  was  enlarged  and 
caseating.  A  few  undoubted  bacilli  tuberculosis  were  found  in  it.  This  and  the  other 
case  will  be  found  in  the  Guy's  Hosj),  Re}).,  1890. 


NEPHRO-LITHOTOMY.  169 

renal  colic  of  extraordinary  severity  began.  The  clinical  examination  in  corroboration  of 
the  patient's  account  left  no  doubt  as  to  the  presence  of  renal  calculus  :  there  were  fre- 
quently blood  and  mucus,  but  no  tubercle  bacilli,  present  in  the  urine;  there  was 
tenderness  in  the  left  flank,  and  pain  was  caused  by  pressure  on  the  ureter  through  its 
abdominal  course.  The  kidney  was  explored,  and  found  to  be  small  and  soft,  bui  do 
calculus  was  present.  The  wound  healed  rapidly,  but  the  symptoms  continued  as  bad 
as  ever. 

Two  months  and  a  week  later  the  kidney  waB  again  explored,  and  then  it  was  discovered 
that  the  ureter  throughout  its  length  was  extraordinarily  hard,  of  nearly  three  times  its 
normal  diameter,  and  presented  at  intervals  enlargements  of  quite  cartilaginous  con- 
sistence. The  ureter  was  permeable  from  kidney  to  bladder,  but  at  three  points  slight 
obstructions  were  present,  due  to  folds  of  thickened  mucous  membrane,  the  result  of 
ureteritis.     Nephrectomy  was  performed,  ami  resulted  in  a  complete  cure. 

7.  Aclting  Kidney. — Under  this  title  Dr.  M.  Duncan  lias  described  a 
condition,  especially  common  in  women,  which  may  simulate  renal 
calculus.  Its  chief  features  are  a  heavy,  wearying  pain,  deep  in  the 
side,  usually  accompanied  by  tenderness,  often  great;  the  pain  may  run 
in  the  course  of  the  great  sciatic  or  anterior  crural,  and  is  frequently 
accompanied  by  irritability  of  the  bladder,  and  by  pain  in  the  course  of 
the  ureter.  The  disease  is  liable  to  be  aggravated  by  exercise.  The 
chief  points  in  the  diagnosis  of  this  condition  are,  Dr.  Duncan  points 
out,  the  absence  of  blood  and  pus,  the  fact  that  the  "  aching  "  often 
occurs  only  at  the  menstrual  periods  and  is  always  worse  then,  from  the 
intimate  connection  between  the  kidneys  and  the  generative  organs, 
not  only  developmental  but  pathological.  A  definite  nephralgia  is 
also  caused  sometimes  by  malaria,  as  pointed  out  by  Morris,  and  may 
be  relieved  by  the  administration  of  quinine. 

8.  Interstitial  Shrinking  Nephritis. — This  condition  may  simulate 
renal  calculus  both  by  hematuria  and  pain. 

Dr.  S.  West  (Lancet,  1885,  vol.  ii.  p.  104)  drew  attention  to  the  hematuria  which  may 
accompany  granular  kidney,  and  published  three  cases,  aged  21,  19,  and  24  ;  in  the  first 
the  haemorrhage  was  profuse.  Mr.  Bowlby  (Clin.  Soc.  Tram.,\ol.  xx.  p.  14)  also  published 
three  cases,  aged  73,  49,  and  64  ;  two  of  these  died,  and  the  kidneys  were  found  markedly 
granular.  He  points  out  the  following  as  distinguishing  this  condition  from  renal  calculus  : 
The  specific  gravity  of  the  urine,  after  the  blood  has  cleared  up.  only  1008  to  1015  ; 
tortuous  arteries,  cardiac  hypertrophy,  and  high  arterial  tension  ;  blurred,  ill-defined  discs, 
some  retinitis  and  effusion  amongst  the  blood-vessels.  The  paper  concludes  with  the 
following  warning  :  "  Unless  it  be  recognised  tbat  blood  may  emanate  from  a  kidney 
which  is  simply  granular,  operations  may  be  undertaken  for  the  removal  of  renal 
calculus." 

With  regard  to  renal  pain  in  granular  kidney,  this  is  of  two  kinds. 
There  is  the  dull  aching  generally  found,  if  the  case  be  watched,  to  be 
felt  across  both  loins,  as  well  as  in  one  side.  Occasionally,  though 
this  is  rarer,  the  pain  occurs  in  violent  paroxysms,  simulating  renal 
colic.  This  was  so  in  the  case  to  which  I  have  alluded,  and  to  a  more 
marked  degree  in  one  brought  by  Mr.  Mansell  Moullin  before  the 
Clinical  Society  (Trans.,  vol.  xxv.  p.  60).  If  now,  in  addition  to  the 
hematuria  and  paroxysmal  pain,  there  be  nausea,  passage  of  uric  acid, 
and  frequent  micturition,  the  mistaken  diagnosis  of  calculus  may  easily 
be  made.  Where  granular  kidney  is  possible,  such  a  case  should  be 
carefully  watched,  and  if  the  specific  gravity  of  the  urine  never  rises  above 
1015,  the  question  of  operation  must  be  entertained  with  the  greatest 
caution,  and  the  very  great  risks  most  clearly  put  before  the  patient. 


170  OPERATIONS  ON  THE  ABDOMEN. 

9.  Renal  growths,  in  these  pain  and  hsematuria  are  independent  of 
jolting  and  other  movements,  the  bleeding  is  more  abundant,  and  it  is 
as  little  controlled  by  rest  as  it  is  unlikely  to  be  induced  by  exercise 
(Morris). 

Other  conditions  mentioned  by  Morris  as  having  been  found  in  some 
of  the  above-mentioned  forty-four  cases  are — small  abscesses,  or  sup- 
purating cysts,  solid  renal  or  peri-renal  tumours,  tense  cysts,  blood 
extravasated  either  under  the  capsule  or  within  the  substance  of  the 
kidney,  dense  adhesions.  To  these  may  be  added  rare  cases  of  villous 
tumour  of  the  pelvis,  nsevus  of  the  pelvis,  and  primary  cystic 
kidney. 

B.  Diseases  of  other  organs  which  may  simulate  renal  calculus. 

1.  Gastric  caul  Duodenal  Ulcer. — Morris  has  seen  a  case  of  gastric 
ulcer  which  simulated  renal  calculus,  and  Ralfe  (Brit.  Med. 
Journ.,  1888,  vol.  i.  p.  183)  gives  one  which  he  thinks  was  due  to 
duodenal  ulcer. 

Thus,  a  patient  had  many  symptoms  of  renal  colic,  and  three  attacks  of  paroxysmal 
pain  accompanied  by  vomiting,  great  tenderness  in  the  right  renal  region,  urine  loaded 
with  uric  acid,  but  no  pus  or  blood.  The  patient,  who  was  losing  flesh,  recovered  with 
treatment  directed  to  duodenal  ulcer. 

2.  Intestinal  Adhesions. — A  case  is  given  by  Dr.  Tirard  {Lancet,  vol.  i. 
1892,  p.  16).  Though  (as  the  kidney  was  only  punctured)  the  presence 
of  a  calculus  cannot  be  excluded  in  this  case,  it  is  very  possible  that  the 
explanation  given  below  may  meet  other  nephralgias.  A  schoolboy, 
aged  12,  gave  a  history  of  hsematuria  with  severe  pain,  after  another 
boy  had  jumped  suddenly  and  roughly  on  his  back.  There  was  only 
this  one  attack  of  hsematuria,  but  from  this  time  occurred  frequent 
attacks  of  severe  pain,  which  seemed  to  return  with  any  sudden  jolting 
movements,  a  railway  journey  or  a  ride  in  a  hansom  often  proving 
sufficient  exciting  cause.  It  was  also  noticed  that  the  pain  was  worse 
with  constipation  or  diarrhoea.  Although  no  certainty  was  felt  about 
the  presence  of  a  renal  calculus,  it  was  generally  thought  that  the 
symptoms  might  be  due  to  this.  At  the  operation  no  stone  could  be 
found,  though  the  pelvis  and  the  substance  of  the  kidney  were  carefully 
explored  with  a  needle.  A  firm  cicatrix  was,  however,  discovered, 
circling  the  capsule  of  the  kidney  and  the  descending  colon,  and  this 
was  so  tough  and  so  extensive  that  it  was  thought  expedient  not  to 
divide  it.  The  lad  recovered,  and  is  now  able  to  keep  fairly  free  from 
pain  so  long  as  he  attends  closely  to  the  action  of  the  bowels. 

3.  Gall  Stones  retained  in  the  Gall  Bladder  may  be  taken  for  right 
renal  calculus.  Dr.  Murchison  pointed  out  long  ago  that  they  not 
infrequently  coexist.  My  old  friend,  G.  A.  Wright,  of  Manchester, 
has  recorded  (Lancet,  1885,  vol.  i.  p.  563)  a  case  in  which  the  right 
kidney  was  explored  for  a  calculus  believed  to  be  in  the  ureter. 

On  exploring  this  tube  a  hard  spot  was  felt  near  the  brim  of  the  pelvis,  and  taken  for  a 
stone  in  the  ureter.  A  calculus  the  size  of  a  pigeon's  egg  was  removed  and  found  to  be  a 
gall-stone.  Acute  peritonitis  carried  off  the  patient,  and  a  stone  was  found  to  exist  in  the 
pelvis  of  the  right  kidney,  with  its  apex  in  the  ureter. 

While  on  this  subject  of  nephralgias  due  to  conditions  of  viscera  near 
the  kidney,  I  may  refer  to  some  remarks  of  Mr.   Godlee  (Pract.,  vol. 


NEPHROLITHOTOMY.  171 

xxxix.  p.  246),  in  which  he  insists  that  repeated  attacks  of  intestinal 
colic,  especially  if  accompanied  by  nausea,  may  be  the  only  symptoms  of 
the  presence  of  either  11  renal  or  biliary  calculus,  and  that  this  fact 
should  lead  the  practitioner  to  investigate  the  state  of  the  kidney  and 
urine,  bearing  in  mind  the  possibility  of  the  symptoms  being  due  to 
renal  or  biliary  calculi. 

4.  Spinal  Disease. — The  great  difficulty  which  may  arise  in  diagnos- 
ing between  certain  cases  of  spinal  caries  and  renal  calculus  is  not  yet 
sufficiently  recognised.  A  writer  already  quoted  from  (G.  A.  Wright, 
Mc<L  Citron.,  No.  vi.  p.  642)  thus  alludes  to  this  matter: 

"  Where  a  local  patch  of  caries  of  a  vertebral  body  exists,  and  especially  where  deep 
suppuration  occurs  and  presses  upon  the  kidney,  as  in  a  case  of  my  own  and  one  or  two 
others  which  I  have  seen,  nearly  all  the  symptoms  of  a  calculus  have  been  present. 
In  my  own  case,  without  any  deformity  or  tenderness  of  the  spine,  there  was  unilateral 
rigidity,  testicular  pain,  intermission  of  symptoms,  increased  frequency  of  micturition, 
nausea  during  attacks,  and  oxaluria,  with  local  pain  and  tenderness.  Subsequently  an 
abscess  developed,  and  on  exploration  a  small  patch  of  caries  was  found,  and  the 
kidney  was  felt  exposed  in  the  anterior  wall  of  the  abscess  cavity.  Probably,  as  in 
floating  kidney,  obstruction  of  the  vessels  and  ureter  may  arise  and  cause  symptoms, 
so  that  pressure  of  the  spinal  abscess  may  disturb  the  kidney,  and  quite  possibly  give  rise 
to  hematuria." 

Mr.  Clement  Lucas  relates  even  a  more  striking  case  {Lancet,  vol.  i. 
1903,  p.  1148). 

"  Caries  of  the  spine,  especially  in  children,  may  give  rise  to  one-sided  backache  and 
radiating  pains  in  front  as  a  lumbar  abscess  is  gradually  forming,  very  similar  to  what  is 
met  with  as  the  result  of  renal  calculus.  The  pressure  of  the  abscess  on  the  renal  vein 
may  even  cause  hematuria,  as  1  once  saw  very  remarkably  demonstrated  some  years  ago. 
I  was  asked  to  go  to  Thetford  to  meet  Dr.  M.  Beverley  of  Norwich  in  regard  to  the 
daughter  of  a  medical  man.  She  had  spinal  disease  in  the  lower  dorsal  region  and  lately 
had  been  passing  blood  with  her  urine.  I  found  a  large  lumbar  abscess  which  I  opened 
and  drained.  The  blood  entirely  disappeared  from  the  urine  on  the  second  day  after  the 
operation.  A  few  months  later  I  received  a  letter  from  the  father  to  say  that  hematuria 
had  again  appeared.  I  wrote  back  :  '  Look  out  for  an  abscess  on  the  other  side  of  the 
spine.'  This  was  discovered  and  opened  when  the  hematuria  again  and  finally  disappeared. 
I  have  seen  this  young  lady  as  a  plump  well-developed  woman  showing  little  or  no  evidence 
of  the  serious  illness  which  she  passed  through  at  the  age  of  nine  years." 

5.  Diseases  of  the  bladder,  such  as  calculus,  papilloma,  epithelioma 
and  tuberculosis,  sometimes  mimic  the  symptoms  of  renal  disease,  and 
fruitless  explorations  of  the  kidneys  have  been  undertaken,  before  the 
real  seat  of  the  disease  has  been  discovered  to  be  in  the  bladder;  thus 
tuberculous  disease,  villous  growth  or  epithelioma  situated  at  or  near 
one  ureteral  orifice  may  obstruct  the  latter,  and  produce  spasmodic 
renal  and  ureteral  pain.  A  coexisting  hematuria  or  pyuria  is  then 
erroneously  thought  to  have  its  origin  at  the  seat  of  pain  in  the  loin. 

A  judicious  use  of  the  sound  and  the  cystoscope  has  done  much  to 
prevent  the  occurrence  of  this  mistake,  but  quite  recently  a  young  man 
came  under  my  care,  suffering  from  pain  in  the  right  loin  and  along  the 
course  of  the  ureter ;  he  also  had  some  pyuria  and  slight  hematuria 
and  frequency  of  micturition.  Six  months  earlier  the  right  kidney  had 
been  explored,  freely  incised,  and  discovered  to  be  large  but  healthy. 
With  the  cystoscope  I  discovered  tuberculous  ulceration  especially 
around  the  right  ureter. 

6.  Appendicitis  may   cause  symptoms  closely   simulating  those    of 


172  OPERATIONS  ON  THE  ABDnMK.V 

renal  calculus,  thus  a  distinguished  surgeon  considered  himself  to  be 
the  subject  of  frequent  attacks  of  renal  colic,  until  at  last  a  swelling 
appeared  over  the  appendix,  which  was  removed  ;  this  relieved  the 
symptoms. 

In  addition  to  the  above,  Morris  alludes  to  having  known  cases  of 
each  of  the  following  conditions  give  rise  to  symptoms  simulating  renal 
calculus  : — malignant  and  tuberculous  growths  in  the  intestines,  aortic, 
or  coeliac  aneurysm  stretching  the  ureter  or  renal  vessels,  abscess  and 
calculus  in  the  prostate,  ovaritis,  and  tuberculous  disease  of  the  Fallopian 
tube.  Finally,  I  must  mention  the  following  exceptional  case  of 
malignant  disease  involving  the  last  dorsal  nerve,  that  came  under  my 
care  seventeen  years  ago  : 

The  patient,  aged  44,  came  with  hematuria,  wearing  pain,  tenderness  in  the  right 
loin  and  thigh,  and  oxaluria.  His  childhood  had  been  passed  in  Norfolk,  and  as  a 
lad  he  had  been  cut  by  Mr.  Birkett  for  stone  in  the  bladder.  I  sounded  him  twice, 
and  finding  no  stone,  I  swept  the  sound  in  contact  with  the  bladder  in  different 
directions,  in  the  hope  of  detaching  fragments  of  growth  if  one  were  present.  No 
relief  being  given  by  drugs,  I  explored  the  right  kidney,  and  could  find  nothing  abnormal. 
Four  days  after  the  operation,  when  all  seemed  to  be  doing  well,  the  patient  died  very 
suddenly.  At  the  necropsy  we  found  (a)  a  primary  carcinomatous  growth  of  the  bladder 
of  a  somewhat  unusual  kind  ;  it  involved  the  apex  as  a  flocculent,  superficially  ulcerated 
area  ;  (V)  a  ring  of  secondary  deposit  surrounding  the  rigid  last  dorsal  nerve,  just  at  its 
exit  from  the  spine  ;  (c)  a  mass  of  enlarged  glands  around  the  inferior  vena  cava,  and 
at  one  spot  sprouting  into  it  ;  (ds)  the  left  kidney  contained  a  large  branching  calculus. 

In  some  cases  it  may  be  difficult  to  decide  which  kidney  to  explore, 
hematuria  being  the  main  symptom,  and  pain  being  bilateral,  indefinite 
or  absent.  The  cystoscope  or  the  segregator  may  then  decide  the 
point,  if  skiagraphy  and  other  means  have  failed  to  do  so. 

Operation. — The  patient  being  in  much  the  same  position  as  that  for 
lumbar  colotomy,  on  the  sound  side,  with  a  firm  pillow  under  the 
opposite  flank,  the  surgeon  defines  carefully  the  lower  border  and 
length  of  the  last  rib.  That  this  is  not  an  unimportant  detail  in  renal 
operations  is  proved  by  the  following: 

Prof.  Dumreicher,*  of  Vienna,  accidentally  opened  the  pleural  cavity  during  an 
attempt  to  remove  a  pyonephrotic,  calculous  kidney.  At  the  necropsy  it  was  found 
that  the  last  rib  was  rudimentary,  that  the  pleura  projected  a  good  deal  below  the 
lower  edge  of  the  eleventh  rib,  and  that  thus,  when  the  incision  was  carried  upwards, 
the  accident  had  become  unavoidable.  Dr.  Lange,  of  New  York,  has  called  attention 
to  the  investigations  of  Dr.  Holl,f  of  Vienna,  on  the  frequency  of  rudimentary 
development  of  the  last  rib,  and  the  importance,  therefore,  of  counting  the  ribs 
before  intended  operations  on  the  kidney.  Dr.  Lange  J  himself  shows  that  in  some 
cases,  which  are,  however,  exceptional,  even  normal  development  of  the  twelfth  rib  may 
demand  extreme  caution,  as  the  pleura  may  project  considerably  below  it.§ 

*  Quoted  by  Dr.  Lange,  loc.  supra  cit. 

t  Dr.  Holl  found  that  in  quite  a  considerable  percentage  the  last  rib  is  so  abnormally 
short  that  it  does  not  reach  as  far  as  the  outer  border  of  the  sacro-lumbalis,  or  so  rudi- 
mentary that  in  some  cases  it  more  resembles  a  transverse  process  ;  and  that  in  these 
cases  the  lower  edge  of  the  pleura  passes  from  the  lower  boundary  of  the  last  dorsal 
vertebra  almost  horizontally  towards  the  lower  edge  of  the  eleventh  rib. 

\  Ann.  of  Surg.,  vol.  ii.,  Oct.  1885,  p.  286. 

§  In  other  cases  the  reverse  condition  may  be  present  ;  though  the  last  rib  be  rudi- 
mentary, the  pleura  may  pass  from  the  lower  edge  of  the  eleventh  dorsal  vertebra 
horizontally  towards  the  eleventh  rib,  and  thus  be  altogether  out  of  danger. 


NKIMIKO-UTIIOTOMY. 


173 


The  surgeon,  having  defined  the  length  and  position  of  the  lowest 
rib,  makes  an  oblique  incision,  at  least  4  inches  long,  ^  inch  below 
it,  and  beginning  about  2.\  inches  from  the  spine.  The  skin  and 
fasciffl  being  divided,  the  muscles — viz.,  anterior  fibres  of  the  latis- 
siinus  dorsi,  the  external  and  internal  oblique — are  cut  through,  either 
on  a  director,  or  simply  by  light  sweeps  of  the  knife.  As  soon  as  the 
yellowish-white  lumbar  fascia  is  reached,  any  bleeding  vessels,  which 
have  been  temporarily  secured  by  Spencer  Wells's  forceps,  are  tied  or 
twisted.  If  the  last  dorsal  nerve  cross  the  incision,  it,  together  with 
its  accompanying  vessels,  should  be  drawn  aside  and  left  untouched 
if  possible.  The  lumbar  fascia  is  next  slit  up  on  a  director.  The  peri- 
renal fat,  which  now  bulges  into  the  wound,  is  torn  through.  With 
two  large  retractors  opening  up  the  wound,  the  surgeon  continues  to 
tear  through  the  above  fat*  till  he  can  see,  or  easily  feel,  the  posterior 
surface  of  the  kidney.  Injury  to  the  peritonaeum  (p.  178)  is  best  avoided 
by  keeping  close  to  the  outer  edge  of  the  quadratus  lumborum.  During 
this  first  stage  of  the  operation  the  surgeon  will  find  sometimes  that 
the  muscles  are  much  thickened  by  reflex  irritation  from  the  presence 
of  the  stone,  and,  if  the  stone  has  been  associated  with  suppuration 
and  peri-renal  inflammation,  the  tissues  will  be  more  or  less  densely 
blended  and  matted  together. 

An  assistant  now  makes  powerful  pressure  on  the  opposite  side  of 
the  abdomen,  so  as  to  keep  the  kidney  up  into  the  wound,  this  being 
widely  opened  by  full-sized  retractors,  aided,  if  needful,  by  an  assistant 
pulling  up  the  lower  ribs  with  his  hand.  Thus  the  surgeon  is  enabled 
to  examine  the  organ,  which  is  done  systematically  :  the  finger  is  first 
directed  to  the  pelvis,  then  to  the  posterior  surface;  next,  by  passing  the 
finger  round  the  outer  border,  to  the  anterior  surface,  which,  as  Sir 
Henry  Howse  has  pointed  out  {Clin.  Soc.  Trans.,  vol.  xvi.  p.  93),  can  be 
done  effectually  by  pressing  the  kidney  back  against  the  firm,  unyielding 
psoas.  The  sensation  given  by  a  stone  has  been  compared  to  that  of 
the  uncut  end  of  a  pencil  (Morris),  or  the  last  joint  of  a  finger  (Howse). 

If  the  above  means  fail,  the  incision  must  be  made  sufficiently  free, 
especially  in  a  fat  patient,  and  a  deep  loin,  to  expose  the  kidney  more 
thoroughly.  Additional  room  may  be  gained  by  converting  the  usual 
lumbar  incision  into  a  T-shaped  one,  or  by  making  use  of  Kbnig's 
incision,  in  which  the  muscles  are  cut  through  as  far  as  the  rectus, 
and  the  peritonaeum  pushed  forwards,  or,  as  recommended  by  Morris, 
continuing  the  original  incision  downwards  and  forwards  to  a  point 
one  inch  above  and  in  front  of  the  anterior  superior  iliac  spine.  Morris 
(Surg.  Diseases  of  Kidney,  vol.  ii.  pp.  185,  209),  also  sometimes 
removes  the  distal  two  or  three  inches  of  the  twelfth  rib,  subperiosteally, 
after  exposing  its  outer  surface  through  a  vertical  incision  carried 
upwards  from  the  oblique  one.  He  also  incises  the  quadratus  lumborum  if 
the  muscle  is  broad,  and  the  ligament  of  Henle  if  obstructing  the  view. 
A  small  stone  in  the  kidney  will  always  be  liable  to  be  overlooked  ;  but 
a  surgeon  does  not  give  his  patient  or  himself  a  fair  chance  who  is 
content  with  exposing  part  of  the  kidney  through  a  limited  incision, 
and  then  trusting  to  punctures  with  a  needle. 

*  If  this  fat  is  very  abundant,  some  of  it  should  be   carefully  torn  away  ;  poorly 
vitalised,  it  is  prone  to  suppurate  tediously  and  to  delay  healing,  when  the  urine  is  septic. 


174  OPERATIONS  ON  THE  ABDOMEN. 

Needling  if  negative  is  inconclusive  ;  if  positive,  an  incision  into  the 
kidney  or  pelvis  becomes  necessary,  so  that  nothing  is  to  be  gained  from 
this  unsatisfactory  and  delaying  procedure. 

If  the  stone  cannot  be  felt  either  in  the  pelvis  or  after  palpation 
of  the  posterior  and  anterior  surfaces  of  the  kidney,  this  should  be 
drawn  up  and  out  of  the  wound  as  far  as  possible,  and  again  examined, 
a  careful  watch  being  kept  upon  the  pulse. 

When  the  kidney  cannot  be  brought  out  on  to  the  loin,  the  incision 
should  be  made  large  enough  to  see  what  is  being  done. 

All  the  above,  including  palpation  of  the  kidney  between  the  finger 
and  thumb,  failing,  the  kidney  itself  or  the  pelvis*  must  be  incised,  and 
explored  with  a  sound  and  the  finger.  During  this  part  of  the  opera- 
tion, haemorrhage  is  prevented  either  by  compressing  the  renal  vessels 
between  the  left  thumb  and  index  finger,  or,  as  advised  by  Cumston  of 
Boston  {Ann.  of  Surg.,  vol.  xxvi.  p.  320),  by  means  of  a  special  clamp 
which  he  has  devised  for  the  purpose.  Cumston  finds  that  pressure  may 
be  kept  up  by  this  means  as  long  as  half  an  hour  without  harm 
resulting,  the  operation  being  accomplished  without  any  loss  of  blood. 
Morris  (Surg.  Diseases  of  the  Kidney,  1901,  vol.  ii.  p.  187)  makes  a 
small  cortical  incision,  which  the  exploring  finger  fills  and  even  distends, 
thus  controlling  the  bleeding  to  a  great  extent  during  the  exploration. 
A  free  incision  is  made  through  the  convex  border  of  the  kidney  into  the 
pelvis,  and  a  thorough  and  systematic  examination  of  each  calyx 
carried  out  by  means  of  the  index  finger  or  a  short-beaked  child's 
bladder-sound.  The  beak  should  be  not  more  than  a  third  of  an  inch 
in  length,  a  stem  of  about  seven  inches,  and  the  size  of  a  No.  3  English 
catheter.  The  position  of  the  calculus  having  been  made  out,  it  is 
removed,  if  small,  through  the  incision  in  the  convex  border  of  the 
kidney.  If  this  is  inconvenient,  or  the  stone  large,  an  incision  is  made 
directly  over  it,  and  the  stone  then  removed.  It  is  quite  immaterial 
whether  this  incision  is  made  into  the  renal  parenchyma  or  the  pelvis, 
provided  that  it  is  sutured  afterwards. 

If  the  stone  is  irregularly  branched,  some  laceration  of  the  kidney 
tissue  may  be  spared  if  the  calculus  is  broken  up  and  removed  in  two 
or  more  fragments.     In  this  case  the  bed  of  the  stone  should  be  freely 

*  In  the  following  case,  under  the  care  of  Mr.  T.  Jones,  of  Manchester  {Med.  (7/ run., 
June,  1887,  p.  212),  opening  the  pelvis  alone  sufficed  to  find  the  stone,  after  systematic 
exploration  of  the  kidney  had  failed  :  "  The  forefinger  was  passed  to  the  anterior  surface, 
and  the  organ  grasped  between  the  finger  and  the  thumb;  nothing,  however,  could  be 
found.  The  kidney  was  then  carefully  explored  by  systematic  puncture  with  a  long 
needle,  also  passed  towards  the  pelvis,  but  no  calculus  could  be  felt.  An  incision, 
sufficiently  large  to  admit  the  tip  of  the  index  finger,  was  then  made  through  the  kidney 
substance  into  the  pelvis  by  means  of  a  fine  bistoury.  On  introducing  the  forefinger,  a 
small  stone  was  discovered  firmly  lodged  in  one  of  the  superior  calyces.  Small,  straight, 
lithotomy-forceps  were  introduced,  and  the  stone  thus  removed."  Very  free  haemorrhage 
attended  the  above  incision,  but  it  yielded  to  pressure  made  with  carbolised  sponges,  and 
kept  up  for  five  minutes.  The  patient  made  a  good  recovery.  The  calculus,  consisting  of 
lime  oxalate,  weighed  twenty  grains.  This  plan  of  opening  the  pelvis  might  be  thought 
to  cause  a  risk  of  leaving  a  urinary  fistula,  but  the  numerous  cases  in  which  calculi 
have  been  removed  from  the  renal  pelvis  with  entire  success  do  not  support  this  view. 
If  the  pelvis  be  dilated  this  spot  should  be  chosen,  otherwise  I  generally  incise  the 
convex  border  at  its  lower  part,  at  a  spot  more  readily  kept  under  notice  if  much  bleeding 
follow. 


XKl'IIi:o-UTIlnTn\IY. 


J75 


washed  out  with  liot  boracic  acid  lotion  or  Thompson's  fluid,*  sons  to 
cluck  oozing  and  remove  all  debrisA  Mr.  1 1.  Morris  ( Brit.  Med.  Jowrn., 
Nov.  16,  1889)  thus  alludes  to  two  difficulties  which  these  stones  may 
cause: — "A  large  branched  calculus  may  he  so  tightly  embraced  by 
the  kidney  substance,  and  the  kidney  may  he  so  uniformly  even  on  its 
surface,  that  nothing  more  than  a  very  firm  tough  organ  may  he  thought 
to  be  present,  and  even  on  passing  a  needle  into  it  no  sense  of  calculus, 
but  rather  the  resistance  of  a  tough  fibroma,  is  met  with.  In  these 
cases  much  difficulty  will  he  experienced  in  freeing  the  stone  from  its 
encasement,  and  for  this  purpose  the  moderately  free  use  of  a  bistoury 
will  be  requisite.  It  is  astonishing  how  some  of  the  large  branches 
of  a  calculus  may  escape  detection  unless  the  surgeon  is  aware  of  the 
firmness  with  which  they  are  embraced  by  the  tough  renal  tissue. 
After  removing  several  large  pieces  of  calculus  I  have,  in  one  or  two 
cases,  thought  that  all  must  have  come  away,  because  with  my  finger 
in  the  kidney  nothing  hut  renal  tissue  could  be  felt,  and  yet,  after 
scratching  through  at  some  points  where  the  resistance  was  greater 
than  elsewhere,  branch  after  branch  of  calculus  has  been  exposed, 
showing  that  more  of  the  calculus  would  have  been  left  behind  than 
had  been  removed  had  the  operation  been  discontinued,  because  no 
further  actual  contact  with  the  calculus  was  made  with  the  finger  in 
the  interior  of  the  kidney." 

If  the  kidney  be  enlarged,  with  expanded  calyces,  the  result  of 
calculous  hydronephrosis  or  pyonephrosis,  on  searching  through  the 
pelvis  after  a  stone,  the  gush  of  fluid  and  collapse  of  the  expanded 
kidney  may  cause  the  stone  to  disappear,  and  thus  lead  to  much  trouble 
in  its  removal  (Symonds,  Clin.  Soe.  Trans.,  vol.  xviii.  p.  181). 

Mr.  Morris  (loc.  supra  cit.)  gives  two  other  conditions  which  may 
prove  embarrassing.  "  Sometimes  in  feeling  over  the  kidney  a  portion 
of  it,  varying  in  size  from  a  sixpence  to  a  five-shilling  piece  or  more, 
is  found  soft,  flaccid,  thin  or  fluctuating,  and  there  is  nowhere  any  sense 
of  hardness  or  increased  resistance,  such  as  might  be  expected  from 
even  a  phosphatic  stone.  On  incising  or  puncturing  this  soft  part, 
pus  or  purulent  urine  is  drawn  off,  but  no  stone  is  felt;  but  on  intro- 
ducing the  finger  into  the  interior  of  such  an  organ,  a  small  calculus 
may  be  detected,  freely  movable  within  an  enlarged  pelvis,  or  fixed 
in  a  dilated  calyx,  or  possibly  at  the  apex  of  a  funnel-shaped  pelvis. 
Such  cases  show  that  aspiration,  or  simple  incision  and  drainage,  are 
insufficient,  and  that  one  ought  not  to  be  satisfied  with  anything  less 
than  a  digital  examination  of  the  interior  of  the  pelvis,  of  the  calyces 
and  commencement  of  the  ureter.  Another  arrangement  of  the  calculus 
is  sometimes  found  in  sacculated  kidneys.     The  renal  cavity  may  be 


*  Water.  4  oz.  ;  glycerine,  4  oz. ;  boras.  2  oz.  To  be  diluted  with  water  to  1  in  io, 
or  1  in  4,  according  to  the  condition  of  the  part  syringed.  Solutions  of  carbolic  acid  or 
mercury  perchloride  should  be  avoided  in  such  cases,  for  fear  of  irritation  or  absorption. 
The  temperature  of  the  fluid  should  be  about  no°. 

t  Mr.  Kemlal  Franks  (Lancet,  1880,  vol.  ii.  p.  1223)  thus  removed,  piecemeal,  a  friable 
stone  weighing  171  grains,  and  composed  of  lime  carbonate  and  phosphates.  In  this  case 
the  urine  had  been  foetid,  though  acid.  The  wound  healed  by  first  intention.  In  cases  of 
piecemeal  removal  of  calculi,  especially  when  friable,  a  certain  amount  of  doubt  will  often 
remain  as  to  the  entire  removal. 


176  OPERATIONS  ON  THE  ABDOMEN 

wholly  or  partially  filled  by  a  soft,  mortary,  phosphatic  calculus  which 
gives  no  sound  or  resistance  to  the  scalpel  or  trocar,  and  yet,  on  incising 
the  renal  substance  and  inserting  the  finger,  a  stone  of  considerable 
size  ma}'  be  felt." 

One  more  difficulty,  which  must,  however,  I  think,  be  a  very  rare  one, 
is  inability  to  reach  the  pelvis  in  a  stout  patient.  Mr.  Mansell  Moullin 
relates  (Clin.  Soc.  Trans.,  vol.  xxv.  p.  57)  a  case  of  this  kind : 

The  patient,  a  lady,  aged  about  40,  and  rather  stout,  had  suffered  for  ten  days  from 
total  suppression  of  urine,  believed,  and  correctly  so,  to  be  due  to  a  calculus  having 
blocked  the  upper  end  of  the  ureter  of  the  only  kidney  which  remained  functionally 
active.  The  left  kidney  was  explored  by  the  usual  lumbar  incision.  "  There  was  no 
difficulty  in  finding  the  kidney,  although  it  seemed  to  lie  unusually  deep.  Its  surface 
was  smooth  and  uniform,  but  very  firm,  and  it  was  not  possible,  either  by  rolling  the 
patient  on  to  her  back,  or  by  hooking  the  kidney  outwards,  to  pass  the  finger  sufficiently 
far  on  to  the  anterior  surface  to  feel  the  pelvis.  The  kidney  was  punctured  and  explored 
by  dressing-forceps  and  sound,  but  no  stone  detected.  The  operation  was  successful  in 
that  urine  soon  began  to  escape,  but  the  patient  sank  with  pyelitis  and  increasing  asthenia 
on  the  twenty-third  day.  The  necropsy  showed  no  trace  of  a  right  kidney.  The  left  was 
much  enlarged,  and  an  oval  uric-acid  calculus  was  impacted  in  the  ureter  at  its  commence- 
ment, lying  nearly  in  the  middle  line  of  the  body. 

If  after  free  incision  and  thorough  exploration  of  the  kidney  no  stone 
is  found,  the  ureter  must  next  be  explored  throughout  its  whole  length 
by  passing  a  No.  3  English  bougie  or  catheter  down  it  into  the  bladder. 
Morris  advises  that  this  step  be  taken  in  all  cases,  whether  a  stone  has 
been  found  in  the  kidney  or  not  ;  this  is  certainly  a  wise  thing  to  do. 
Urine  or  injected  coloured  solution  should  be  withdrawn  by  the 
catheter  from  the  bladder  ;  the  surgeon  is  then  certain  that  the  passage 
is  clear.  The  catbeter  may  be  passed  through  the  incision  in  the 
kidney  into  the  ureter.  If,  however,  the  orifice  of  the  ureter  cannot 
be  hit  off  in  this  way,  Morris  advises  a  small  puncture  in  the  posterior 
aspect  of  the  infundibulum,  through  which  the  catheter  can  be  more 
easily  passed  into  the  ureter.  After  the  exploration  this  incision  can  be 
closed  by  a  catgut  suture. 

Should  a  stone  be  found  to  be  impacted  in  the  ureter,  it  must  now  be 
exposed  and  removed.  The  following  description  of  the  methods  of 
reaching  the  different  parts  of  the  ureter  is  chiefly  based  on  the  lines 
laid  down  by  Morris  : — The  original  oblique  incision  is  prolonged  down- 
wards and  forwards  to  a  point  one  inch  above  and  in  front  of  the 
anterior  superior  iliac  spine,  and,  if  necessary,  still  further  forwards 
towards  Poupart's  ligament,  and  then,  parallel  to  this  structure  and  one 
inch  above  it,  as  far  as  the  level  of  the  internal  abdominal  ring,  or  even 
farther.  Through  this  incision  both  the  abdominal  and  pelvic  portions 
of  the  male  ureter  can  be  exposed,  and  the  abdominal  part  and  upper 
half  of  the  pelvic  portion  in  the  female. 

Since  the  ureter  is  frequently  dilated  behind  a  stone,  after  the  calculus 
has  been  reached  with  the  finger  in  the  manner  described,  it  can 
generally  be  gradually  pushed  up  the  dilated  ureter  towards  the  kidney. 
If  possible  this  should  be  done,  for  two  reasons  :  in  the  first  place,  the 
higher  in  the  ureter  the  more  accessible  will  this  structure  be  for 
removal  of  the  stone  and  suture  ;  and,  secondly,  damage  to  a  portion  of 
the  ureter  already  probably  inflamed  or  ulcerated  by  the  calculus  will 
be  avoided,  and  thus  more  rapid  healing  ensured. 


NEPHROLITHOTOMY. 


177 


In  order  to  remove  the  stone  the  ureter  must  be  incised  over  it  in  a 
longitudinal  direction  with  a  sharp  tenotome.  The  wound  in  the  ureter 
is  then  immediately  (dosed  by  means  of  Lembert  sutures  passing  through 
the  outer  coats  only,  the  number  of  sutures  depending  on  the  size  of 
the  incision  in  the  ureter.  Incisions  nnule  into  the  kidney  can  usually 
also  he  sutured.  When,  however,  the  kidney  substance  has  been 
much  lacerated  in  the  removal  of  a  large  calculus,  sutures  are  better 
dispensed  with.  For  incisions  into  the  infundibulum,  Lembert  sutures 
of  fine  catgut  are  employed.  Incisions  in  the  renal  parenchyma 
may  be  closed  in  the  following  manner  :  Several  sutures  of  medium- 
sized  catgut  are  used  (if  too  fine,  they  will  cut  through).  They 
are  passed  deeply  through  the  kidney  by  means  of  large,  fully-curved 
needles,  three  to  five  sutures  being  used,  according  to  the  size  of  the 
incision. 

These  sutures  are  passed  and  tied  before  the  compression  of 
the  renal  vessels  is  relaxed,  Cumston  (loc.  supra  cit.)  suturing  the 
kidney  before  removal  of  the  clamp.  In  this  way  two  very  impor- 
tant advantages  are  gained — the  prevention  of  haemorrhage  from 
the  kidney,  and  also  usually  the  prevention  of  leakage  of  urine  ;  the 
result  is  that  primary  union  of  the  incisions  generally  takes  place, 
and  rapid  healing  of  the  whole  wound  and  early  convalescence  thus 
ensured. 

A  drainage-tube  or  a  strip  of  iodoform  gauze  is  now  passed  down  to 
the  kidney  or  the  incision  in  the  ureter,  in  order  to  allow  of  free 
drainage  should  leakage  of  urine  occur.  The  rest  of  the  wound 
is  then  closed,  the  muscles  being  first  brought  together  by  buried 
sutures. 

If,  however,  the  kidney  has  been  much  lacerated,  or  if  for  an}r  other 
reason  no  sutures  are  placed  in  the  kidne}',  a  full-sized  drainage-tube 
must  be  passed  down  to  the  kidney  in  order  to  allow  of  free  drainage  ; 
or  if  there  is  free  oozing  the  wound  may  be  packed  with  iodoform  gauze, 
which  is  left  in  position  for  twenty-four  hours.  The  ends  only  of  the 
wound  must  be  sutured  in  this  case,  and  the  dressings  changed  as  often 
as  they  become  soaked  with  urine. 

A  stone  may  be  missed  at  the  operation,  and  come  away  from  the 
wound,  or  be  passed  later  on  per  urethram.  An  instance  of  the  former 
is  given  by  Mr.  Bruce  Clarke  {Illus.  Med.  News,  p.  4).  The  latter  hap- 
pened to  me  in  case  No.  9  in  the  table  (p.  188). 

After-treatment. 

The  chief  points  here  are  :  1.  The  meeting  of  shock  after  a  prolonged 
operation.  2.  The  patient's  attitude  in  bed  should  be  recumbent  but 
with  pillows  placed  behind  the  shoulder  and  ileum  of  the  affected  side; 
pressure  on  the  wound  is  thus  avoided.  Later  the  patient  may  be 
propped  up  for  the  better  drainage  along  the  ureter.  3.  Changing  of 
the  dressing  at  sufficiently  frequent  intervals  at  first,  if  any  urine  or 
blood  or  both  soak  through.  4.  Removal  of  the  tube  on  the  third  or 
fourth  day  unless  discharge  continues,  when  the  tube  should  be 
gradually  shortened  ;  this  is  likely  to  be  necessary  where  there  has  been 
much  interference  with  the  surrounding  parts  or  where  pus  has  been 
present  in  the  kidney.  5.  Rectal  feeding  until  vomiting  has  ceased, 
but  water,  coffee  or  tea  can  be  given  by  the  mouth  from  the  first  to 
allay    thirst,    moisten   the    mouth,    and    promote    urinary    secretion. 

s. — vol.  11.  12 


178  OPERATIONS  ON  THE  ABDOMEN. 

6.  Care  must  be  taken  to  relieve  the  bladder  by  passing  a  catheter  if 
necessary.  If  suppression  occurs,  saline  injections  into  the  rectum 
or  subcutaneous  tissues  are  indicated.  Subcutaneous  injection  of 
pilocarpine  may  also  be  tried. 

Lastly,  it  may  be  pointed  out  that  the  life-histories  of  these  cases 
should  be  followed  up  most  carefully,  to  see  how  far  the  cure  remains  a 
complete  one ;  to  aid  this,  the  patient  should  pay  lifelong  attention  to 
his  diet,  habits,  exercise,  &c. 

Difficulties  in  Nephrolithotomy. 

1.  An  insufficient  incision  and  a  narrow  ileo-costal  space.  2. 
Abundant  fat— -e.g.,  in  the  subcutaneous  tissues,  around  the  kidney,  and 
extra-peritonaeal,  rendering  the  wound  veiy  deep.  3.  Rigidity,  and 
perhaps  thickening,  of  the  muscles,  due  to  the  irritation  of  the  stone. 
This  condition  was  present  in  a  very  marked  degree  in  a  patient  from 
whom  I  removed  the  smaller  calcium-oxalate  calculus  (Fig.  63).  No 
amount  of  anaesthetic  seemed  to  have  any  effect  on  this  condition. 
Fortunately  the  loin  was  a  thin  one,  and  the  stone  very  obvious  on  reach- 
ing the  pelvis.  4.  Matting  of  the  parts  around  the  kidney,  rendering 
it  difficult  to  explore  this  organ,  its  different  parts  and  relations,  exactty. 
5.  An  indurated  condition  of  the  kidney  itself  from  the  irritation  of 
a  stone.  6.  Troublesome  flatulent  distension  of  the  colon.  This  is 
not  at  all  uncommon.  The  bowel  should  be  packed  away  with  sponges 
fastened  on  to  silk,  and  pushed  deeply  into  the  front  of  the  wound. 

7.  Opening  the  peritonaeum.  This  accident  occasionally  occurs  in 
difficult  cases.  If  the  wound  be  kept  aseptic,  there  will  be  no  serious 
consequences. 

In  case  11  of  the  series  below,  1  opened  the  peritonaeum  under  the  following  circum- 
stances :  The  week  before,  in  No.  10,  the  kidney  lay  very  high  up  under  the  ribs.  In 
No.  1 1  it  was  placed  very  low,  closely  surrounded  by  the  colon,  and  with  its  lower  end 
in  the  left  iliac  fossa.  It  was  also  the  seat  of  a  small  hydronephrosis,  and  therefore 
soft  and  yielding.  On  slitting  up  the  lumbar  fascia  the  descending  colon  came  into 
view  with  a  soft  mass  behind  it,  which  I  took  for  pultaceous  fascal  contents.  I  accord- 
ingly explored  with  my  finger  higher  up,  and  under  the  ribs  found  a  body  firm  and 
fleshy,  with  a  feel  like  the  kidney,  but  too  small.  This  proved  to  be  the  spleen, 
unusually  movable.  The  opening  in  the  peritonaeum  was  kept  covered  by  aseptic 
sponges,  and  the  mass  behind  the  colon  investigated.  This  proved  to  be  the  kidney,  ex- 
tremely low  down,  and  containing  a  calculus  in  the  pelvis,  this  last  being  also  distended 
with  fluid.  For  the  first  few  days  I  kept  strips  of  sal  alembroth  gauze,  changed  two  or 
three  times  in  the  twenty-four  hours,  tucked  up  under  the  ribs,  and  stitched  the  low- 
lying  kidney  well  up  into  the  wound,  so  that  the  urine  should  escape  freely.  The  patient 
recovered  without  a  bad  symptom.  Smaller  openings  should  be  tied  up  with  chromic 
gut,  or  sutured  with  the  same. 

8.  *A  stone  present,  but  very  difficult  to  detect.  This  may  be  due  to 
(a)  its  small  size,  especially  if  it  lies  deeply  in  a  calyx,  or  is  surrounded 
by  very  indurated  kidney  tissue.  A  very  small  stone  may  cause  severe 
symptoms.  This  was  proved  by  some  of  the  cases  in  the  table  given  at 
p.  188. 

Thus,  in  Case  5,  a  stone,  weighing  but  fourteen  grains,  and  situated  in  the  top  of  the 
ureter,  quite  incapacitated  the  patient  from  any  work.  In  case  No.  8,  another  very  small 
stone,  firmly  fixed  in  a  calyx  at  the  upper  part  of  the  kidney,  caused  severe  hasniaturia 
and  pain. 


NEPHRO-LITHOTOM  Y .  779 

The  following  case,  under  the  care  of  Dr.  Murphy,  of  Sunderland 
{Brit.  Med.  Journ.,  vol.  i.  1891,  p.  757),  shows  still  more  clearly  what 
urgent  symptoms  a  tiny  calculus  may  cause  : 

The  patient,  aged  39,  had  been  a  complete  invalid  for  nine  months,  owing  to  repeated 
attacks  of  renal  colic,  which  morphine  failed  to  relieve,  the  administration  of  ehloroforra 
being  frequently  required.  At  the  operation,  "a  very  small  stone,  about  the  size  of  a 
hemp-seed,  escaped  with  a  flush  of  blood,"  when  the  kidney  was  incised.  The  site  of  the 
stone  is  not  given.     A  good  recovery  followed. 

How  impossible  it  is  to  detect  some  stones,  without  incision  of  the 
kidney,  is  shown  by  a  case  published  by  Mr.  Morris  :  * 

This  authority,  with  all  his  experience,  after  thoroughly  exploring  the  kidney,  com- 
pressing it  all  over  with  the  finger  and  thumb,  and  also  after  puncturing  it,  failed  to 
detect  a  stone  which  lay  in  a  hollowed-out  calyx.  Though  the  calculus  was  the  size 
of  a  small  marble,  it  was  so  thickly  surrounded  by  kidney-tissue  that,  even  after 
the  removal  of  the  kidney,  the  position  of  the  stone  could  not  be  detected  by  pressing 
on  the  kidney  with  the  fingers  as  it  lay  01  a  table.  The  patient  made  a  good 
recovery. 

(/?)  A  sacculated  kidney,  into  one  of  the  sacculi  of  which  a  small 
stone  may  fall  and  be  hard  to  find  (p.  175). 

9.  A  stone  on  the  anterior  surface  of  the  kidney,  especially  if  near 
the  entrance  of  the  vessels.  10.  A  very  large  or  a  branching  stone 
(p.  175).  Mere  size  does  not  necessarily  create  difficulties  in  extrac- 
tion, though,  owing  to  the  changes  entailed  in  the  kidneys,  the  general 
health,  &c,  by  the  long  duration  of  a  calculus,  the  prognosis  is  rendered 
very  much  less  favourable.  Thus,  in  the  calculus  (Fig.  63)  weighing 
473  gi'ains,  or  very  nearly  an  ounce,  the  verj'  bulk  of  the  stone  rendered 
its  detection  easy  ;  it  was  readily  loosened  from  the  much  dilated  pelvis 
with  lithotomy  forceps.  A  branched  calculus  presents,  of  course,  much 
greater  difficulties  (p.  175). 

Mr.  Bennett  May  has  published  {Clin.  Soc.  Trans.,vol.  xvi.  p.  90)  an  excellent  instance 
of  this  kind,  in  which  he  successfully  removed  a  very  large,  somewhat  S-shaped  calculus 
from  a  man  aged  34,  with  symptoms  of  sixteen  years'  duration.  Though  the  stone  weighed 
473  grains,  and  was  three  inches  loag,  manipulation  failed  to  make  it  out  distinctly,  but 
acupuncture  detected  it  at  once. 

Mr.  Footner,  of  Tunbridge  Wells,  removed  a  calculus  weighing  822  grains,  or  nearly 
two  ounces.  The  patient  made  a  good  recovery,  but  a  sinus  persisted,  through 
which,  on  two  occasions,  a  millet-seed  calculus  was  passed  {Brit.  Med.  Journ.,  1892, 
vol.  ii.  p.  69).  A  calculus  far  exceeding  the  above  was  brought  by  Mr.  D.  Day,  of 
Norwich,  before  the  Clinical  Society  {Trans.,  vol.  xxvi.  p.  24).  This  calculus, 
mainly  phosphatic,  weighed  1331  grains.  The  patient  made  a  good  recovery,  with 
a  sinus  persisting  in  the  loin.  A  calculus  larger  than  either  of  these  is  mentioned 
at  p.  184. 

11.  A  stone  which  breaks  up  rapidly  (p.  175).  Another  condition 
allied  in  difficulty  is  where  a  calculous  deposit  rather  than  a  distinct 
calculus  is  present.  This  is  more  grave,  as  the  deposit  here  will  usually 
be  phosphatic,  and  point  to  co-existing  pyo-nephrosis.  12.  Multiple 
calculi.  Stones  (usually  minute  in  size)  numbering  over  60 
or    100,    have    been   removed    on    several    occasions.     In  such  cases 

*  Med.  Chir.  Trans.,  vol.  xlviii.  p.  69.  The  woodcut  (p.  73)  shows  well  the  relation  of 
the  stone  to  the  surrounding  kidney. 

12 — 2 


180  OPERATIONS  ON  THE  ABDOMEN. 

it  is  always  possible  that  the  minute  calculi  have  been  retained, 
owing  to  a  larger  calculus — e.g.,  in  the  pelvis  or  ureter — blocking 
their  exit.  13.  A  very  mobile  kidnej\  The  importance  of  having  an 
assistant  to  push  the  kidney  well  up  into  the  wound  has  already  been 
insisted  on.  It  is  essential  to  have  this  done  botli  for  detection  of  the 
stone  and  for  its  removal,  in  order  to  avoid  needless  disturbance  of  the 
surrounding  parts,  or  the  kidney  may  be  secured  with  sutures  at  the 
commencement. 

Mr.  May  (loc.  supra  cit.')  explains  the  remarkable  fact  that  his  large  stone  was 
not  felt  when  the  kidney  was  thoroughly  exposed,  by  the  fact  that  the  organ  fell 
forwards  and  thus  embarrassingly  increased  the  depth  of  the  wound. 

14.  A  kidney  situated  very  high  up  under  the  ribs  (p.  178),  especially 
if  there  be  firm  adhesions  around  it.  In  such  a  case,  it  may  be  necessary 
to  remove  the  distal  two-thirds  of  the  last  rib,  care  being  taken  to 
preserve  the  pleura.  15.  A  kidney,  the  pelvis  of  which  it  is  difficult 
to  reach  owing  to  the  stoutness  of  the  patient,  as  in  the  case  given 
at  p.  176. 

Question  of  Nephrectomy  during  a  Nephrolithotomy. — In  several 
of  the  above  conditions  the  question  of  the  advisability  of  removal  of  the 
kidney  will  arise — e.g.,  where  the  kidney  has  been  much  handled  and 
repeatedly  incised,  where  the  stone  is  large  and  branched  and  difficult  of 
removal,  where  many  stones  are  present,  or  where  one  is  present  and 
very  friable,  where  the  kidney  is  much  altered  b}r  pyo-  or  hydro- 
nephrosis, and,  finally,  where  the  surgeon  is  certain  a  stone  exists  but 
cannot  find  it,  as  in  Mr.  Morris's  case  already  alluded  to  at  p.  179. 

In  such  cases  the  surgeon  will  be  guided  by  the  age  of  the  patient ; 
the  knowledge  he  possesses  as  to  the  condition  of  the  other  kidney 
(the  amount  of  urine,  &c.) ;  the  proportion  of  the  urea  excreted  by  each 
kidney,  the  evidence  of  skiagraphy  of  the  opposite  kidney,  &c,  the 
degree  to  which  the  kidney  he  is  operating  on  has  been  disturbed  from 
its  relations,  and  its  structure  interfered  with  ;  the  amount  of  disease, 
e.g.,  number  of  sacculi,  condition  of  pus  contained  in  them,  the  thinning 
of  the  cortex,  &e.  When  the  surgeon  is  certain,  from  the  history  and 
failure  of  previous  treatment,  that  a  stone  exists  which  cannot  be  found, 
he  must  be  chiefly  guided  by  the  degree  to  which  life  has  been  made 
miserable.  Finally,  the  length  of  time  that  the  operation  of  nephro- 
lithotomy has  already  lasted,  and  the  condition  of  the  patient,  must  be 
taken  into  account.  Where  the  patient  is  young,  where  the  other  kidney 
is  healthy,  where  the  kidney  operated  on  is  much  damaged  either  by 
previous  disease  or  by  manipulation  added  to  disease,  where  several 
stones  are  present,  nephrectomy,  either  now,  or  a  little  later,  is  indi- 
cated ;  of  these,  immediate  removal  of  the  kidney  is  preferable  if  the 
patient's  condition  admits  of  it.*    But  the  question  is  a  very  different 

*  An  instructive  case  which  was  under  my  care  illustrates  well  many  of  the  above 
difficulties — viz.,  multiple  and  large  calculi,  a  mobile  kidney,  the  question  of  nephrectomy 
arising  during  nephro-lithotomy,  and  the  formation  of  multiple  calculi  in  one  kidney 
without  symptoms.  In  February,  1888,  I  was  asked  by  Dr.  Goodhart  to  see  a  case  of 
probable  renal  calculus.  The  boy,  aged  15,  had  been  admitted  with  abdominal  pain  and 
grating  of  an  indistinct  and  delicate  nature  in  the  left  renal  region.  This  kidney  was 
slightly  enlarged.     When  asked  to  localise  his  pain,  the  patient  pointed  to  the  region  of 


NEPHRO-LITHOTOMY.  181 

one  whore  tlie  kidney  is  a  large  one  after  its  fluid  contents  as  well  as 
a  stone  have  been  removed  ;  or  where  it  is  a  cms"  of  multiple  calculi  iii 
a  suppurating,  damaged  kidney.  Nephrectomy  should,  as  a  rule,  be 
deferred  here,  and  the  kidney  thoroughly  drained,  for  (i)  additional 
shuck  and  loss  of  blood  will  he  avoided.  (2)  The  condition  of  the 
opposite  kidney,  very  possibly  calculous  also,  will  be  made  clearer  by 
waiting.  (3)  The  bulk  of  the  kidney  will  be  lessened  by  drainage. 
(4)  Though  a  source  of  discomfort  (if  an  open  sinus  persist)  it  may  still 
do  some  and  important  work. 

Causes  of  Death  after  Nephrolithotomy. — Very  few  unsuccessful 
cases  have  been  published  ;  the  following  appear  to  be  most  probable 
causes  of  after-trouble  : 

1.  Haemorrhage.  A  most  interesting  case  of  haemorrhage,  fatal  on 
the  seventh  day  after  nephrolithotomy,  was  brought  before  the  Clinical 
Society  {Trans  ,  vol.  xxii.  p.  214),  by  Dr.  Stevenson  and  Mr.  Butler 
Smythe  : 

Several  small  and  one  larger  stone  (this  one  being  tightly  fixed  in  the  pelvis  and 
ureter)  having  been  removed  from  a  kidney,  the  site  of  hydro-nephrosis,  the  patient 
did  well,  save  for  a  temperature  which  was  1030  on  the  third  and  fifth  days  and 
all  along  very  variable,  until  the  sixth  day,  when  bright  blood  and  urine  were 
passed  both  by  the  urethra  and  by  the  wound.  On  the  seventh  day  about  half  a 
pint  of  bright  bloody  urine  was  drawn  off  from  the  bladder,  and  death  took  place 
soon  after,  with  symptoms  of  internal  haemorrhage.  The  kidney  was  found  enor- 
mously distended  with  blood-clot  and  bloody  urine.  The  opening  made  at  the 
operation   was   small   and   blocked   up   by   clot.     Embedded   in   the  kidney  substance, 


the  left  kidney  and  the  left  loin.  This  kidney  being  explored  was  found  to  be  occupied 
by  irregular  nodulated  masses.  A  hare-lip  pin  at  once  came  on  and  between  calculi.  The 
kidney  being  incised,  hosts  of  calculi,  comparable  only  to  a  gravel-pit,  were  found  in  the 
calyces  and  pelvis,  the  chief  nests  being  at  the  upper  and  lower  extremities.  The  former 
of  these,  lying  as  they  did  high  up  under  the  ribs,  gave  much  trouble.  To  get  at  them  the 
kidney-tissue  was  again  scraped  through  directly  over  them,  and  many  of  them  thus 
reached.  The  chief  difficulty  of  the  operation,  in  addition  to  the  number  of  stones,  was 
the  great  mobility  of  the  kidney,  though  this  organ  was  well  pushed  up  from  the  front. 
The  condition  was  perhaps  due  to  the  almost  entire  absence  of  surrounding  fat.  When  I 
realised  the  condition  of  the  kidney,  I  expressed  myself  in  favour  of  nephrectomy,  as  the 
organ  was  almost  useless,  as  the  stones  were  so  numerous,  and  as  a  prolonged  attempt  at 
removal  would  produce  more  shock  in  so  weakly  a  subject.  One  or  two  less  important 
points  in  favour  of  nephrectomy  were  the  mobility  of  the  kidney  and  the  entire  absence  of 
adhesions.  Dr.  Goodhart's  counsel  was,  however,  against  this  step,  owing  to  the  small 
percentage  of  urea, — this  had  never  been  above  12  per  cent.,  and  often  less.  I  accordingly 
continued  ;  when  forty-six  calculi  had  been  removed  and  the  operation  had  lasted  three- 
quarters  of  an  hour,  the  pulse  failed  so  ominously  that  I  was  obliged  to  desist.  Very  little 
blood  escaped  as  long  as  the  opening  was  plugged  with  the  finger,  but  considerable  oozing 
followed  as  the  finger  brought  out  the  stones.  The  patient  never  rallied  well,  and  died 
three  hours  and  a  half  after  the  operation.  The  necropsy  showed  a  little  ecchymosis 
around  the  left  kidney  :  this  still  contained  calculi  at  its  upper  and  lower  parts.  The 
right  kidney,  of  which  the  boy  had  never  complained,  also  contained  a  large  number  of 
stones.  Its  substance,  though  much  wasted,  still  contained  a  fair  amount  of  secreting 
substance.  The  condition  of  the  opposite  kidney  thus  abundantly  justified  my  old  friend's 
opinion.  Feeling  that  unsuccessful  cases  of  nephrolithotomy  have  not  been  sufficiently 
published,  I  brought  this  and  the  case  at  page  182  before  the  Clinical  Society.  A  detailed 
account  of  each  will  be  found,  with  ten  others,  in  the  Transactions,  vols.  xxii.  p.  198, 
and  xxiv.  p.  155. 


182  OPERATIONS  OX  THE  ABDOMEN. 

close  to  the  pelvis,  was  a  round  spiked  calculus,  which  had  ulcerated  into  a  branch 
of  the  renal  artery  just  at  its  entrance  into  the  kidney,  and  had  given  rise  to 
profuse  bleeding  into  this  dilated  organ. 

2.  Shock.     This    may  he    lessened   by  wrapping  up  the  limbs  in 

gamgee  tissue  before  an  operation  which  is  expected  to  he  difficult  and 
tedious.  It  may  he  combated  by  saline  infusion  and  injections  of 
adrenalin,   strychine  or  aseptic  ergot. 

The  following  possible  causes  of  haemorrhage  after  nephrolithotomy 
must  also  be  remembered  : 

In  case  Xo.  19  in  the  table,  p.  189,  the  patient  was  a  young  Welsh  miner,  with  all  the 
symptoms  of  renal  calculus  well  marked.  At  the  operation  two  calculi  were  easily  found 
and  removed  from  the  lower  part  of  the  right  kidney.  About  three  hours  after  the 
operation  the  usual  soakage  of  urine  had  taken  place  through  the  dressings  ;  but  it  was 
noticed  to  be  unusually  brightly  stained  with  blood.  When  the  dressings  were  removed 
blood  was  seen  to  be  trickling  through  the  tube  which  I  had  left  in  contact  with  the 
wound  made  in  the  lower  part  of  the  outer  border  of  the  kidney.  Dr.  Bligh,  now  of 
Caterham  Valley,  and  then  house-surgeon,  plugged  the  wound,  and,  the  patient  passing 
into  a  state  of  collapse,  resorted  to  saline  infusion.  On  my  arrival  at  this  time,  I  found 
that  the  patient  had  partially  rallied.  Similar  bleeding  followed  about  two  hours  later, 
the  wound  was  replugged,  and  transfusion  again  reported  to  :  but  the  patient  sank 
seventeen  hours  after  the  operation.  At  the  necropsy  nothing  was  found  in  the  wound 
beyond  some  coagula  and  ecchymosis  round  the  kidney,  and  a  very  small  calculus,  which 
1  had  overlooked  when  the  two  others  were  remove!.  There  was  marked  contraction  of 
the  mitral  valve.  It  is  very  difficult  to  estimate  the  loss  of  blood  in  such  a  case,  but  it  was 
thought  not  to  exceed  six  or  seven  ounces,  and  there  were  no  coagula.  The  operation  was 
of  the  simplest  kind,  but  the  marked  pallor  of  the  patient's  face  ought  to  have  led  me  to 
inquire  for  a  cause  beyond  that  which  I  too  readily  took  for  granted,  viz.,  the  pain,  &c, 
set  up  by  the  renal  caiculi.  I  am  not  aware  of  any  case  that  has  been  published  in  which 
surgical  haemorrhage  has  been  associated  with  a  contracted  mitral  valve,  but  I  have  been 
given  to  understand  that  parturient  women  with  the  above  lesion  are  especially  liable  to 
the  peril  of  flooding. 

Another  possible  cause  of  haemorrhage    after  nephrolithotomy    is 

where  calculi  are  associated  with  a  growth  in  the  pelvis  of  the  kidney. 
Air.  Buttle  has  recorded  a  most  interesting  instance  of  this  {Brit.  Med. 
Journ.,  vol.  i.  1S95,  p.  1206) : 

At  a  lumbar  nephro-lithotomy  several  oxalate  calculi  were  removed  and  a  villous 
growth  scrap>ed  away  from  the  lower  anterior  aspect  of  the  pelvis.  The  patient  resumed 
work,  but  the  hematuria  returned  and  became  profuse  and  constant,  and  the  kidney  was 
removed  about  eighteen  months  after  the  first  operation.  The  surface  about  the  pelvis 
was  papillated  and  firm,  and  the  microscope  showed  evidence  of  a  new  growth  at  this 
spot,  but  whether  this  was  a  simple  papilloma  or  a  squamous  epithelioma  remained 
doubt  fuL 

Hemorrhage  may  be  treated  by  tightly  packing  the  wound  and 
applying  firm  pressure.  Nephrectomy  may  have  to  be  done  in  a  few 
cases. 

3.  Cellulitis.  If  it  has  been  needful  to  incise  or  tear  the  kidney 
freely,  if  the  urine  is  foul,  and  the  bleeding  has  been  arrested  with 
difficulty  after  imperfect  and  repeated  plugging,  this  may  be  readily 
brought  on.  Other  causes  of  this  will  be  found  in  much  disturbance 
of  the  wound  or  fingering  by  many  hands. 

4.  Urtemia,  if  the  other  kidney  is  the  site  of  calculous  disease  or 


NEPHRO-LITHOTOMY. 


E83 


disorganised.     'Tin's  w;is  chiefly  the  cause  of  death  in  the  case  in  which 
I  removed  the  large  stone  (Fig.  63). 

The  patient  was  a  solicitor,  aged  58,  of  sedentary  life,  and  gouty  history,  who  bad 
Buffered  from  attacks  of  right  renal  colic  off  and  on  for  upwards  of  thirty  \> 
these  attacks  having  become  increasingly  fierce  for  about  six  months.  Occasionally 
he  had  had  slight  pain  on  the.  left  side,  and  on  the  morning  fixed  for  the  operation 
he  passed  two  small,  fawn-coloured  calculi  of  lithic  acid  and  lit  hates.  These  were  quite 
Insufficient  to  account  for  all  his  suffering,  and  as  prolonged  and  careful  treatment  had 
entirely  failed,  and  as  his  "life  was  not  worth  having  at  the  price,"  the  operation  was  pro- 
ceeded with,  and  the  huge  renal  calculus 


figured  removed.  This  was  effected  with 
the  utmost  ease,  as  the  stone,  from  its 
size  and  hardness,  was  readily  detected 
occupying  the  distended  pelvis  of  the 
kidney.  A  profuse  jet  of  venous  blood 
followed  its  removal  with  lithotomy  for- 
ceps, after  it  had  been  loosened  by  a 
scooping  movement  of  the  finger.  The 
haemorrhage  was  at  once  arrested  by 
sponge-pressure  kept  up  for  a  few 
minutes.  All  went  well  for  the  first 
week,  save  for  persistent  oxaluria,  which 
no  treatment  could  remove.  The  patient 
was  able  to  sit  up  and  read  ;  appetite 
returned,  and  the  wound  was  healing 
well.  On  the  sixth  day  a  change  for 
the  worse  set  in,  first  much  flatulence 
and  nausea,  then  constant  restlessness, 
followed  by  coma,  ending  in  death  on 
the  morning  of  the  eighth  day.  I  can- 
not doubt  that  the  opposite  kidney  was 
here  also  the  seat  of  stone,  and  its  tissue 
too  much  impaired  to  admit  of  recovery, 
though  I  was  unable  to  obtain  a  post- 
mortem examination  to  verify  this.  I 
should  add  that  the  urine  in  this  patient 


Fig.  63. 


The  larger  calculus  is  the  one  mentioned  here 
in  the  text.  It  weighed  473  gr.,  and  consisted 
of  lithic  acid  and  lithates.  The  main  mass  lay 
in  the  dilated  pelvis,  the  processes  fitted  into 
the  calyces.  The  smaller  calculus,  composed 
chiefly  of  oxalates,  was  successfully  removed 
from  a  patient  aged  24.  It  weighed  42  grs. 
The  two  are  good  instances  of  what  nephro- 
lithotomy can,  and  what  it  cannot  do,  without 
grave  risks. 


before  the  operation  was  acid,  of  sp.  gr. 

1018,  and  without  sugar  or  albumen.     The  quantity  passed  was  natural,  and  the  urea 

sometimes  normal,  sometimes  slightly  deficient. 

Dr.  Whipham  and  Mr.  Haward  (Clin,  Soc.  Trans.,  vol.  xv.  p.  123) 
have  recorded  a  case  which,  with  my  own  just  given,  points  urgently 
to  the  importance  of  surgeons  being  permitted  to  explore  earlier  : 

The  patient,  aged  56,  had  for  "several  years"  been  troubled  with  "gravel."  The 
symptoms  here  were  chiefly  indicative  of  calculous  mischief  in  the  left  kidney,  but  there 
was  some  tenderness  on  the  right  side  as  well.  The  urine  here  was  1006  sp.  gr.,  alkaline, 
and  contained  pus.  The  left  kidney  was  explored,  and  found  in  a  state  of  pyo-nephrosis  ; 
no  calculus  was  found,  but  a  copious  discharge  of  pus  took  place  soon  afterwards,  giving 
great  relief.     The  patient  a  little  later  again  lost  ground,  and  the  wound  was  thoroughly 


*  This  long  duration  of  symptoms  was  unfavourable.  Mr.  Keetley  was  more  fortunate 
in  a  case  equally  long  standing,  in  a  much  younger  patient  (Brit.  Med.  Jon m.,  vol.  i.  1890, 
p.  134).  A  gentleman,  aged  44,  for  thirty  years  had  not  passed  twenty-four  consecutive 
hours  without  pain.  Mr.  Keetley  removed  150  calculi  from  the  right  kidney.  A  large 
rough  calculus  had  blocked  the  way  into  the  ureter  for  the  numerous  smooth  calculi 
which  formed  behind  it.     The  patient  made  a  good  recovery. 


184  OPERATIONS  ON  THE  ABDOMEN. 

explored  a  second  time,  but  the  patient  sank  a  few  hours  after  this,  a  month  after  the 
first  operation.  The  left  kidney-pelvis  was  much  dilated  in  its  upper  part,  and  com- 
municated with  a  large  peri-nephritic  abscess.  The  right  kidney  contained  a  large 
branching  calculus. 

Modern  methods  of  examination  will  do  much  to  diminish  the 
number  of  deaths  from  uraemia,  by  enabling  the  surgeon  to  press  and 
the  patient  to  accept  operation  earlier,  and  by  preventing  the  surgeon 
from  operating  on  unsuitable  cases  with  deficient  functional  capacity  of 
the  other  kidney. 

5.  Septicaemia.  This  condition  may  be  induced  by  the  wound 
becoming  foul,  a  complication  which  can  always  be  prevented  after 
removal  of  small  stones  from  healthy  kidneys.  But  where  pyo- 
nephrosis exists,  it  may  be  impossible  to  keep  the  wound  sweet  from 
the  first.     This  was  so  in  Case  6  of  the  subjoined  table. 

Here,  after  removal  of  nine  calculi,  I  was  obliged  to  remove  the  kidney  a  year  later, 
owing  to  the  persistence  of  a  foetid  sinus. 

And  it  is  to  be  noted  that  septicaemia  may  occur  after  a  nephro- 
lithotomy, successful  as  far  as  the  removal  of  the  stone  goes,  after 
a  considerable  interval,  where  pyo-nephrosis  coexists.  This  is  an 
additional  reason  for  carefully  considering  the  advisability  of  perform- 
ing nephrectomy  in  such  cases. 

Dr.  Shepherd,  of  Montreal,  has  published*  a  very  interesting 
instance  of  this  kind  : 

Nephrolithotomy  was  performed  in  a  patient  aged  26,  who  had  suffered  from  symptoms 
of  stone  for  seven  years,  with  no  tumour,  and  pus  in  the  urine.  An  enormous,  unbreakable 
stone  of  triple  phosphate  was  removed  with  much  difficulty  from  the  left  kidney.  It 
weighed  4  oz.  7  dr.,  and  measured  3J  inches  in  length  and  9  inches  in  circumference. 
The  tissue  of  the  lower  part  of  the  kidney  exposed  seemed  healthy,  and  no  pus  being 
evacuated  it  was  thought  best  not  to  remove  tbe  organ.  The  wound  continued  to 
discharge  pus,  and  the  temperature  varied  correspondingly  for  three  months  and  a 
half  after  the  operation,  when  septicaemia  set  in  and  proved  fatal.  The  necropsy  showed 
that  the  upper  part  of  the  kidney,  which  was  not  exposed,  consisted  of  large  communi- 
cating sacs,  containing  over  10  oz.  of  fetid  pus,  and  a  number  of  irregular  branched  calculi. 
Dr.  Shepherd  points  out  that  the  fatal  septicaemia  was  undoubtedly  due  to  these  abscesses, 
showing  the  need  of  thorough  exploration  in  all  cases  where  a  large  stone  has  set  up 
grave  changes,  and  of  extirpation  in  most  of  them. 

I  have  described  lumbar  nephrolithotomy  fully  because  I  believe 
that,  on  the  whole,  it  is  much  the  safer  operation  for  the  great 
majority  of  operators.  But,  to  make  the  account  complete,  reference 
must  be  made  to  the  proposal  that  abdominal  should  replace  lumbar 
nephro-lithotomy. 

As  might  be  expected,  this  proposal  has  come  from  a  specialist  in 
abdominal  surgery.  Mr.  K.  Thornton  (Harveian  Lectures,  "  Surgery 
of  the  Kidneys,"  p.  34)  gives  the  following  reasons  for  preferring  his 
combined  method  :  "  Recognising  the  difficulty  in  the  diagnosis  of  a 
stone,  and  the  still  further  complication  introduced  by  the  transference 
of  pain  in  some  cases  to  the  opposite  side,  and  the  importance  of 
being  able  to  examine  the  other  kidney  and  both  ureters   thoroughly, 

*  Phil  a  del  phi  a  News,  April  23,  1887;  Ann.  of  Surg.,  vol.  vi.,  August  1887,  p.  185. 
The  right  kidney  is  stated  to  have  been  perfectly  healthy,  but  double  its  normal  size. 


NEPHRO-LITHOTOMY.  105 

throughout  their  whole  course,  I  proposed  to  open  the  abdomen  by 
Langenbtich's  incision  over  the  suspected  kidney,  examine  carefully 
both  kidneys  and  ureters,  and,  having  found  a  stone,  to  employ  one 
hand  in  the  peritonseum  to  fix  the  kidney  and  stone,  and  guard  the 
colon,  while  with  the  other  I  could  cut  down  upon  the  stone  directly 
from  the  loin,  merely  making  an  opening  through  the  loin  tissues 
large  enough  to  introduce  the  finger  and  necessary  forceps  for  the 
extraction  of  the  stone."  And  again,  at  p.  36  :  "  We  are  certain  that 
the  patient  has  the  usual  allowance  of  kidneys.  The  chances  of 
overlooking  the  stone,  if  there  is  one  present  in  either  kidney,  is 
reduced  to  a  minimum.  I  do  not  say  that  the  abdominal  handling  is 
absolutely  infallible,  but  in  fourteen  operations  I  have  only  once  failed 
to  find  a  stone,  and  the  recovery  and  present  health  of  this  one  patient 
make  it  highly  improbable  that  there  was,  or  is,  a  stone  in  her  kidney. 
This  result  compares  very  favourably  with  the  large  number  of 
unsuccessful  lumbar  explorations  already  recorded." 

No  one  who  has  seen  much  of  lumbar  nephrolithotomy  would  allow 
the  above  remarks  to  pass  uncriticised. 

While  I  am  fully  aware  of  the  difficulties  in  determining  whether 
a  stone  is  present,  and  in  what  part  of  the  kidney  it  lies,  I  am 
convinced  that  every  year  that  goes  by  will  perfect  our  power  of 
diagnosis,  by  making  clearer  to  us  the  conditions  that  simulate  stone. 
"  The  large  number  of  unsuccessful  lumbar  explorations  "  of  which 
Mr.  Thornton  makes  a  strong  point  is  not  quite  correctly  referred  to 
by  him.  He  implies  that  a  stone  was  there,  but  that  operators  making 
use  of  lumbar  nephro- lithotomy  failed  to  find  it.  Now  this  is  not 
quite  the  case.  In  the  great  majority  of  cases  no  stone  was  present. 
They  were  cases  in  which  the  diagnosis  was  at  fault.  It  has  always 
been  so  with  every  new  operation,  and  is  one  of  those  faults  which 
time  alone  puts  straight.  In  reality,  these  failures  to  find  a  stone 
are  rather  creditable  to  the  lumbar  operation.  The  operators  have 
been  of  the  most  varying  degrees  of  experience,  and  the  great  majority 
of  their  cases*  have  recovered.  Would  this  have  been  the  case  if 
the  explorations  had  been  through  the  peritonseal  cavity  with  "  the 
necessary  manipulations  to  examine  the  kidneys  and  ureters  "  ?  Now, 
on  this  hangs  one  of  1113'  chief  points.  No  one  who  knows  anything 
of  what  Mr.  Thornton  has  done  for  abdominal  surgery  will  doubt 
for  a  moment  that  operations  on  the  kidne}^  through  the  peritonaeum 
are  certain  to  be  as  safe  in  his  hands  as  any  such  operation  can 
be.  But  what  this  book  has  to  try  and  teach  is  what  operation 
is  the  safest  for  the  largest  number  of  operators.  I  cannot  agree 
with  Mr.  Thornton  that  the  increased  risk  due  to  the  opening  of  the 
peritonaeum  is  practically  nil — i.e.,  if  the  surgeon  will  take  the  pains 
to  perform  a  thoroughly  aseptic  operation.  I  should  agree  that  the 
risk  of  peritonitis  is  now  much  smaller  than  it  was,  but  there  are 
other  risks  which  are  inseparable  from  this  mode  of  exploring  the 
kidney. f     I  refer  to  the  shock  which  the  necessary  manipulations  of 

*  I  Lave  pointed  out  (p.  181)  that  there  is  reason  to  fear  that  fatal  cases  have  not  been 
published.     But  this  would  not  apply  to  the  lumbar  operation  only. 

f  Every  one  who  has  seen  much  of  renal  surgery  will  know  that  grave  shocks  may 
readily  be  met  with  in  some  of  these  explorations  of  the  kidney.     Thus,  in  the  case  of 


1 86  OPERATIONS  ON  THE  ABDOMEN. 

certain  very  vital  parts  must  entail.  Mr.  Thornton  will  be  able  to  go 
straight  to  the  kidneys  with  a  minimum  of  disturbance  of  the  over- 
lying parts.  But  is  it  to  be  believed  for  a  moment  that  this  would 
be  the  case  with  the  majority  of  operators  ?  And  this  brings  me 
to  another  point.  Others  who  have  tried  this  method  have  not 
found  it  so  easy  to  detect  the  presence  of  a  renal  calculus  or  to 
determine  the  condition  of  the  kidneys.  With  regard  to  the  latter 
point,  I  ma}'  mention  the  following  : 

A  woman  was  sent  to  me  with  long-standing  pyuria  of  renal  origin.  She  was  clearly 
very  near  her  end  from  kidney  failure,  and  during  the  five  days  she  lived  no  operation 
was  admissible.  After  her  death  I  thought  it  a  good  opportunity  to  investigate  the 
condition  of  the  kidneys  by  an  abdominal  incision.  I  was  able  to  feel  that  there  was  a 
right  kidney,  which  felt  so  hard  that  I  thought  it  contained  a  stone.  About  the  condition 
of  the  left  kidney  I  was  quite  unable  to  satisfy  myself.  The  necropsy  showed  that  the 
right  kidney  was  in  a  condition  of  fibroid  atrophy  ;  no  stone  was  present.  The  left  was 
a  thin-walled  sac  containing  pus.  Owing  to  the  great  tenderness  on  this  side,  I  had 
looked  on  this  kidney  as  the  source  of  the  pyuria.  It  would  have  been  readily  reached 
from  the  loin. 

I  have  only  once  tried  to  detect  a  renal  calculus  through  an 
abdominal  incision. 

The  case  was  No.  21  in  the  table  at  p.  189.  As,  in  addition  to  the  renal  symptoms, 
there  was  trouble  indicating  oophorectomy,  I  took  the  occasion,  after  Dr.  Galabin  had 
removed  the  ovaries,  to  explore  the  left  kidney,  where  the  presence  of  a  stone  was 
suspected.  The  existence  of  a  calculus,  which  felt  a  large  one — in  reality,  three  were 
present — and  of  a  small  hydro-nephrosis  could  be  made  out,  conditions  which  were  verified 
at  the  time  of  the  nephrolithotomy  a  little  later. 

In  this  case  the  kidney  was  not  enlarged,  of  the  ordinary  firm 
consistence,  save  near  the  pelvis,  and  free  from  the  results  of  past 
inflammation.  In  such  cases  as  these  it  will  always  be  easy  to  detect 
the  presence  of  the  stone,  but  it  will  be  very  different  in  those  cases 
where  the  stone  lies  in  an  enlarged  kidne}r,  the  seat  of  a  collection  of 
fluid,  or  in  one  matted  down  with  much  thickening  of  surrounding 
tissues  from  long-standing  inflammation. 

But  I  would  rather  quote  the  opinions  of  others.  Mr.  T.  Smith 
(Discussion  at  the  Clinical  Society,  Brit.  Med.  Joum.,  1887,  vol.  i. 
p.  393)  said  that  Mr.  Thornton  had  seemed  to  represent  that  by  open- 
ing the  abdomen  from  the  front  one  could  ascertain  with  certainty 
whether  there  was  a  stone  in  the  one  or  other  kidney.  But  one  could 
not  always  tell  this  even  if  one  felt  the  kidney  out  of  the  body.  In 
three  different  cases  in  which  he  had  handled  kidneys  so  removed  no 
stone  could  be  detected  therein  until  the  kidneys  were  cut  open.* 
Another  very  interesting  case,  brought  by  Mr.  Page  before  the  Medico- 
Chirurgical  Society  (Brit.  Med.  Joum.,  1888,  vol.  i.  p.  795)  shows  what 

nephrolithotomy  (No.  12  in  the  table,  p.  188)  in  a  lady  of  40,  with  fifteen  years'  history, 
from  whom  I  removed  three  cystine  calculi,  the  patient  was  so  anaemic  and  unhealthy 
from  her  long-continued  pain  and  marred  life,  that  she  nearly  succumbed  during  the 
operation.  Yet  this  was  of  the  simplest,  the  loin  thin,  the  calculi  (387  gr.)  found  at  once 
and  extracted  easily,  the  operation  itself  not  exceeding  twelve  minutes.  A.C.E.  followed 
by  ether  had  been  given,  but  the  pulse,  always  weak,  became  almost  imperceptible  after 
the  first  incision. 

*  On, this  point  see  Mr.  Morris's  case,  p-  179. 


NEPHROLITHOTOMY.  ,,S7 

care  is  needed  when  abdominal  exploration  for  the  examination  of  the 

kidneys  is  made  use  of. 

Mr.  Page  thought  that  in  this  case  abdominal  exploration,  bad  he  made  it,  would 
probably  have  led  him  astray,  as  the  left  kidney,  whieh,  though  small,  was  the  working 
one,  would  have  been  removed,  while  the  right  viscus,  which  was  really  the  seat  of: 
pyelitis  and  contained  some  small  stones,  would  have  been  Looked  upon  as  merely 
enlarged  to  do  the  work  of  two,  this  increase  in  size  being  really  due  to  its  diseased 
condition. 

Mr.  K.  Thornton  (p.  3J)  mentions  a  case  in  which  it  took  an  hour  to 
find  the  kidney  by  the  lumbar  incision,  and  which  ended  fatally,  and 
another  in  which  the  surgeon  failed  entirely  to  find  the  kidney  by  the 
same  method.  Such  cases,  as  shown  by  their  number,  are  quite 
exceptional.  When  the  large  number  of  explorations  of  the  kidney 
by  the  lumbar  method  is  considered,  it  will  be  acknowledged  that  the 
lumbar  inethod  is  characterised  by  the  ease  with  which  the  kidney  is 
found,  and  the  well-doing  of  the  cases  afterwards,  especially  when  the 
great  number  and  the  diversity  of  operators  are  considered. 

With  regard  to  pain  in  one  loin  due  to  mischief  in  the  opposite 
kidney,  we  have  very  little  knowledge  as  to  sympathy  between  the 
kidneys.  But  this  condition  is  certainly  rare.  As  a  rule,  in  renal 
calculus,  pain  is  alone  complained  of  on  the  side  in  which  the  stone 
lies.  Pain  in  both  loins  means  usually  stones  or  disease  on  both  sides, 
a  far  graver  thing  than  "  sympathy." 

Mr.  Thornton,  in  his  combined  method,  which  I  have  described  at 
p.  185,  lays  stress  upon  the  small  clean  cut  which  is  made  upon  the 
stone  by  the  loin,  only  large  enough  to  introduce  the  finger  and  forceps. 
It  is  difficult  to  see  how  such  an  opening  would  suffice  to  remove  a 
small  stone  lying  in  a  calyx  on  the  anterior  surface  of  the  kidney,  one 
of  the  most  difficult  of  all  cases.  By  the  lumbar  operation  the  surgeon 
will  be  able,  after  freeing  the  kidney,  as  is  nearly  always  feasible,  to 
bring  it  out  of  the  wound  on  to  the  loin,  and  carefully  handle  the 
anterior  as  well  as  the  posterior  surface,  and  if  necessaiy  he  can  incise 
the  organ  freely  and  examine  the  cavity  of  the  pelvis  with  the  finger. 
Only  after  such  a  thorough  exploration  can  it  be  concluded  that  a  stone 
is  absent.  With  regard  to  the  risk  of  the  hernia  which  Mr.  Thornton 
states  {loc.  supra  tit.)  to  be  "a  not  uncommon  result  of  the  lumbar 
operation,"  the  experience  of  most  surgeons  will  be  quite  the  opposite. 
As  already  stated  (p.  127),  the  tissues  in  the  lumbar  region  are  so 
strong  and  unyielding,  compared  with  those  in  the  anterior  abdominal 
wall,  that  a  protrusion  does  not  readihy  take  place  here.  Time  and 
experience  have  amply  proved  the  wisdom  and  moderation  of  these 
criticisms,  which  were  made  some  years  ago.  The  introduction  of  the 
Rontgen-rays,  the  cystoscope,  and  the  segregator,  has  given  us  far 
better  means  of  determining  the  presence  or  absence  of  a  stone,  and 
the  condition  of  the  other  kidney,  than  a  laparotomy  can  allow.  It  is 
not  surprising,  therefore,  that  the  combined  method  advocated  b}r  Mr. 
Thornton  and  others  has  fallen  into  deserved  disuse,  and  is  now  of 
little  more  than  historical  interest. 


OPERATIONS  ON  THE  ABDOMEN. 


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igo  OPERATIONS   ON    THE   ABDOMEN. 


THE    TREATMENT    OF    CALCULOUS    ANURIA. 

Although  spontaneous  recover}'  from  this  very  grave  condition  may 
occasionally  occur,  it  is  certain  that  an  early  and  suitable  operation  is 
by  far  the  best  treatment.  Morris  (Surg.  Diseases  of  the  Kidneys  and 
Ureters,  vol.  ii.  p.  159)  found  that  only  20*8  per  cent,  cures  occurred 
in  48  cases  treated  without  operation,  whereas  51  per  cent,  out  of 
49  cases  recovered  after  operation.  Out  of  56  cases  collected  by 
Legueu,  28*5  per  cent,  recovered  without  operation ;  it  is  probable 
that  the  obstruction  was  never  complete  in  some  of  these  cases. 

Before  operating,  the  surgeon  should  remember,  that  the  stone  is 
nearly  always  in  the  ureter  of  the  only  functional  kidney,  but  that  both 
ureters  may  become  simultaneously  obstructed  in  some  cases,  and  also 
that  two  exceptional  cases  have  been  recorded  in  which  a  vesical  stone 
closed  the  orifices  of  both  ureters  (Morris,  loc.  cit.).  Morris  draws 
attention  to  the  three  important  factors  in  the  production  of  calculous 
anuria. 

1.  "Along-standing  change  in  one  of  the  kidneys  causing  a  diminu- 
tion if  not  suppression  of  its  function ;  or  else  a  congenital  anomaly 
(absence  or  atrophy). 

2.  "A  recent  or  recently  aggravated  lesion  of  the  principal  kidney. 
This  lesion  is  mechanical,  and  caused  by  a  calculus. 

3.  "A  reflex  inhibitory  effect  upon  the  disorganised  kidney,  leading 
to  complete  suppression  of  its  imperfect  functional  power." 

The  surgeon  may  restore  the  function  of  the  principal  kidney  by  a 
prompt  removal  of  the  obstructing  stone,  or  failing  this  he  may  simply 
form  a  temporary  fistula  in  the  loin ;  the  other  kidney  may  then  regain 
its  use. 

Diagnosis. — Calculous  anuria  can  be  readily  distinguished  from  the 
temporary  reflex  suppression  that  may  follow  operations  on  the  lower 
urinary  organs,  by  the  history,  and  from  the  uraemia  of  Bright's 
disease,  also  by  the  history  and  by  the  absence  of  the  early  and 
characteristic  symptoms  of  non-obstructive  uraemia,  such  as  headache, 
nervous  disturbances  coma,  and  convulsions.  The  subject  of  calculous 
anuria  ma}r  remain  so  well  for  many  days,  that  it  may  be  difficult  to 
make  him  realise  the  gravity  of  his  condition. 

It  is  not  always  easy  to  tell  the  side  of  the  principal  kidney  and  the 
exact  position  of  the  calculus  which  has  recently  obstructed  its  ureter, 
but  every  effort  must  be  made  to  determine  these  points,  for  the  opera- 
tion must  be  performed  on  the  side  of  the  healthiest  kidney,  which  is 
nearly  always  the  last  affected. 

A  history  of  previous  attacks  of  renal  colic  on  one  side  and  of  a  sudden 
recent  onset  of  colic  on  the  same  side  associated  or  rapidly  followed 
by  anuria,  may  indicate  the  affected  side  with  more  or  less  certainty, 
but  if  the  last  attack  of  colic,  which  has  been  followed  by  anuria,  be  on 
the  other  side  the  obstruction  is  practically  certain  to  be  on  that 
side.  Bigidity,  tenderness  and,  more  rarely,  swelling  on  one  side  may 
confirm  the  diagnosis. 

When  no  history  of  value  is  available,  palpation  may  discover 
tenderness  or  rigidity  over  one  kidney  or  ureter,  although  the  subjects 
of  anuria  are  usually  too  stout  to  allow  palpation  of  the  ureter.     Bectal 


TREATMENT    OF    CALCULOUS    ANURIA. 


E91 


and  vaginal  examination  may  enable  the  surgeon  to  feel  a  calculus 
low  down,  and  Morris  lias  detected  a  stone  in  the  ureteral  orifice  after 
dilating  the  female  urethra,  and  such  a  calculus  has  also  been  seen 
through  the  cystoscope.  Examination  of  the  ureteral  orifices  by 
means  of  this  instrument  may  add  a  link  to  the  chain  of  lads  required 
for  accurate  diagnosis.  Mr.  Clayton  Greene  (Lancet,  vol.  i.  p.  91, 
1906)  records  a  case  in  which  it  was  fairly  clear  from  other  evidence 
that  the  obstruction  was  on  the  right  side.  The  cystoscope  showed  a 
healthy  right  ureter,  but  the  left  orifice  was  distended  with  some  whitish 
material  which  was  thought  to  be  a  phospliatic  stone.  In  this  case 
the  cystoscope  proved  that  the  calculus  was  not  in  the  vesical  part  of 
the  ureter,  but  it  is  clear,  that,  taken  by  itself,  the  appearance  of  the 
left  ureter  might  have  led  to  a  wrong  conclusion  and  an  exploration  on 
the  wrong  side.  In  cases  of  partial  anuria,  the  segregator  may  serve 
to  show  which  kidney  is  the  principal  one,  as  is  demonstrated  by  the 
following  interesting  case  recorded  b}r  Mr.  Bruce  Clarke  (Lancet,  vol.  i. 
p.  5,  1905). 

"  The  first  instance  in  which  I  made  use  of  it  the  segregator  was  one,  as  yon  will  see,  of 
obstructive  suppression — that  is  to  say,  a  case  in  which  one  kidney  had  been  practically 
destroyed  by  a  calculus  and  in  which  complete  obstruction  was  being  threatened  owing  to 
the  impending  blockage  of  the  opposite  ureter.  Such  cases  when  they  are  typical 
are  not  very  difficult  to  detect,  but  in  this  instance  no  history  could  be  obtained  of  a 
previous  attack  of  renal  colic  or  any  evidence  of  even  the  probability  of  such  an  attack. 
The  illness  from  which  the  patient  was  suffering  had  come  on  suddenly  in  a  man,  aged 
46  years.  He  had  been  seized  without  warning  with  violent  pain  in  the  region  of  the 
left  kidney  and  ureter  which  had  temporarily  yielded  to  fomentations,  hot  baths,  sedatives, 
and  rest  in  bed.  Each  time  one  of  these  attacks  supervened  there  was  an  arrest  in  the 
secretion  of  urine,  though  it  could  hardly  be  said  to  amount  to  complete  suppression. 
There  had  been  some  six  or  seven  attacks  in  the  past  three  weeks.  The  longest  one  had 
lasted  three  days  and  the  shortest  only  a  few  hours,  but  latterly  the  pain  had  invaded 
both  loins.  The  urine  was  highly  coloured,  tinged  with  blood  sometimes,  and  there  was 
a  little  pus  in  the  specimen  which  I  examined  ;  it  had  a  specific  gravity  1014,  gave  an 
acid  reaction,  and  contained  a  trace  of  albumin.  The  day  before  I  saw  the  patient  he 
had  had  a  severe  attack  over  the  region  of  the  right  kidney  and  both  loins  were  tender 
to  touch.  His  temperature  was  a  little  raised  and  he  was  evidently  ill.  Though  on  the 
whole  it  seemed  most  probable  that  a  stone  in  the  pelvis  of  the  left  kidney  afforded  the 
clue  to  his  symptoms,  and  recent  pain  over  the  right  kidney  region  made  the  condition 
of  that  kidney  a  matter  of  considerable  doubt.  In  these  circumstances  I  introduced 
the  separator,  and  within  a  few  seconds  urine  began  to  issue  from  the  left  catheter. 
It  was  not  until  nearly  half  an  ounce  had  come  from  this  side  that  urine  began  to 
issue  from  the  right  catheter.  In  a  quarter  of  an  hour  quite  enough  had  been  collected 
for  purposes  of  examination  and  the  instrument  was  withdrawn. 

"  The  appearance  of  the  urine  from  the  two  sides  was  absolutely  different.  That  from 
the  right  side  was  small  in  amount  (scarcely  more  than  a  teaspoonf  ul)  whilst  three-quarters 
of  an  ounce  had  come  from  the  left  kidney.  The  examination  of  the  two  specimens 
yielding  the  following  result.  The  urine  from  the  right  kidney  was  slightly  alkaline  and 
contained  a  little  pus  and  some  albumin  ;  that  from  the  left  kidney  was  acid,  clear,  with 
not  a  trace  of  pus  or  albumin.  It  was  now  established  beyond  all  possibility  of  doubt 
that  the  kidney  on  the  left  side  was  the  working  kidney  and  was  presumably  healthy, 
though  it  probably  contained  a  calculus.  The  right  kidney  had  probably  been  so  damaged 
by  some  previous  attack  as  practically  to  be  useless. 

"  An  operation  was  performed  a  few  days  later  on  the  left  kidney.  The  stone  which 
I  hold  in  my  hand  was  extracted  from  its  pelvis." 

If  one  kidney  is  known  to  have  been  diseased  for  some  time,  and 
especially  if  it  has  been  explored  by  an  operation,  the  recent  obstruction 


ig2  OPERATIONS  ON  THE  ABDOMEN, 

is  almost  certain  to  be  on  the  opposite  side.  When  one  kidney- 
has  been  removed  and  anuria  suddenly  supervenes  some  time  after- 
wards, it  is  imperative  to  explore  the  remaining  kidney,  but  this  has 
not  always  been  done  ;  thus  a  young  woman  had  her  left  kidney 
removed  for  tuberculous  disease.  Some  months  later  she  was  taken 
to  another  hospital  suffering  from  anuria,  which  was  considered  to  be 
due  to  tuberculous  disease  of  the  remaining  kidney,  but  the  autopsy 
disclosed  a  small  calculus  impacted  in  the  right  ureter  and  a 
hypertrophied  healthy  kidney. 

With  certain  precautions,  radiography  may  give  information  which 
may  serve  to  complete  the  diagnosis  by  localising  the  stone,  but  a 
negative  result  must  not  be  relied  upon,  because  a  stone  which  is  large 
enough  to  obstruct  the  ureter  may  yet  be  too  small  or  too  transparent 
(uratic)  to  give  a  shadow  in  a  fat  subject.  A  positive  result  ma}'  also 
mislead,  for  a  large  calculus  may  be  present  in  the  pelvis  of  the  other 
kidney,  and  only  a  small  one  in  the  ureter  last  obstructed.  To  arrive 
at  a  diagnosis,  all-  the  facts  available  must  be  reviewed  and  too  much 
reliance  must  not  be  placed  upon  any  one  sign. 

It  must  not  be  forgotten  that  cancer  of  the  uterus  and  of  the 
bladder  may  rarely  cause  sudden  anuria,  and  lead  to  a  hasty  diagnosis 
of  calculous  anuria,  but  a  thorough  examination  ought  to  prevent  this 
mistake. 

Morris  relates  a  case  of  polycystic  disease  of  both  kidneys,  which  led 
to  error.  A  history  of  passing  gravel  and  a  stone  was  very  misleading 
in  this  case  (Morris,  Vol.  I.  p.  168). 

The  nature  of  the  operation. — In  most  cases  it  is  best  to  explore 
the  kidney  which  is  considered  to  be  the  principal  one  through  the 
usual  incision  in  the  loin,  and  to  remove  an}'  stone  that  may  be 
discovered  in  the  pelvis  or  the  upper  part  of  the  ureter.  Morris  states 
that  in  twenty  out  of  thirty  cases,  this  incision  would  have  served  to 
remove  the  calculus  at  the  primary  operation.  If  a  calculus  cannot  be 
found  in  this  way,  a  ureteral  catheter  should  be  passed  downwards  to 
locate  it.  Sometimes  it  may  be  removed  by  prolonging  the  incision, 
or  through  a  separate  extra-peritonseal  incision  in  the  groin,  if  the 
calculus  is  lower  down.  In  grave  and  late  cases,  however,  it  will  be 
wise  not  to  endanger  the  life  of  the  patient  by  prolonging  the  operation 
unnecessarily,  and  to  defer  what  may  prove  to  be  a  difficult  and  long 
operation  until  the  patient  has  recovered  from  his  immediate  danger  ; 
by  forming  a  fistula  the  surgeon  will  have  done  all  that  is  urgently 
required  to  save  life,  and  to  re-establish  the  secretion  of  urine. 

If  it  be  known  beforehand  that  the  stone  is  too  low  to  be  reached 
from  the  loin,  extra-peritonasal  ureterotomy  should  be  performed  at  once, 
the  stone  removed  through  a  longitudinal  incision,  and  a  catheter 
passed  down  into  the  bladder  to  make  certain  that  the  passage  is 
clear.  The  incision  into  the  ureter  may  be  partly  closed  by  catgut 
sutures,  but  it  is  not  safe  to  invert  the  edges  and  thus  to  narrow  the 
lumen  of  the  only  ureter,  unless  the  latter  be  dilated  at  the  site  of  the 
incision. 

Blood  clot  in  the  lower  part  of  the  ureter  may  be  sufficient  to  pre- 
vent or  delay  the  return  of  urinary  secretion  as  pointed  out  by  Mr. 
Clayton  Greene  (loc.  cit.).  In  any  case  a  drain  must  be  placed  near  the 
ureter  to  prevent  possible  urinary  extravasation. 


TREATMENT   OF   CALCULOUS   ANURIA.  [g3 

If  the  stone  be  known  to  be  impacted  at  or  near  the  lower  end  of  the 
ureter,  primary  nephrotomy  may  be  done  in  grave  cases,  and  the  calculus 
may  be  removed  later,  if  not  naturally  passed.  In  one  case  a  stone  has 
boon  removed  through  the  rectum. 

Garceau  (Boston  Med.  and  Sv/rg.  Joum.,  April  21,  1904)  removed  a 
stone  which  was  impacted  near  the  lower  end  of  the  ureter  through  an 
incision  in  the  anterior  vaginal  wall.  The  operation  only  took  ten 
minutes,  and  it  was  completely  successful. 

Sometimes,  although  very  rarely,  it  may  happen  that  all  the  efforts 
of  the  surgeon  may  not  suffice  to  enable  him  to  decide  upon  which 
kidney  to  operate.  He  must  then  explore  one  kidney  through  the  loin, 
and  if  this  be  found  to  be  atrophied  or  greatly  diseased  he  must  perform  a 
nephrotomy  on  the  other  side.  This  is  better  than  doing  an  explora- 
tory laparotomy,  for  it  may  be  very  difficult  to  find  and  examine  the 
ureters,  especially  in  fat  subjects  (vide  p.  186)  ;  and  even  if  a  calculus 
be  found  it  is  not  wise  to  try  to  remove  it  through  the  peritonaeum  for 
several  reasons.  The  contents  of  the  ureter  above  the  stone  are  very 
likely  to  be  septic,  and  it  may  be  necessary  to  drain  the  ureter,  which 
is  more  safely  done  extra-peritonaeally ;  if  the  incised  ureter  be  sewn 
up,  it  may  leak  into  the  peritonaeum  later.  Moreover,  palpation  of  the 
kidneys  may  mislead  the  surgeon,  the  largest  kidney  being  the  most 
diseased  one  in  some  cases.  Even  if  a  correct  diagnosis  be  arrived  at 
h}'  a  laparotoni}^  another  operation  is  necessary  to  drain  the  kidney 
and  remove  the  calculus,  as  in  Mr.  Duke's  case  (Lancet,  1904,  vol.  ii. 
p.  174).  In  this  case  all  that  the  surgeon  could  discover  with  his  hand 
in  the  abdomen  was  that  the  right  kidney  "  was  apparently  a  little 
larger  than  the  left."  On  this  slight  evidence  the  right  kidney  was 
opened  through  the  loin,  and  two  calculi  discovered  in  the  pelvis ;  one 
of  these,  weighing  3*2  grains,  was  removed  later,  and  the  patient 
recovered,  although  she  had  suffered  from  complete  anuria  for  ten  days. 

Cabot  advocates  exploratory  laparotomy  (Ann. of  Surg.,  October,  1904), 
if  other  methods  fail  to  indicate  the  site  of  the  recent  obstruction.  He 
relates  two  very  interesting  cases,  in  each  of  which  the  operation  failed 
to  discover  the  calculus,  but  probably  served  to  dislodge  it.  In  one  case 
bimanual  examination  through  a  median  laparotomy  and  an  incision  in 
the  loin  failed  to  discover  the  calcareous  obstruction.  In  the  other 
patient  only  a  lumbar  nephrotomy  was  performed.  Both  patients 
recovered. 

One  of  the  most  brilliant  examples  of  what  nephrolithotomy  can  do 
in  some  cases  of  suppression  of  urine  is  shown  by  a  case  brought  by 
Mr.  R.  C.  Lucas  before  the  Medico-Chirurgical  Society  (Trans.,  vol. 
lxxiv.  p.  129)  : 

The  patient,  aged  37,  hail  had  her  right  kidney,  a  "mere  shell,  containing  masses 
of  stone  weighing  twenty-one  ounces,"  successfully  removed.  Three  months  later  she 
was  seized  with  agonising  pain  in  the  back  and  left  loin.  Suppression  of  urine  quickly 
set  in,  and  on  the  fifth  day  a  calculus  was  removed  which  was  exactly  of  the  shape  to  act 
as  a  ball-valve  to  the  top  of  the  left  ureter.  The  patient  made  an  excellent  recovery,  and 
has  survived  for  many  years  now. 

But  in  many  cases  of  suppression  the  indications  are  less  clear,  and 
there  is  often  much  difficulty  in  deciding  which  ureter  is  blocked,  owing 
to  the  deficient  history.     An  excellent  instance  of  such  cases,  in  which 

s. — vol.  11.  13 


194  OPERATIONS  ON  THE  ABDOMEN. 

the  surrounding  difficulties  were  most  successfully  met,  is  recorded  by 
Dr.  Fraser  and  Mr.  Parkin,  of  Hull  (Lancet,  vol.  ii.  1893,  p.  688)  : 

The  patient  here  suffering  from  suppression  of  urine  was  74  years  of  age.  Beyond  the 
evidence  pointing  to  obstructive  anuria,  there  was  very  little  to  throw  light  on  the 
condition  of  the  kidneys,  or  which  organ  should  be  explored.  As  the  patient  had  been 
observed  by  her  friends  to  support  the  left  side  in  walking,  and  as  there  was  deep-seated 
tenderness  in  this  loin,  Mr.  Parkin  explored  the  left  kidney  from  the  loin.  The  organ  was 
enlarged,  distended,  and  hypertrophied.  About  six  ounces  of  urine  escaped  when  the 
kidney  was  incised  along  its  convex  border,  the  last  portion  to  come  away  being  mixed 
with  some  pus.  No  stone  was  found,  and  the  cause  of  the  suppression  must  remain  obscure, 
as  the  patient,  though  74,  made  a  good  recovery,  with  a  sinus  from  which  most  of  the 
urine  passed. 

The  above  cases  show  the  importance  of  knowing  the  history  of  the 
case,  and,  where  this  is  deficient,  making  a  most  minute  examination, 
no  point  being  considered  too  trivial  to  be  pieced  in  with  others,  before 
it  is  decided  which  kidney  is  the  working  one  and  now  obstructed,  and 
which  is  obsolete. 

The  Time  for  Operation. — Any  operative  interference  should  be 
undertaken,  if  possible,  long  before  the  final  stage  of  constant  hiccough 
and  vomiting,  subnormal  temperature,  irregular  pulse,  tremor,  and 
drowsiness.  As  soon  as  the  diagnosis  becomes  certain  an  operation 
should  be  resorted  to,  for  it  must  be  remembered  that  if  the  obstruction 
be  too  long  continued,  its  removal  may  not  relieve  the  suppression. 
A  few  patients  have  recovered  after  suffering  from  complete  anuria  for 
ten  or  more  days,  but  others  have  died  after  three  or  four  days.  Cases 
of  incomplete  obstruction  last  much  longer,  of  course. 

Anuria  following  injuries  is  much  less  hopeful,  owing  to  concomitant 
injuries.     The  following  are  examples  :— 

Mr.  Cock  recorded  (Path.  Sac.  Trims.,  vol.  i.  p.  293)  the  case  of  a  young  man  who  died 
comatose  on  the  eleventh  day  after  an  accident.  All  the  symptoms  of  the  original  injury 
and  the  subsequent  peritonitis  subsided  in  a  few  days,  save  that  the  catheter  withdrew 
nothing  but  blood.  The  autopsy  showed  a  ruptured  single  kidney.  In  Mr.  Poland's  case 
Q6fuy's  ffosp.  Rep.,  vol.  xiv.)  the  complete  suppression  of  urine  which  followed  an  injury 
was  due  to  thrombosis  of  the  renal  vessels  of  one  kidney,  and  rupture  of  the  pelvis  on  the 
other  side. 

Mr.  Butler,  of  Guildford,  records  (Lancet,  vol.  i.  1890,  p.  79)  a  case  of  suppression  of 
urine  lasting  thirteen  days.  The  necropsy  showed  that  the  ureter  of  the  only  working 
kidney  (the  left  one)  was  greatly  distended  with  urine  and  plugged  by  a  solid  hard  bod}' 
in  about  its  centre.  This  proved  to  be  a  venous  thrombus,  which,  formed  in  one  of  the 
veins  in  the  kidney,  had  passed  through  a  rent  in  the  kidney  tissue  into  the  pelvis  and  ureter. 
Here  the  suppression  came  on  four  days  after  a  blow  on  the  abdomen.  No  symptoms  had 
pointed  to  renal  disease,  and,  save  that  the  blow  was  on  the  left  side,  there  was  nothing 
to  tell  on  which  side  the  obstruction  was. 


NEPHRECTOMY. 

Indications. 

i.  Cases  of  renal  tuberculosis,  preferably  as  the  primary  operation, 
and  also  cases  of  tuberculous  pyonephrosis  explored  previously  and 
drained  by  nephrotomy,  but  in  which  a  discharging  sinus  persists. 
Here  the  kidney  should  be  removed  when  the  following  conditions  are 
favourable,  viz.,  the  age  and  strength  of  the  patient,  the  absence  of 


NEPHRECTOMY. 


195 


visceral  infection,  tubercular  or  lardaceous,  and,  if  possible,  a  date 
not  too  long  deferred,  for  the  additional  reason  that  the  kidney  will  he 
increasingly  matted  down  and  difficult  of  removal,  while  its  fellow  may 
have  become  involved  in  the  disease. 

On  this  point  I  may  quote  again  from  my  paper  on  the  conditions 
which  simulate  renal  calculus  {Brit.  Med.  Jowrn.,  1890,  vol.  i.  p.  117)  : 

"I  would  most  strongly  urge  this  course  (early  exploration  of  the 
kidney)  with  a  twofold  object:  (1)  to  clear  up  the  case  and  (3)  to 
perform  nephrectomy  if  the  kidney  is  found  to  be  the  site  of  so  fatal  a 
disease.  If  I  am  told  of  the  unwisdom  of  this  step,  owing  to  the 
probability  of  both  kidneys  being  affected,  I  would  reply  that,  as  a 
rule,  both  kidneys  are  not  affected  at  an  early  stage.  Tims  Dr.  Fagge 
(Medicine,  vol.  ii.  p.  488)  gives  a  list  of  thirteen  cases  which  show  'the 
characters  of  tuberculous  disease  of  the  kidney  at  its  commencement.' 
In  only  three  of  these  were  both  kidneys  affected,  and  in  all  these 
tubercular  mischief  was  present  in  the  bladder  also.  If  during  this 
early  exploration  one  or  two  pyelitic  dilatations  are  found,  extirpation 
of  the  kidney  should  be  performed  while  the  organ  is  still  small  and 
movable,  and  before  the  rest  of  the  genito-urinary  tract  becomes 
involved. 

"  I  need  not  remind  my  hearers  of  the  miseries  which  lie  before  a 
patient  with  established  tubercular  kidney,  the  results  of  ulceration  of 
his  bladder,  with,  perhaps,  vomica?  in  his  prostate,  and  the  inevitable 
course  downhill,  arrested,  it  may  be,  for  a  little  while  by  nephrotomy 
and  drainage." 

My  own  experience  of  drainage  alone  in  established  tubercular 
kidney  is  most  unfavourable,  the  relief  being  slight  and  short-lived, 
and  not  arresting  long  the  hectic  and  increasing  debility.  On  the 
other  hand,  in  four  cases  in  which  I  have  been  able  to  perform 
nephrectomy  early  (cases  Nos.  8,  12,  13,  16,  p.  217)  the  result  has 
been  most  satisfactory.  In  four  others  (3,  4,  11,  17,  ibid.),  the 
recovery,  though  less  complete,  was  very  satisfactory.  Finally,  in  two 
(cases  15  and  22,  ibid.),  the  eleventh  and  twelfth  cases  in  which  I  have 
removed  a  tubercular  kidney,  the  disease  was  too  advanced  in  both  for 
the  result  to  be  satisfactory. 

Pousson  (Lancet,  Aug.  11,  1900)  found  that  out  of  63  cases  of 
nephrotomy  39  died  in  the  first  year  from  the  spread  of  their  tuber- 
culosis or  complications  arising  from  incomplete  operation.  Twenty- 
four  were  alive,  some  of  these  were  known  to  have  survived  for  two, 
five,  and  ten  years,  but  all  of  them  had  fistulas. 

Ramsay  (loc.  cit.,  p.  161)  gives  the  results  of  191  cases  of  primary 
nephrectomy  for  renal  tuberculosis.  Of  these  106  were  noted  as  cured, 
31  were  improved,  ^y  died  within  one  month  of  the  operation,  and  17 
died  at  a  later  period. 

Forty-nine  cases  of  secondary  nephrectomy  after  a  previous  nephro- 
tomy are  also  given.  Of  these  18  died  shortly  after  the  operation, 
and  23,  or  46  per  cent.,  were  cured.  Of  the  37  deaths  resulting  from 
primary  nephrectomy,  9  were  due  to  uraemia,  3  to  tuberculosis  of 
the  other  kidney,  and  2  to  amyloid  degeneration  of  the  other  kidney. 
These  14  deaths  serve  to  emphasise  the  importance  of  thorough 
investigation  of  the  capacity  of  the  other  kidney  before  nephrectomy  is 
decided  upon.     For  although  the  second  kidne}r,  as  mentioned  above, 

13—2 


196  OPERATIONS  ON  THE  ABDOMEN. 

is  not  often  affected  in  early  cases,  yet  when  the  case  only  comes 
under  observation  in  the  more  advanced  stages,  it  will  very  possibly  be 
diseased  (vide  pp.  150  to  160). 

Pousson  (Lancet,  Aug.  11,  1900)  strongly  advocates  primary 
nephrectomy  at  an  early  date,  giving  its  mortality  as  21*79  per  cent., 
whereas  that  of  secondary  nephrectomy  is  30*76  per  cent. 

The  cystoscope  and  the  segregator,  used  with  caution  and  full 
knowledge  of  possible  fallacies,  are  very  valuable  in  determining  the 
state  of  the  other  kidney.  Ureteral  catheterisation  is  to  be  condemned 
as  difficult,  dangerous,  fallacious  and  unnecessary  in  these  cases.  The 
importance  of  estimating  the  total  amount  of  urea  and  of  the  share 
taken  by  each  kidney  in  its  excretion  has  been  already  alluded  to 
(p«  I59)«  Undoubted  tuberculous  ulceration  of  the  bladder,  unless 
limited  to  one  ureteral  orifice,  is  a  strong  contra-indication  to  nephrec- 
tomy, but  care  must  be  taken  not  to  mistake  simple  or  septic  cystitis, 
which  is  often  associated  with  tuberculosis  of  the  kidney,  for  tuberculous 
disease. 

Should  the  condition  of  the  other  kidney  still  remain  doubtful  after 
the  available  methods  of  investigation  have  been  exhausted,  then  it 
becomes  necessary  to  examine  it  by  means  of  an  exploratory  incision. 
If  the  segregator  can  be  used  the  need  for  this  operation  can  scarcely 
arise.  Edebohls  (Ann.  of  Surg.,  April,  1898)  advises  a  lumbar 
exploration,  and  this  is  doubtless  the  safer  and  more  certain  method. 
The  disturbance  caused  will  be  comparatively  slight,  and  is  more  than 
balanced  by  the  additional  security  that  the  surgeon  will  feel  when 
proceeding  to  perform  nephrectomy  a  week  later.  The  doubtful 
utility  of  examination  of  the  other  kidney  through  an  abdominal 
incision  has  been  referred  to  above  (p.  186).  Mr.  Barling  (Ann.  of 
Surg.,  March,  1906,  p.  418),  however,  recommends  palpation  of  the 
opposite  kidney  through  an  incision  into  the  peritonaeum  at  the 
anterior  part  of  the  usual  lumbar  incision.  This  plan  is  certainly 
simpler  than  making  a  separate  abdominal  or  lumbar  incision, 
although  it  cannot  be  said  to  be  as  reliable  as  the  latter,  the  eye  being 
more  trustworthy  than  the  hand.  These  remarks  apply  equally  to  the 
two  following  conditions,  calculous  disease  and  hydro-nephrosis. 

ii.  Calculous  pyelitis  or  pyo-nephrosis  where  the  kidney  is  destroyed 
by  long  formation  of  calculi  and  consequent  suppuration,  where 
numerous  calculi  exist  with  sacculation  of  the  kidney,  or  where  a  large 
and  branching  calculus  is  so  embedded  as  to  resist  removal.  These 
indications  for  nephrectomy  have  been  already  considered  under  the 
heading  "  Nephrolithotomy  "  (p.  180),  as  it  is  during  the  performance 
of  this  operation  that  the  question  of  removing  the  kidney  for  the  above 
conditions  will  arise. 

iii.  A  kidney  the  site  of  hydro-nephrosis  or  pyo-nephrosis  in  which 
the  cause  is  irremovable,  or  the  kidney  beyond  hope  of  recovery 
(Barling,  loc.  cit.).  The  treatment  here  will  vary  according  to  the 
degree  to  which  the  disease  has  advanced.  Aspiration,  lumbar 
nephrotomy,  and  drainage,  the  edges  of  the  cyst  being  stitched  in  the 
wound,  and  nephrectomy  have  each  been  advocated  here.  Occa- 
sionally repeated  aspirations  are  sufficient,  as  in  Mr.  Croft's  case 
(Clin.  Soc.  Trans.,  vol.  xiv.  p.  107),  in  which  eight  aspirations 
(through  the  lumbar  region)  within  four  months,   between  three   and 


NEPHRECTOMY. 


197 


four  pints  being  withdrawn  each  time,  sufficed  to  cure  a  hydro- 
nephrosis in  ;i  boy  aged  12.  It  is  noteworthy  that  the  case  was 
distinctly  traumatic  in  origin,  and  that  the  last  fluid  withdrawn  con- 
tained a  very  large  amount  of  albumen.  It  is  for  Buch  cases, 
especially  if  the  interval  between  the  aspirations  lengthens  each  time, 
that  aspiration  should  he  reserved.  This  method  is,  however,  so  rarely 
successful  that  the  surgeon  will,  in  advanced  cases,  have  to  decide 
between  nephrotomy  and  drainage,  and  nephrectomy.  It  is  now 
acknowledged  by  the  advocates  of  the  former  step  that  it  has  given 
less  favourable  results  than  were  expected.  The  time  taken  is  usually 
very  great,  the  frequent  change  of  dressing  necessitated  by  the  con- 
stant soakage  is  most  irksome,  and,  later,  the  wearing  of  a  lumbar 
urinal  is  most  inconvenient,  leading  as  it  often  does  to  an  eczematous, 
raw  area  around  the  sinus.  The  sinus,  moreover,  is  liable  to  become 
foul  and  to  contain  phosphatic  material.  The  tube  also,  which  leads 
into  the  urinal  from  the  sinus,  easily  becomes  blocked,  and  causes 
much  discomfort  from  redistension  of  the  cyst. 

During  the  operation  of  nephrotomy  the  ureter  must  be  carefully 
examined  with  the  view  of  discovering  any  removable  obstruction  in 
the  form  of  a  kink,  valve,  stricture,  or  a  calculus  placed  low  down.  A 
ureteral  catheter  should  be  passed  as  far  as  the  bladder  to  make 
certain  that  the  tube  is  patent. 

In  future,  nephrectomy  will  be  oftener  performed  for  hydro-nephrosis 
where  the  kidney  is  much  altered,  either  as  a  primary  operation  or 
after  allowing  a  sufficient  interval  to  elapse  for  shrinking  of  a  large 
cyst,  but  no  prolonged  delay.  Where,  therefore,  the  patients  are 
young,  with  every  prospect  of  a  long  and  active  life  before  them,  where 
a  month's  drainage  has  failed  to  bring  about  any  considerable  diminu- 
tion in  the  amount  escaping,  and  where  the  fluid  thus  coming  away 
contains  but  a  small  amount  of  urine,  and  where  there  is  evidence  that 
the  other  kidney  is  competent,  the  cyst  and  remaining  kidney  tissue 
should  be  extirpated  from  the  loin  before  it  has  become  more  firmly 
matted  to  the  surrounding  parts.* 

A  papilloma  of  the  renal  pelvis  may  cause  a  large  hydro-nephrosis 
with  destruction  of  the  renal  tissue.  Dr.  Reynolds  (Ann.  of  Surg., 
1904,  vol.  xxxix.  p.  743)  describes  such  a  case  requiring  nephrectomy. 
Albarran  and  Imbert  were  only  able  to  collect  accounts  of  22  cases. 
It  is  possible  that  early  diagnosis  may  enable  the  surgeon  to  save  the 
kidney  by  removing  the  growth  only,  but  it  should  not  be  forgotten 
that  these  growths  are  very  liable  to  become  malignant. 

In  cases  where  the  hydro-nephrosis  is  early  and  due  to  movable 
kidney  nephrorraphy  will  often  suffice  (p.  220).  In  a  few  other  cases 
the  hydro-nephrosis  may  be  due  to  valve  or  stricture  of  the  ureter. 
For  an  account  of  the  different  operations  performed  for  the  relief 
of  these  conditions,  I  may  refer  my  reader  to  the  surgery  of  the 
ureter  (p.  241). 

iv.  Certain  cases  of  malignant  disease.  These  fall  into  two  groups, 
which  must  be  looked  at  separately  from  an  operative  point  of  view. 

*  If  in  hydro-nephrosis,  after  an  exploratory  nephrotomy,  bloody  urine  descends  into 
the  bladder,  the  indication  for  leaving  the  kidney  will  be  greater,  especially  if  the  viscus 
Bhow  a  cortex  of  fair  thickness,  and  is  not  a  mere  sac  with  little,  if  any.  secreting  tissue. 


198  OPERATIONS  ON  THE  ABDOMEN. 

One  group,  the  sarcomata,  occurs  in  children  before  10,  usually  much 
earlier,  before  5.  In  such  cases  the  risks  of  immediate  death  from 
shock,  aided  often  by  peritonitis,  of  early  recurrence,  or  of  death  from 
secondary  deposits  elsewhere,  should  be  put  clearly  before  the  parents, 
together  with  the  certainty  of  an  early  death  if  the  growth  is  left. 

The  other  group,  the  carcinomata,  occurs  usually  in  patients  past 
middle  age. 

In  either  case  an  operation  should  only  be  performed  in  an  early 
stage,  while  the  growth  is  still  internal  to  the  capsule,  and  while  the 
strength,  health,  and  condition  of  the  viscera  are  satisfactory.  On  the 
other  hand,  where  the  history  makes  it  probable  that  the  growth  has 
got  beyond  the  earlier  stage,  when  there  is  any  extension  to  the  lumbar 
glands  or  other  viscera,  when  there  is  nausea,  emaciation,  haemoptysis 
or  a  temperature  inclined  to  fall,  the  time  for  operation  has  gone  by. 
So,  too,  any  ascites  or  oedema  of  the  lower  limb  are  absolute  contra- 
indications. Varicocele  is  so  uncertain  a  symptom,  that  it  cannot  be 
held  to  contra-indicate  operation  (Richards,  Guy's  Hosp.  Rep., 
vol.  lix.). 

With  regard  to  the  frequency  of  secondary  deposits,  the  fact  that  Dr.  Dickinson* 
found  these  to  be  present  in  no  fewer  than  15  out  of  19  cases  strengthens,  very 
decisively,  the  argument  in  favour  of  early  operations  while  these  growths  are  small, 
at  which  time,  moreover,  they  can  be  successfully  attacked  through  a  lumbar  incision 
sufficiently  enlarged  by  the  steps  given  at  p.  205,  or  by  one  made  anteriorly. 

Much  information  may  be  gained  from  a  very  complete  study  of 
sarcoma  of  the  kidney  in  children  by  Mr.  George  Walker,  of  Baltimore 
{Ann.  of  Surg.,  vol.  ii.  1897,  p.  529  ct  seq.).  In  all,  74  cases  in  children 
in  which  nephrectomy  was  performed  are  here  collected.  Of  these  27 
died  from  the  effects  of  the  operation,  28  died  from  recurrence,  14  passed 
out  of  sight,  and  4  remained  well  from  three  to  five  years  after  the 
operation.  The  immediate  mortality  is  therefore  36*4  per  cent.  Though 
still  very  high,  this  is  a  vast  improvement  on  the  earlier  published 
figures  ;  for  instance,  Butlin  (Oper.  Surg,  of  Malig.  Disease,  p.  254) 
gives  60  per  cent.  As  regards  cures,  4  cases,  or  5*4  per  cent.,  may 
be  considered  as  probable  cures,  but  it  is  quite  possible  that  some  of  the 
14  cases  that  passed  out  of  sight  were  cured,  since  they  were  all  of 
them  well  when  last  heard  of;  in  this  case,  5*4  per  cent,  is  too  low. 
Since  the  publication  of  this  paper  one  of  the  supposed  "  cures " 
died  of  recurrence  or  of  independent  and  similar  disease  in  the  other 
kidney,  and  2  incomplete  cases  have  been  reported  to  be  well  after  six 
and  ten  years  respectively.  So  that  the  proportion  of  cures  may  now 
be  said  to  be  at  least  6*7  per  cent.  Briefly,  the  most  important  points 
in  connection  with  four  of  these  successful  cases  are  as  follows  : — 

1.  Israel's  cane.  Boy  aged  14  years.  The  tumour,  about  double  the  size  of  a  man's 
fist,  was  removed  through  a  T-shaped  lumbar  incision.  The  peri-renal  fatty  tissue 
was  freely  excised  after  removal  of  the  growth.     Well  five  years  later. 

2.  Schmidt's  case.  Girl  aged  6  months.  The  tumour  was  the  size  of  a  child's  head, 
and  was  removed  through  an  incision  two  fingers'  breadth  to  the  left  of  the  middle  line 
of  the  abdomen.  The  peritonaeum  was  not  sutured.  The  child  was  well  four  years 
later. 

3.  Aide's  case.  Girl  aged  2  years.     The  tumour,  which  weighed  2§  lbs.,  was  removed 

*  Dis.  of  the  Kidney  and  Urinary  Derangements, 


NEPHRECTOMY. 


through  ;i  transverse  incision  extending  from  the  lumbar  region  to  near  the  middle 
line  of  the  abdomen.  The  child  was  well  four  years  after,  but  she  died  of  Barcoma  of  the 
other  kidney  nine  months  later. 

4.  Abbe's  ease.  Girl  14  months  old.    A  transvei  in  was  again  used,  extending 

from  the  middle  line  of  the  abdomen  to  within  6  cm.  of  the  spine.     The  child  we! 
15  lbs.,  the  tumour  j\  lbs.     The  child  was  well  three  and  a  half  years  later. 

A 11.  >ther  successful  case  is  described  by  Malcolm  {Clin.  Soc.  Trans., 
vols,  xxvii.  and  xxviii.),  the  child  being  in  good  health  two  years  and 
lour  months  after  the  operation. 

Morris  (vol.  i.  p.  603)  concludes  that  the  mortality  from  the  opera- 
tion lias  been  reduced  to  between  20  and  25  per  cent.,  and  thinks  that 
it  is  not  likely  to  fall  much  lower  than  this. 

Heresco  (Thesis,  Paris,  1899,  and  quoted  by  Owen  Richards  in  an 
excellent  paper  in  the  Guy's  Hosp.  Rep.,  vol.  lix.),  in  his  53  cases 
in  infants  operated  upon  since  1890,  found  a  mortality  of  only  17 
per  cent. 

Ultimate  Results. — Over  10  per  cent,  of  the  adult  cases  "  were  '  cured  ' 
in  the  sense  that  they  were  known  to  be  well  at  the  end  of  three  years, 
and  are  not  known  to  have  had  recurrence  since,"  although  the 
results  are  less  favourable  in  children,  about  7  per  cent,  of  "  cures  " 
occurring  (Owen  Richards). 

Mr.  Walker  also  compares  the  length  of  life,  from  the  time  of  the 
discovery  of  the  tumour,  in  cases  not  operated  on  with  those  that  were 
operated  on.  In  68  cases  not  operated  on  the  average  length  of  life 
was  8'o8  months ;  in  the  operation  cases  the  average  was  1677  months, 
an  average  gain,  that  is,  of  8*69  months  by  operation. 

Since  this  disease,  when  left  to  itself,  is  necessarily  alwa}rs  fatal,  a  rate 
of  cure  after  operation  of  nearly  10  per  cent,  constitutes  very  strong 
evidence  in  favour  of  operation  wherever  there  is  a  reasonable  hope  that 
the  whole  of  the  disease  can  be  removed. 

With  earlier  diagnosis  and  improved  technique,  it  is  to  be  hoped 
that  a  still  greater  measure  of  success  will  obtain. 

To  secure  this  improvement  the  following  points  deserve  attention. 
An  exploratory  incision  should  be  made  as  soon  as  obstinate  pain  and 
swelling  (perhaps  revealed  by  an  anaesthetic),  or  free  and  recurrent 
bleeding  shown  to  come  from  one  kidney  by  means  of  the  separator 
or  the  cystoscope  or  both,  call  attention  to  the  possibility  of  a  growth, 
and  before  time  has  elapsed  for  lymphatic  infection.  Where  the  case 
comes  before  the  surgeon  in  a  more  advanced  stage,  he  should  bear 
Mr.  Malcolm's  advice  in  mind.  As  in  the  "  treatment  of  new  growths 
elsewhere,  the  more  definite  the  outline  of  the  tumour,  the  more  mobile 
it  is,  the  slower  its  growth,  the  better  the  state  of  the  patient's  health 
— in  fact,  the  stronger  the  evidence  that  the  patient  is  only  locally 
affected — *the  more  likely  is  operative  treatment  to  be  followed  by 
prolonged  immunity  from  disease."  Cases  may  be  observed,  on  the 
other  hand,  in  which  the  tumour  has  no  definite  outline,  being  fixed 
to  and  incorporated  with  the  neighbouring  structures,  so  as  to  be 
absolutely  immobile,  being  also  of  very  rapid  growth  and  accompanied 
by  extreme  emaciation.  Such  cases  are  obviously  unsuitable  for  surgical 
interference.  "Before  the  operation  every  precaution  should  be  taken 
against  shock.  Thus  the  limbs  should  previously  be  bandaged  in  cotton 
wool,  the  site  of  the  wound  only  exposed,  the  head  kept  low,  injections 


200  OPERATIONS  ON  THE  ABDOMEN. 

of  brandy  and  strychnine  should  be  ready,  ether  administered,  warmth 
maintained  by  operating  on  a  hot-water  table  when  possible,  and  warm 
irrigating  fluid  used.  Finally,  an  assistant  should  always  be  at  hand  to 
perform  saline  infusion,  and  this,  if  used,  should  be  resorted  to  before 
the  close  of  the  operation,  when  the  condition  of  shock  may  be  irre- 
mediable."* 

During  the  operation  itself  the  incision  must  be  sufficiently  free.  The 
lumbar  one,  carried  very  freely  forward  t  (p.  205),  will  give  sufficient 
room  for  all  except  large  tumours.  The  peritonaeum  will  only  be 
opened  when  the  growth  is  very  large  or  adherent.  Where  grave 
shock  is  imminent,  haemorrhage  may  be  controlled  by  forceps  left 
in  situ  for  thirty-six  or  forty-eight  hours.  It  is  easy  to  prevent  a 
child  from  rolling  on  to  these  by  packing  the  patient  firmly  on  either 
side  with  pillows  in  a  cot.  Finally,  as  Mr.  Malcolm  has  shown,  every 
vestige  of  the  capsule,  and  all  fat  adjacent  to  it,  together  with  an}-  fat 
or  glands  about  the  renal  vessels,  should  be  removed. 

The  removal  of  renal  growths  through  an  anterior  trans-peritonaeal 
route  used  to  be  attended  by  about  twice  the  mortality  of  the  lumbar 
operation.  This  was  chiefly  due  to  greater  risk  of  sepsis,  but  also  to  the 
fact  that  this  method  was  used  particularly  for  very  large  growths, 
considered  to  be  too  big  to  be  removed  through  the  loin. 

In  later  cases,  as  shown  by  Heresco  (loc.  cit.),  there  has  been  very 
little  difference  in  the  mortalities  of  the  two  methods. 

Morris  strongly  advocates  a  combination  of  the  lumbar  and  lateral 
trans-peritonajal  methods  for  malignant  tumours  of  the  kidney.  He 
first  explores  through  the  linea  semilunaris  and  examines  the  con- 
nections of  the  tumour ;  then,  after  temporarily  closing  this  incision, 
he  enucleates  the  kidney  through  the  usual  incision  in  the  loin.  The 
original  wound  is  then  reopened  and  the  peritonaeum  raised  from  the 
tumour,  the  pedicle  secured,  and  the  growth  pushed  and  delivered 
through  the  anterior  incision. 

It  is  claimed  that  this  method  enables  the  surgeon  to  thoroughly 
explore  the  tumour  and  to  determine  the  presence  or  absence  of  early 
secondary  growths  in  the  peritonaeum  and  abdominal  viscera  before 
beginning  the  enucleation  ;  also  that  the  risk  of  injury  of  the  great 
vessels  is  less  than  if  either  an  anterior  or  posterior  incision  is  used 
alone  ;  that  the  delivery  of  the  tumour  forwards  is  facilitated  by  a  hand 
in  the  posterior  wound.  Moreover,  the  lumbar  wound  is  the  best  for 
drainage. 

v.  Certain  cases  of  injury.  These  are  very  rare,  and  fall  into  the 
following  groups :  (a)  Where  an  injured  kidney  protrudes  from  a 
wound  of  the  abdomen,  usually  the  loin,  (b)  In  some  cases  of  non- 
penetrating wound  of  the  kidney>  as  when  it  is  ruptured  from  a  fall  or 
blow.     (1)  Where  haematuria  does  not  yield  to  treatment,}  the  bleeding 

*  Dr.  Abbe  strongly  advises  the  use  of  the  Trendelenberg's  position  as  emptying  the 
blood  from  the  growth  into  more  important  parts,  and  the  injection  of  strong  coffee  and 
brandy  into  the  rectum  after  the  operation. 

t  Dr.  Abbe  used  a  similar  one  in  his  two  successful  cases  mentioned  above. 

J  In  Mr.  Rawdon's  case  (loc.  infra  cit.')  nephrectomy  was  performed  for  haemorrhage 
after  an  injury,  but  at  rather  a  later  date — e.g.,  on  the  seventeenth  day  after  the  fall — to 
prevent  blood  from  entering  the  bladder  and  increasing  the  acute  cystitis  present.  Here 
Hi''  hematuria  had  diminished  at  first,  and  subsequently  increased. 


NEPHRECTOMY.  201 

being  well  marked,  or  latent  and  insidious,  giving  evidence  indirectly  of 
it--  existence  by  the  increasing  pallor,  the  failing  pulse,  impending 
Byncope,  and  perhaps  a  swelling  in  the  loin,  as  in  case  No.  20,  Table, 
p.  219.  (2)  Later  on,  when  the  injured  kidney  is  setting  up  serious 
suppuration,  which  does  not  yield  to  drainage.  (3)  Forruptured  ureter 
and  traumatic  hydro-nephrosis.  Mr.  Barker  lias  recorded  (Lancet, 
Jan.  17,  1885)  a  most  successful  case,  in  which,  after  other  treatment 
had  failed,  he  removed  a  kidney  three  months  after  the  rupture. 

The  child,  aged  3!.  had  been  run  over,  but  beyond  some  bruising  and  one 
clot  passed  there  was  aothing  to  point  to  injury  of  the  urinary  tract.  Having  left 
the  hospital  in  a  fortnight,  apparently  convalescent,  he  was.  a  few  days  later,  admitted 
with  a  fluctuating  swelling  in  the  right  loin.  This  increasing,  was  aspirated,  the  fluid 
yielding  \  per  cent,  of  urea.  The  swelling  was  subsequently  drained,  and  the  drainage- 
tube  becoming  blocked  with  phosphatic  deposits,  and  thus  causing  a  good  deal  of  con- 
stitutional disturbance,  the  kidney  was  removed.  It  proved  to  be  healthy,  the  ureter 
being  torn  across  just  below  it. 

At  the  present  time,  if  this  condition  be  discovered  at  an  exploration 
for  traumatic  hydro-nephrosis,  it  may  be  found  possible  to  save  the 
kidney  by  performing  a  plastic  operation  on  the  ureter.  Tilden  Brown, 
however,  failed  to  discover  a  rent  in  the  ureter  until  suppurative 
nephritis  had  developed,  and  he  was  forced  to  remove  the  kidney  about 
seven  weeks  after  the  injury  (Ann.  of  Surg.,  1905,  vol.  xli.).  "When 
the  ureter  is  accidentally  divided  during  a  pelvic  operation,  if  the 
calamity  is  discovered  at  once  immediate  anastomosis  should  be  per- 
formed. If  this  fails,  and  suppurative  nephritis  and  a  fistula  follow, 
then  nephrectomy  may  become  necessary. 

(c)  Penetrating  wounds.  Very  rarely  indeed  nephrectomy  may  be 
called  for  here  (1)  when  haemorrhage  does  not  yield  to  treatment  aided 
by  exploration  and  plugging;  (2)  when  a  urinary  fistula  persists  after 
such  a  wound  in  certain  cases — e.g.,  when  the  other  kidney  is  healthy. 
('/)  Gunshot  wounds.  Owing  to  the  increase  of  revolver-injuries  and 
recent  advances  in  abdominal  surgery,  this  matter  has  lately  received 
much  attention.*  Whether  in  civil  or  military  practice,  gunshot  wounds 
of  the  kidney  are  only  too  likely  to  be  complicated  with  injuries  of  the 
intestines,  liver,  and  spine.  When,  in  the  course  of  an  exploratory 
operation  in  the  case  of  a  gunshot  wound  of  the  abdomen,  the  kidney 
is  found  to  be  the  seat  of  haemorrhage,  if  uncontrollable  by  other  means, 
nephrectomy  should  be  performed. 

vi.  In  a  very  few  cases  of  movable  kidney.  Where  nephrorraphy 
has  been  properly  performed,  as,  e.g.,  by  the  method  given  at  p.  224, 

*  As  might  be  expected,  American  surgeons  have  not  been  slow  to  avail  themselves  of 
their  opportunities.  Prof.  Kancrede  {Ann.  of  Surg.,  June,  1887,  p.  480)  suggests  that 
where  the  renal  or  splenic  artery  is  cut  by  a  bullet  the  viscus  should  be  removed,  as  gan- 
grene is  inevitable.  Dr.  Parkes  (loe.  supra  cit..  November,  1887,  p.  379),  in  a  case  of  bullet- 
wound  of  the  abdomen,  having  sewn  up  five  perforations  of  the  intestine,  found  that  the 
left  kidney  was  perforated.  The  haemorrhage  was  very  slight  at  this  time.  After  doing 
well  for  twenty-four  hours,  the  patient  began  suddenly  to  fail,  and  died,  collapsed,  from 
haemorrhage  from  the  kidney.  Dr.  Parkes  regretted  that  he  had  not  performed  nephrec- 
tomy. Dr.  C.  Briddon,  of  New  York  {Ann.  of  Surg.,  1894,  vol.  i.  p.  641),  in  three  cases 
explored  an  injury  to  the  kidney  by  a  lumbar  incision  at  a  date  varying  from  one  to  four 
weeks  after  the  accident,  and  by  evacuating  bloody  urine,  foetid  clots,  irrigating,  and 
tamponnading  with  iodoform  gauze,  saved  his  patients  from  a  state  of  grave  peril. 


202  OPERATIONS  ON  THE  ABDOMEN. 

nephrectomy  will  never  he  required.  In  a  few  cases  nephrorraphy  will 
fail,  owing  to  the  complication  of  organic  disease,  as  in  the  instances 
given  at  p.  221. 

vii.  For  a  few  rare  diseases  of  the  ureter.  Israel's  case  (quoted  at 
p.  168)  of  chronic  ureteritis,  for  which  nephrectomy  was  performed,  may 
be  again  referred  to  here.  Another  very  instructive  case,  one  of  ureteral 
papillomata,  is  described  by  Le  Dentu  and  Albarran  (Bull,  de  V 'Acad, 
de  Med.,  No.  9,  1899)  : 

Male.  33,  had  had  frequent  attacks  of  renal  colic  for  which  nephrotomy  had  been 
performed  without  benefit.  A  diagnosis  of  ureteral  papilloma  was  arrived  at  by  means 
of  the  cystoscope.  The  kidney  and  ureter  were  therefore  removed.  The  kidney  was 
hydro-nephrotic,  and  the  ureter  contained  two  papillomata,  one  three-quarters  of  an 
inch  below  the  renal  pelvis,  the  other  at  the  vesical  orifice. 

viii.  Hydatid  disease  of  the  kidney.  Jerosch  (Centralbl.  f.  Chir., 
No.  38,  1899)  has  recently  recorded  two  cases  of  nephrectomy  for  this 
rare  condition.  In  the  first  case,  death  took  place  on  the  third  day 
from  exhaustion ;  the  second  case  recovered. 

The  results  of  nephrectomy  for  hydatid  disease  have  been  poor,  but 
in  several  instances  this  was  due  to  excision  of  the  only  kidney,*  a 
mistake  which  should  be  avoidable  at  the  present  day  by  adopting  the 
methods  of  thorough  examination  advocated  at  p.  149. 

Morris  points  out  that  the  structure  of  the  kidney  may  not  be 
seriously  affected  by  hydatid  disease,  and  that  nephrotomy  is  therefore 
more  suitable  than  nephrectomy,  which  should  only  be  adopted  when 
there  is  "  suppuration  of  the  kidney,  or  rupture  of  the  hydatid  cyst 
into  the  lung  or  peritoneum."  Secondary  nephrectomy  may  be  found 
to  be  required  if  nephrotomy  and  drainage,  or  excision  of  the  cyst,  fail 
to  cure  the  disease. 

ix.  Cystic  disease.  Surgical  interference  for  polycystic  disease  of 
the  kidney  has  been  generally  considered  to  be  unwise,  because  of  the 
frequenc}'  of  bilateral  disease,  and  the  belief  that  the  second  kidney 
may  rapidly  develop  the  same  disease  after  the  removal  of  the  first. 
There  are  exceptional  cases,  however,  in  which  nephrectomy  is  called 
for.  These  are  cases  in  which  the  disease  has  been  proved  to  be 
unilateral,  and  the  symptoms  are  grave  from  rapid  growth  and 
increasing  distension,  and  especially  when  repeated  and  profuse 
hematuria  occurs. 

Morris  performed  nephrectomy  in  four  cases.  Two  of  the  patients  were 
well  three  and  seven  years  later,  one  died  of  similar  disease  in  the  other 
kidney  four  months  later,  and  the  other  died  on  the  second  day  from 
suffocation  due  to  vomiting. 

Morris  (vol.  i.  p.  66)  advocates  his  combined  operation,  with 
examination  of  the  other  kidney,  by  palpation,  which  he  considers 
satisfactory  in  these  cases,  any  enlargement  being  easily  detected. 
When  the  condition  is  discovered  for  the  first  time  during  a  lumbar 
exploration,  the  other  kidney  should  be  explored  through  the  loin,  or 
through  the  anterior  end  of  the  wound  already  made  (Barling,  loc.  cit.), 
before  proceeding  to  excise  the  diseased  kidney.  This  course  may  not 
be  always  necessary,  for  the  cystoscope,  the  segregator,  and  estimation 

*  Houzel,  quoted  by  Morris,  vol.  i.  p.  681. 


NKIMIIIKCTOMY.  203 

of  the  urea,  may  have  afforded  ample  evidence  of  the  condition  of  the 
other  kidney.  It  may  be  easy  to  tell  that  the  kidney  which  is  displayed 
in  the  wound  is  so  diseased  that  it  can  take  very  little  or  no  part  in 
the  excretion.  In  two  cases  known  to  meat  Guy's  Hospital,  it  was 
considered  to  he  unnecessary  to  explore  the  opposite  kidney  for  these 
reasons.  Both  of  them  did  well.  The  first  had  repeated  and  severe 
attacks  of  unilateral  hematuria,  which  was  thought  to  be  due  to  malig- 
nant growth  ;  the  other  was  diagnosed  as  a  tuberculous  pyo -nephrosis. 
It  must  not  he  forgotten  that  a  large  cystic  kidney  may  not  be  palpable 
through  the  parietes.  Dr.  Bevan  (Ann.  of  Surg.,  1906,  vol.  xxxix. 
p.  467)  removed  a  large  polycystic  kidney  which  he  discovered  during 
an  exploration  for  hematuria  with  severe  pain  on  one  side.  The  con- 
dition of  the  other  kidney  was  not  known,  but  the  patient  recovered 
and  was  well  a  year  later.  Dr.  Parker  Syms  (loc.  cit.,  p.  598)  was 
unable  to  discover  any  enlargement  of  one  kidney  in  a  very  thin  woman 
with  flaccid  abdomen,  and  he  therefore  judged  that  it  was  not  enlarged; 
therefore  when  the  other  kidney,  which  was  greatly  enlarged,  was 
proved  to  be  cystic  on  exploration,  it  was  removed.  The  patient  was 
quite  well  a  fortnight  later.  It  is  needless  to  say  that  the  after-history 
is  too  short.  Dr.  Hay  lies  (loc.  cit.,  p.  599)  candidly  reported  the 
removal  of  one  of  two  cystic  kidneys,  the  patient  dying  urspmic  a 
fortnight  later. 

x.  Aneurysm  of  the  renal  artery.  Prof.  W.  W.  Keen  (Philad.  Med. 
Joum.,  May  5,  1900)  reports  a  successful  case  of  nephrectomy  for  this 
rare  form  of  aneurysm  : 

The  patient  was  a  lady,  aged  45,  who  had  suffered  for  about  five  years  from  severe 
attacks  which  began  with  chilly  sensations,  followed  by  nausea  and  considerable  rises 
of  temperature.  These  attacks  lasted  a  variable  time  and  were  thought  to  be  "bilious." 
Once  ouly,  during  the  last  attack,  there  was  a  small  amount  of  blood  in  the  urine.  A 
large  tumour,  thought  to  be  probably  a  hydro-nephrosis,  was  found  occupying  the  whole 
right  ilio-costal  space,  and  extending  from  the  right  flank  to  a  point  about  5  cm.  beyond 
the  middle  line.  The  tumour,  which  was  removed  without  great  difficulty,  was  found  to 
consist  of  the  kidney  flattened  out  on  the  surface  of  a  large  aneurysm  of  a  branch  of  the 
right  renal  artery. 

Prof.  Keen  gives  abstracts  of  twelve  similar  cases,  two  of  which  were 
operated  on.  Recovery  took  place  in  both  these.  Prof.  Keen  remarks 
that  "  there  is  nothing  peculiar  about  any  of  the  three  operations  other 
than  the  danger  of  haemorrhage,  especially  from  the  pedicle.  In  my 
own  case  the  pedicle  was  broader  than  I  have  ever  encountered  in  any 
prior  case  of  nephrectomy,  so  that  I  had  to  tie  it  in  seven  different 
sections.  All  three  of  the  operative  cases  have  terminated  in  recovery, 
a  most  encouraging  outlook  for  the  future." 

Operations. 

These  are  :  A.  Through  the  Lumbar  Region.  B.  Through  the 
Abdominal  Wall,  and  the  Peritonaeum  as  well — (a)  by  an  incision 
at  the  outer  edge  of  the  rectus  ;  (b)  by  one  in  the  linea  alba.  C.  Through 
the  Abdominal  "Wall  without  opening  the  Peritonaeum.  These 
methods  are  compared  at  p.  212.  D.  A  Combination  of  the  Abdo- 
minal and  Lumbar  Incisions.  E.  Morris's  Combined  Method. 
F.  Knowsley  Thornton's  Combined  Method. 


204  OPERATIONS    OX    THE   ABDOMEN. 

A.  Lumbar  Nephrectomy. 

Operation. 

The  position*  of  the  patient  and  the  earlier  steps  are  much  as  those 
already  given  in  the  account  of  nephrolithotomy,  p.  172. 

When  the  lumbar  fascia  has  been  slit  up  and  the  fat  around  the 
kidney  torn  through,  this  organ  should  be  well  thrust  up  by  an 
assistant  making  careful,  steady  pressure  with  his  fist  against  the 
abdominal  wall ;  the  wound  being  now  widely  dilated  with  retractors,  the 
surgeon  examines  the  kidney,  and  has  next  to  decide  on  three  points  : 
(1)  Is  removal  required?!  (2)  Will  more  room  be  wanted?  If  so, 
the  incision  already  made,  slightly  oblique  and  about  half  an  inch 
below  the  twelfth  rib,  should  either  be  converted  into  a  T-shaped  one 
by  another  made  downwards  from  its  centre,  or  at  its  posterior 
extremity,  along  the  outer  edge  of  the  quadratus  lumborum,  or  con- 
tinued downwards  and  forwards,  as  described  under  "Nephro-lithotomy" 
(vide  p.  173).  Additional  room  may  also  be  gained  by  an  assistant 
slipping  his  fingers  under  the  lower  ribs  and  drawing  them  forcibly  up- 
wards. (3)  Is  the  kidney  firmly  matted  down  or  no  ?  If  there  has 
been  no  surrounding  inflammation,  the  extra-peritonaeal  fat,  the  perito- 
naeum, and  colon  will  be  readily  separated  by  the  finger  working  close 
to  the  kidney  until  the  pelvis  and  vessels  are  reached.  But  if  inflam- 
mation has  caused  firm  adhesion  and  matting  down  of  the  kidney  to 
adjacent  parts,  the  altered  fat  and  thickened  and  adherent  capsule  must 
be  divided  down  to  the  kidney  itself,  and  this  gradually  enucleated  (partly 
with  the  finger,  partly  with  a  probe-pointed  bistoury)  from  out  of  its 
capsule,  which  is  left  behind.  This  method  is  not  to  be  recommended 
unless  it  is  absolutely  necessary,  because  disease  may  be  left  behind, 
troublesome  fistula  may  persist,  or  a  hematoma  may  form  within  the 
rigid  walls  of  the  cavity  (Morris,  Lancet,  Jan.  1,  1898). 

The  only  guide  in  such  a  case  is  the  tissue  of  the  kidney  itself,  close 
to  which  the  finger  and  knife  must  be  kept. 

A  case  of  Mr.  H.  Marsh's  well  shows  this  difficulty  : 

Removal  of  the  kidney  could  not  here  be  effected,  owing  to  its  size  and  the  firmness 
with  which  it  was  embedded  in  the  surrounding  condensed  areolar  tissue.  That  part 
of  the  kidney  which  had  been  exposed  was  accordingly  transfixed  with  a  strong  double 
ligature,  and  cut  away.  Complete  suppression  of  urine  followed  the  operation,  and  the 
patient  died  in  about  thirty  hours.  At  the  post-mortem  examination  the  remaining 
part  of  the  right  kidney  and  its  ureter  were  found  to  be  so  firmly  embedded  in  dense 
cicatricial  material  that  they  were  dissected  out  only  with  difficulty.  The  kidney 
itself  was  converted  into  numerous  sacculi,  in  the  walls  of  which,  however,  some  remains 
of  renal  structure  could  still  be  traced.  The  opposite  kidney  weighed  G  oz.  Its  capsule 
was  adherent,  and  there  were  two  or  three  cysts  on  its  surface.  On  section  its  structure 
looked  somewhat  confused  and  cloudy,  but  its  condition  was  not  such  as  to  indicate 
advanced  disease. 

Mr.  Greig  Smith  stated  (Ahdom.  Surg.,  p.  508)  that,  in  cases  of  old- 
standing  suppuration  with  great  enlargement,  the  vena  cava  and  the 

*  Additional  care  should  be  taken  to  open  out  the  space  between  the  last  jib  and  the 
crest  of  the  ilium  by  the  arrangement  of  pillows  underneath  the  loin  ;  the  precautions 
given  to  avoid  shock  (p.  199)  must  also  be  taken  here. 

f  This  question  has  already  been  alluded  to  in  the  case  of  a  strumous  kidney  incised 
and  drained  (p.  194)  :  in  that  of  a  kidney  much  damaged  by  one  or  more  calculi,  under 
the  subject  of  nephro-lithotomy  (p.  180)  ;  and  in  the  case  of  hydro-nephrosis  (p.  196). 


NEPHRECTOMY.  205 

aorta  may  be  intimately  adherent  to  the  capsule.  "  One  such  case  was 
nitt  with  in  the  post-mortem  room  of  the  Bristol  Infirmary;  here  it 
was  simply  impossible,  after  (lath,  to  dissert  apart  the  venous  wall  and 
the  renal  capsule.  In  another  case,  for  similar  reasons,  the  organ 
could  not  have  been  removed  by  any  proceeding  claiming  to  be 
ignised  as  surgical."* 

If  further  room  is  still  required,  this  may  be  easily  and  effectually 
gained  by  making  use  of  additional  incisions,  as  recommended  under 
"Nephro-lithotomy/'or  by  adopting  the  method  advocated  by  Prof.  Konig, 
of  Gottingen  (Cent./.  Chir.,  1886,  Hft.  35;  Ann.  of  Surg.,  November, 
1886,  p.  445).  This  surgeon,  having  found  great  difficulty  in  getting  free 
access  to  the  kidney  by  the  ordinary  lumbar  incision,  cuts  througb 
the  soft  parts  vertically  downwards  along  the  border  of  the  erector 
spimr  to  just  above  the  iliac  crest.  He  then  curves  the  incision  towards 
the  navel,  and  ends  at  about  the  outer  border  of  the  rectus,  if  necessary 
going  througb  this  muscle  to  the  umbilicus.  It  may  be  often  advisable 
to  make  the  perpendicular  cut  oblique,  running  in  a  flat  curve  into  the 
umbilical  part.  All  the  muscles  are  incised  quite  down  to  the  perito- 
naeum. This  method  gives  a  surprisingly  free  entrance,  but  it  can  be 
much  improved  by  introducing  the  hand  through  the  perpendicular 
part  of  the  cut,  separating  the  peritonaeum  in  front  and  pushing  it 
forwards.  Prof.  Konig  proposes  to  call  this  the  retro-peritonaeal  lumbo- 
abdominal  incision.  If  sufficient  space  is  not  thus  afforded,  or  if,  for 
diagnostic  or  operative  purposes,  it  is  desirable  to  approach  the  tumour 
from  the  abdominal  cavity,  the  peritonaeum  can  be  divided  in  the  trans- 
verse cut.  If  infective  material  is  to  be  removed,  this  peritonaea! 
opening  must  be  carefully  looked  after.  Tbe  need  of  free  division  of 
muscular  fibres,  involving  undue  liability  of  ventral  hernia,  is  a  serious 
objection  to  adopting  Konig's  incision. 

Very  large  kidneys  and  renal  tumours  can  be  got  out  through  very 
free  lumbar  incisions.  I  may  state  here  that  I  twice,  in  1890,  removed 
kidneys  eight  inches  long  through  the  very  limited  ilio-costal  space  of 
little  children  aged  respectively  3  and  3^.  One  was  a  case  of  sarcoma, 
the  other  of  cystic  kidney.  Both  made  excellent  recoveries ;  but  as 
in  the  former  the  renal  vein  was  thrombosed  with  growth,  it  was  clear 
that  a  few  months  would  see  the  end.  In  each  case' the  lumbar  incision 
was  carried  forward  very  freely,  and  the  long  axis  of  the  tumour 
brought  out  in  that  of  the  wound. 

In  both  Abbe's  successful  cases  of  sarcoma  (ride  supra,  p.  198) 
long  transverse  lumbar  incisions  were  found  to  give  ample  room,  in 
the  second  case  the  tumour  weighing  7J  lbs.  in  a  child  only  14  months 
old.     Many  other  cases  might  be  quoted. 

The  danger  of  ventral  hernia  is  guarded  against  by  using  deep 
sutures,  by  allowing  only  gentle  movements  at  first  when  the  patient 
gets  up,  and  by  the  use  of  a  support.  By  these  means  the  risk  of 
hernia  may  be  reduced  to  a  minimum. 

*  As  will  be  seen  from  case  22  in  the  table  at  p.  219,  in  which  I  injured  the  vena 
cava  in  the  case  of  a  large  tubercular  kidney,  very  adherent,  the  most  difficult  case  I 
have  met  with.  In  a  case  of  attempted  nephrectomy  (Amer.  Journ.  Med.  Set.,  1882, 
vol.  ii.  p.  116)  the  removal  of  the  organ  was  rendered  impossible,  not  only  by  its  adhesions 
to  the  tissues  around,  but  also,  as  was  proved  post  mortem,  to  the  colon  and  pancreas 
as  well. 


206  OPERATIONS  ON  THE  ABDOMEN. 

When  the  kidney  has  heen  sufficiently  enucleated  either  out  of  its 
capsule,  or,  together  with  this,  out  of  the  peri-renal  fat,  the  vessels 
and  ureter  must  be  dealt  with.  The  latter  should  be  taken  first,  as 
this  step,  especially  if  the  ureter  be  enlarged,  will  facilitate  dealing 
with  the  vessels. 

If  the  ureter  is  dilated,  and  contains  foul  pus  or  tubercular  matter, 
it  should  be  tied  with  catgut  and  divided  as  low  down  as  the  pelvic 
brim  or  lower  if  necessary,  and  the  stump  carefully  cleaned  out  with  a 
sharp  spoon  and  dusted  with  iodoform,  or  cauterised  with  strong 
carbolic  acid.  The  diseased  ureter  should  be  removed  with  the  kidney, 
its  lower  extremity  having  been  clamped  to  prevent  infection  of  the 
wound. 

The  vessels  are  then  tied  in  at  least  two  bundles  with  sufficiently 
stout  carbolised  silk,  or  chromic  gut.  This  is  passed,  with  an 
aneurysm-needle  of  sufficient  length  and  suitable  curve,  through  the 
centre  of  the  bundle,  each  half  of  which  is  tied  separately,  and 
finally  one  of  the  ligatures  is  thrown  round  both  halves  together. 
In  passing  the  ligatures,  they  should  be  pushed  well  in  towards  the 
spine,  so  as  to  leave  ample  room  between  them  and  the  kidney  to 
prevent  all  risk '  of  their  slipping.  If  the  kidney  can  be  raised  out 
of  the  wound,  passing  the  ligature  is  much  simplified.  If  this  is 
impossible,  the  surgeon  may  find  help  by  having  the  lower  ribs  well 
pulled  up  by  an  assistant,  while  another  keeps  the  kidney  well  up 
by  pressure  against  the  abdominal  walls,  light  being  also  thrown  in,  in  case 
of  need,  by  a  forehead  mirror  or  electric  lamp.  While  the  ligatures 
are  being  tied  and  the  pedicle  divided,  no  tension  should  be  put  upon 
the  vessels. 

As  soon  as  the  ligatures  are  secured  in  position,  the  pedicle  is  snipped 
through  at  a  safe  distance  from  them  with  blunt-pointed  scissors.  If  the 
pelvis  of  the  kidney  contains  foul  or  tubercular  pus,  and  if  there  is 
room,  a  large  pair  of  Spencer  Wells's  forceps  should  be  put  on  the  ureter, 
and  the  pedicle  cut  through  between  this  and  the  ligatures,  so  as  to 
prevent  the  escape  of  septic  material.  If  any  hiemorrhage  now  takes 
place,  it  is  probably  due  to  some  vessel*  not  being  included,  or  to  an 
artery  having  slipped  through  the  knot  owing  to  the  parts  being 
stretched  at  the  moment  of  ligature.  The  bleeding  point,  to  which 
the  ligatures  will  act  as  guides,  is  now  secured  with  forceps  and 
ligatured.     The  ligatures  are  then  cut  short. 

When  a  pedicle  presents  especial  difficulties  from  its  shortness,  thick- 
ness, and  the  way  in  which  it  is  overlapped  by  the  kidney,  a  preliminary 
ligature  should  be  applied  and  the  kidney  cut  away  well  in  front  of 

*  The  late  Mr.  Greig  Smith  (Joe.  supra  cit.~)  gave  the  following  practical  hints  as  to 
the  vessels  : — The  veins  are  a  good  deal  larger  than  the  arteries,  and  overlap  them.  At  the 
hilum  the  veins  branch  quite  as  much  as  the  arteries — i.e.,  four  or  five  times — and  the 
subdivision  extends  farther  towards  the  middle  line.  It  is  very  frequent  for  two  or  more 
trunks  to  represent  the  renal  vein,  and  sometimes  surround  the  artery.  The  want  of 
uniformity  in  the  renal  vessels  is  against  the  possibility  of  ligaturing  the  artery  and  vein 
separately.  In  many  cases  this  will  be  found  impossible  ;  in  none  is  it  necessary. 
Indeed,  the  walls  of  the  veins,  by  acting  as  a  sort  of  padding,  may  add  to  the  safety  of 
ligatures,  preventing  the  thread  from  slipping.  Mr.  Greig  Smith  further  states  that  the 
only  deaths  as  yet  recorded  from  secondary  haemorrhage  were  in  two  cases  where  the 
vessels  were  separately  tied. 


NEPHRECTOMY.  207 

it,*  a  Btep  which  will  give  access  to  the  vessels  and  ureter;  a  double 
ligature  is  then  applied  behind  the  temporary  ligature,  which  is  now 

removed.  Again,  where  the  pedicle  is  very  short,  a  portion  of  kidney 
may  be  left  to  ensure  the  ligature  retaining  a  sale  hold.  I  was  obliged 
to  adopt  this  course  in  a  case  of  nephrectomy  for  calculous  pyelitis  in 

which  I  had  removed  twelve  stones  a  year  before  (case  No.  7,  Table, 
p.  -'i/).  A  sinus  persisted,  which  became  abominably  septic.  As  the 
stump  of  the  kidney  was  foetid,  I  inserted  no  sutures,  and  packed  the 
wound  with  strips  of  sal  alembroth  gauze  wrung  out  of  turpentine. 
The  patient  made  a  good  recovery. 

A  modification  of  the  method  of  leaving  a  portion  of  the  kidney 
to  form  the  pedicle  may  be  made  use  of  in  cases  of  kidneys  of  large 
size  which  cannot  be  brought  through  the  wound.  In  such  cases,  the 
vessels  having  been  secured  by  a  temporary  ligature  or  by  Spencer 
"Wells's  forceps,  the  kidney  should  be  cut  away  in  separate  portions, 
thus  doing  away  with  the  struggle  required  in  bringing  out  a  large 
kidney  and  the  risks  of  producing  serious  shock  by  pulling  on  the 
vessels.! 

Another  means  of  treating  the  pedicle,  where  this  is  short  and  matted 
down,  is  to  cut  it  through  piece  by  piece,  securing  each  bleeding  point 
with  compression  forceps,  and  tying  them  off  one  by  one.  Or  the  vessels 
may  be  underrun,  as  in  excision  of  the  knee,  but  on  a  larger  scale  and 
more  en  masse. 

By  such  methods  as  the  above  the  risk  of  wounding  the  cava  or  aorta 
is  avoided.  If  the  amount  of  kidney  left  is  small,  it  will  no  doubt 
atrophy  and  give  no  further  trouble,  but  if  large,  some  sloughing  will 
probably  take  place  ;  in  such  a  case,  iodoform  or  glutol  should  be  dusted 
on  to  the  stump  and  free  drainage  provided. 

Another  difficulty  which  may  be  present  now  is  caused  by  the 
kidney  having  contracted  adhesions  to  the  peritonaeum  and  some  of 
its  contents. 

I  have  three  times  opened  the  peritonaeum  when  using  the  lumbar 
incision.  To  one  case,  a  nephrolithotomy,  I  have  alluded  at  p.  178  ; 
the  other  two  were  cases  of  growth  and  tubercular  pyelitis,  for  which  I 
was  removing  the  kidney.  All  three  cases  recovered.  The  opening,  in 
the  two  latter  cases  a  small  one,  was  at  once  covered  by  an  aseptic 
sponge,  and  sutured  with  fine  chromic  gut. 

*  Dr.  Lange  (New  York  Surg.  Soc,  Nov.  22,  1S86  ;  Ann.  of  Surg.,  April,  1887)  has 
shown  that  in  a  case  in  which  he  adopted  this  course  no  sloughing  took  place,  as  the 
thick,  flesh^v  part  of  the  pedicle  beyond  the  ligatures  was  gradually  absorbed  by  the 
health}'  granulations  of  the  wound,  which  remained  aseptic.  Dr.  Leopold  (Arch,  fur 
Gijniili..  xix.  i),in  a  case  of  nephrectomy,  tied  the  pedicle  in  three,  and  left  a  triangular 
portion  of  the  kidney  parenchyma,  in  order  to  prevent  haemorrhage.  The  patient  made  a 
good  recovery. 

f  The  question  of  how  far  serious  shock  may  be  induced  by  tightening  ligatures  on 
parts  in  such  intimate  relation  with  the  abdominal  sympathetic  centres  is  one  of  great 
importance  and  needs  further  investigation.  According  to  Mr.  Barker  {Dirt,  of  Surg., 
vol.  ii.  p.  49),  who  has  taken  the  trouble  to  have  the  pulse  watched  carefully  at  this  stage 
of  the  operation,  it  is  not  much  affected  to  the  touch,  but  a  sphygmographic  tracing  taken 
in  one  case  showed  some  irregularity  during  the  necessary  handling  of  the  kidney,  and 
increased  arterial  tension  when  the  pedicle  was  ligatured.  In  my  own  experience,  any 
alterations  in  the  pulse  are  occasional  only,  and  quite  inconstant.  Dragging  on  the 
pedicle  is  much  more  likely  to  produce  shock. 


208  OPERATIONS  ON  THE  ABDOMEN. 

Where  it  is  certain  that  septic  fluid  from  the  kidney  has  entered  a 
wound  in  the  peritonaeum,  the  surgeon  should,  after  the  operation  is 
completed,  make  a  small  opening  in  the  lower  part  of  the  linea  alba, 
wash  out  the  peritonaeal  cavity  with  boiled  water,  and  place  a  drainage- 
tube  in  Douglas's  pouch,  this  being  regularly  emptied  as  often  as  is 
requisite.  Mr.  Page,  of  Newcastle,  adopted  this  plan  in  two  cases, 
with  entire  success  (Lancet,  vol.  i.  1893,  p.  999). 

The  question  may  arise  as  to  what  is  to  be  done  if  hemorrhage  still 
persists  after  the  kidney  is  got  out  and  its  pedicle  tied.  Very  few  cases 
will  occur  in  which  ligatures  cannot  be  applied  to  each  bleeding  point 
if  the  wound  be  well  opened  up,  carefully  dried,  and  if  light  be  thrown 
down  to  the  bottom.  But  when  bleeding  still  goes  on,  Spencer  Wells's 
forceps  must  be  applied  to  the  bleeding  point  and  left  in  situ  for  two  or 
three  days,  during  which  time  they  will  also  help  to  drain  the  wound. 
I  have  used  this  method  twice  with  good  results.  If  the  forceps  will 
not  hold,  careful  plugging  must  be  resorted  to,  strips  of  iodoform  or  sal 
alembroth  gauze  wrung  out  of  carbolic  acid  lotion  1  in  20,  the  deepest 
attached  to  silk,  and  systematically  packed  into  the  bottom  of  the  wound 
around  a  large  drainage-tube  till  the  wound  is  thoroughly  filled  ;  an 
external  gauze  dressing  is  then  applied,  and  over  this  a  firm  but  elastic 
padding  of  sal  alembroth  wool,  which  is  kept  in  situ  by  firm  bandaging. 
Mr.  Clement  Lucas  (Trans.  Intern.  Med.  Congr.,  vol.  ii.  p.  271)  nearly 
lost,  from  secondary  haemorrhage,  a  case  in  which  nephrectomy  had 
been  successfully  performed  for  suppurating  tuberculous  pyelitis.  The 
bleeding  came  on  about  the  fifteenth  day,  probably  from  the  ligatures, 
which  had  been  left  long,  being  dragged  upon.  The  haemorrhage  again 
occurred  on  the  sixteenth  day,  when  an  attempt  was  made,  after  open- 
ing up  the  wound,  to  slip  a  ligature  along  the  old  ones,  and  thus  to 
retie  the  pedicle.  Haemorrhage  again  occurring  on  the  seventeenth 
day,  and  the  patient  being  in  a  most  precarious  state,  the  wound 
was  tightly  and  forcibly  plugged  with  two  large  sponges  steeped  in 
perchloride  of  iron,  and  the  abdomen  bound  firmly  round  with  a 
flannel  bandage.  Morphia  was  given  subcutaneously.  About  a  week 
later  the  removal  of  the  sponges,  by  cutting  away  the  protruding  part, 
was  commenced,  and  this  was  completed  by  the  end  of  another  week. 
No  bleeding  recurred  after  the  plugging,  and  the  patient  made  a  good 
recovery. 

When  all  bleeding  is  stopped,  a  large  drainage-tube  should  be 
inserted,  with  one  end  carried  down  to  the  very  bottom  of  the  wound, 
and  the  other  cut  almost  flush  with  the  surface.  The  wound  is  then 
partially  closed  with  catgut  and  salmon-gut  sutures,  some  iodoform 
dusted  on,  and  aseptic  dressings  applied.  If  there  has  been  much 
difficulty  in  getting  out  the  kidney — and  in  cases  of  old  inflammation 
it  has  to  be  dug  out  by  touch,  with  very  little  help  from  sight  — as  in 
case  No.  2,  Table,  p.  217 — no  sutures  should  be  used,  the  wound 
being  merely  lightly  plugged  with  iodoform  gauze  wrung  out  of  carbolic 
acid  lotion  1  in  20. 

Dr.  Weir,  of  Xew  York  (Arm.  0/ Surg.,  April.  1SS5.  p.  311).  during  a  nephrectomy 
in  a  young  woman  the  subject  of  pyo-nephrosis,  met  with  very  severe  haemorrhage 
after  ligature  of  the  pedicle.  This  had  apparently  been  effected  with  a  single  ligature. 
After  removin?  the  kidney,  a  gush  of  venous  blood  ensued,  which  was  only'  partly 
arrested  after  repeated  seizures  with  long  pressur  -  >uf   was  finally  controlled  by 


NEPHRECTOMY.  209 

staffing  t he  wotmtl  full  of  sponges  and  turning  the  patient  on  her  back.  The  Bhock 
was  profound,  and  all  the  measures  to  produce  reaction  were  rransi 

performed  twice  to  a  total  amount  of  22  oz.  gave  rise  at  first  to  great  improvement,  but 
the  patient  died  ten  hours  after  the  operation.  The  necropsy  showed  that  the  haemor- 
rhage came  from  a  vein  of  considerable  size,  15  centimetre  above  those  Becured  by  the 
ligature  and  foi 

B.  Nephrectomy  by  Abdominal  Incision  through  the 
Peritonaeum. 

a.  By  Langenbiich's  Incision  at  the  Outer  Edge  of  the  Rectus. 

b.  By  an  Incision  in  the  Linea  Alba. 

These  two  methods  may  be  taken  together.  The  former  is  the  one 
most  usually  employed,  as  it  has  the  following  great  advantages  : — 

1.  The  incision  is  nearer  the  vessels  and  ureter.  2.  There  is  much 
less  general  exposure  of  the  peritoneal  sac  (Knowsley  Thornton). 
3.  The  kidney  is  reached  through  the  outer  or  posterior  layer  of  the 
meso-colon,  a  step  which  avoids  (a)  haemorrhage  and  (b)  the  risk  of 
sloughing  of  the  colon,  as  it  is  the  inner  or  anterior  layer — that  between 
the  colon  and  the  middle  line — which  contains  most  of  the  vessels  to 
the  colon,  and  is  especially  rich  in  veins.  It  is  this  layer  which  is 
divided  in  the  incision  through  the  linea  alba.  4.  The  operation  can  be 
rendered  largely  extra-peritonaeal  by  having  the  inner  edge  of  the  cut 
meso-colon  and  that  of  the  parietal  peritonaeum  held  in  apposition  or 
sutured  with  catgut. 

Both  operations  give  good  room  for  necessary  manipulations,  both 
afford  an  opportunity  for  examining  with  the  hand  the  condition  of  the 
opposite  kidney.*  After  both,  the  wound  can  be  drained  posteriorly 
from  the  loin,  but  more  easily  after  Langenbiich's  incision. 

a.  Langenbiich's  Incision.  —  The  abdominal  wall  having  been 
cleansed,  an  incision  is  made,  at  least  four  inches  long  at  first,  com- 
mencing just  below  the  ribs,  in  the  line  of  the  linea  semilunaris  on 
the  side  of  the  disease,  the  centre  of  the  incision  being  usually  opposite 
to  the  umbilicus.  The  skin,  subcutaneous  tissue,  and  the  aponeuroses 
at  the  outer  edge  of  the  rectus  having  been  divided  down  to  the  trans- 
versalis  fascia,  and  all  haemorrhage  t  having  been  carefully  arrested, 
the  transversalis  fascia  and  the  peritonaeum  are  pinched  up  together, 
punctured,  and  slit  up  on  a  finger  used  as  a  director,  the  hand  is 

*  I  cannot  but  think  that  this  advantage  of  the  incisions  through  the  peritonaeum  has 
been  made  too  much  of.  In  Mr.  Barker's  words  (Diet,  of  Surg.,  vol.  ii.  p.  48),  "  Though 
the  hand  may  reach  the  kidney  opposite  to  the  one  it  is  proposed  to  excise,  its  souu 
or  the  reverse  cannot  be  ascertained  by  mere  palpation.  Great  enlargement,  or,  on  the 
other  hand,  great  reduction,  in  size,  or  complete  absence,  might  be  detected ;  but  the 
organ  might  be  tubercular,  or  fibroid,  or  contain  a  moderate-sized  calculus,  and  yet  the 
hand  be  unable  to  detect  the  condition."  I  have  also  referred  to  this  matter,  p.  186. 
Morris  (Disrates  of  the  Kidney  and  Ureter,  1901,  vol.  ii.  p.  269)  records  an  interesting  case 
in  which  the  opposite  mistake  was  made.  A  surgeon,  exploring  through  the  right  linea 
semilunaris,  discovered  what  he  thought  to  be  a  renal  sarcoma.  With  his  hand  in  the 
abdominal  cavity  he  could  not  discover  the  left  kidney,  and  he  therefore  concluded  that 
the  condition  was  hopeless.  Later  Morris  was  able  to  feel  the  left  kidney  by  bimanual 
examination.     The  growth,  which  was  successfully  removed,  was  an  ovarian  dermoid. 

t  The  amount  of  this,  as  will  be  familiar  to  all  surgeons  who  have  opened  the 
peritonaeal  sac  by  this  incision  for  intestinal  obstruction,  &c.,  varies  a  good  deal.  In  the 
case  of  growth,  large  vessels  are  often  present  in  the  peritonaeum  over  the  kidney. 

S. VOL.  II.  14 


210  OPERATIONS   ON   THE   ABDOMEN. 

introduced,  and  the  size  of  the  growth  and  the  condition  of  the 
opposite  kidney  investigated.  In  the  case  of  a  large  growth  the 
incision  will  now  be  enlarged,  and  an}r  further  haemorrhage  arrested. 
The  growth,  if  large,  is  usually  now  seen  in  part.  Any  presenting 
intestine  is  turned  over  to  the  opposite  side,  and  kept  out  of  the  wa}r 
with  a  pad  of  aseptic  gauze.  The  outer  or  posterior  layer  of  the  meso- 
colon will  now  probably  present  itself,  pushed  forward  by  the  growth, 
which  is  often  bluish-white  in  appearance  and  covered  b}'  large  veins. 
The  above-mentioned  layer  of  the  meso-colon  is  next  torn  through, 
either  in  a  vertical  or  transverse  direction,  as  will  best  avoid  the  vessels 
exposed.  Any  bleeding  should  be  at  once  arrested  by  Spencer  "Wells's 
forceps  and  ligatures  of  fine  silk.  The  intestines  are  then  packed 
away  with  sterile  gauze. 

A  sufficient  opening  having  been  made  in  the  outer  layer  of  the 
meso-colon,  the  fingers  are  introduced  to  examine  into  and  further 
separate  the  connections  of  the  kidney. 

During  all  the  necessary  manipulations  in  the  case,  of  a  growth,  the 
greatest  possible  gentleness  must  be  used  so  as  not  to  rupture  the 
capsule.  In  rapidly  growing  sarcomata,  especially  in  children,  the 
consistenc}'  may  be  jelly  ^  or  glue-like,  and  thus,  if  the  capsule  is  opened, 
portions  of  the  growth  may  readily  be  left  behind.  Again,  haemor- 
rhage may  easily  follow  this  accident,  and  prove  most  embarrassing.* 
If  the  bleeding  is  of  the  nature  of  troublesome  oozing  it  may  be  met 
by  packing  the  cavity  with  iodoform  gauze,  the  ends  of  which  are 
brought  out  through  a  counter-incision  in  the  loin.  The  wound  in  the 
peritonaeum  is  next  carefully  sutured  over  the  gauze,  thus  shutting  off 
the  abdominal  cavity.  The  gauze  maybe  removed  in  forty-eight  hours 
(F.  Page,  Lancet,  vol.  ii.  1893,  p.  1188).  If  the  bleeding  is  from  one  or 
two  points  which  cannot  be  tied,  Spencer  Wells's  forceps  may  be  left 
in  situ,  and  removed  in  forty-eight  hours. 

The  same  precautions  as  to  not  damaging  the  capsule  should  be  taken 
in  the  case  of  a  kidne}'  full  of  fluid.  Where  there  is  any  risk  of  such 
fluid  or  of  soft  growth  escaping  into  the  peritonaeal  sac,  sterile  gauze 
should  be  carefully  packed  around,  or  the  cut  edges  of  the  meso-colon 
and  the  parietal  peritonaeum  united. 

If  the  parts  about  the  pedicle  are  free  from  adhesions,  the  vessels 
may  be  tied  before  the  kidney  is  enucleated,  which  will  render  this 
latter  step  bloodless.  Wherever  it  is  possible,  forceps  should  be  placed 
on  the  vessels  close  to  the  kidney  before  they  are  divided,  to  save 
spilling  of  blood  from  the  kidney  J  and  where  this  contains  pus,  the 
same  precaution  should  be  taken  with  the  ureter. 

The  vessels  should  be  tied  with  the  precautions  given  above  (p.  206). 
All  dragging  on  the  pedicle  should  be  scrupulously  avoided. 

The  kidney  being  removed,  the  site  of  the  operation  is  most  carefully 


*  Thus  it  has  even  happened  to  Prof.  Czerny,  whose  experience  in  nephrectomy  is 
almost  unrivalled,  to  be  driven  to  tie  the  abdominal  aorta.  The  profuse  haemorrhage  met 
with  in  removing  a  large  growth  of  the  left  kidney  could  only  be  stopped  by  pressure  on 
the  abdominal  aorta.  This  vessel  was  accordingly  tied.  Death  took  place  ten  hours  later. 
It  was  found  that  the  renal  artery  had  been  torn  through  at  its  entrance  into  the  tumour. 
The  ligature  on  the  aorta  had  been  so  placed  that,  while  the  blood-supply  through  the  left 
was  cut  off,  the  right  vessel  was  pervious. 


NEPHRECTOMY. 


211 


cleansed  and  dried.  If  troublesome  oozing  bus  occurred  and  is  at  all 
likely  to  persist,  a  large  drainage-tube  bad  best  be  passed  out  through 
the  loin  by  pushing  a  short  pair  of  dressing-forceps  from  the  site  of  tin- 
kidney  so  that  it  bulges  in  the  loin,  where  it  is  cut  down  upon,  and 
used  to  seize  the  tube.  It  has  been  suggested  that  the  divided  edges 
of  the  meso-colon  may  be  united  with  a  few  points  of  catgut  suture,  but 
this  precaution  does  not  seem  to  be  absolutely  needful,  as  the  edges 
usually  fall  readily  into  apposition. 

Mr.  Knowsley  Thornton  lays  stress  upon  his  method  of  treating  the 
ureter.  This  tube  is  taken  last  in  the  enucleation  of  the  kidney,  "  and, 
before  separation,  its  renal  end  should  be  secured  by  pressure-forceps, 
then  a  ligature  tied  a  little  way  from  the  forceps,  and  a  sponge  placed 
under  it  before  it  is  divided.  Whenever  it  is  possible,  I  enucleate  it  for 
some  distance  from  the  kidney  before  dividing  it,  so  that  its  cut  end, 
with  the  sponge  under  it,  may  be  at  once  drawn  outside  the  abdomen  ; 
and  afterwards  fix  it  in  the  lower  angle,  or  most  convenient  part  of  the 
abdominal  incision,  with  a  cleansed  safety-pin.  I  regard  this  fixing  out 
of  the  stump  of  the  ureter  as  the  most  important  detail  in  the  operation, 
and  in  every  case  in  which  I  have  been  obliged  to  cut  it  off  deep  in  the 
wound  I  have  had  distinct  evidence  of  suppuration  and  trouble  around 
it."  Mr.  Thornton  considers  the  objection  that  this  method  risks  the 
occurrence  of  future  intestinal  obstruction  an  entirely  fanciful  one.  At 
the  worst,  a  ureter  so  treated  is  only  a  slight  ridge  over  a  small  surface 
of  the  abdominal  wall,  quickly  disappearing  by  atrophy.  Other  surgeons, 
who  have  treated  the  ureter  by  ligature  and  dropping  it  in,  have  not 
met  with  the  results  of  suppuration  and  sloughing  which  Mr.  Thornton 
thinks  are  very  likely  to  follow  on  this  course.  The  only  after-trouble 
which  I  have  known  the  ureter  to  give  is  in  cases  of  removal  of  tuber- 
cular kidne}-.  Unless  this  operation  is  performed  at  a  very  early  stage, 
there  must  always  be  a  great  risk  that,  owing  to  the  ureter  having 
become  involved,  the  mischief  will  spread  to  the  bladder. 

Eamsay  (loc.  supra  cit.)  discusses  the  mode  of  dealing  with  the  ureter 
in  tuberculous  cases  at  some  length,  and  quotes  Regnier  as  having 
removed  a  tuberculous  ureter  some  months  after  the  nephrectomj'. 
Kelly,  in  the  Johns  Hopkins  Bulletin,  March,  1896,  reports  three  cases 
in  which  he  removed  the  whole  of  the  tuberculous  ureter  with  success  at 
the  time  of  the  nephrectomy.  On  the  other  hand,  there  is  evidence  to 
show  that  tuberculous  disease  of  the  ureter  tends  to  undergo  a  process 
of  cure  after  nephrectomy.  One  case  in  point  is  that  of  Tilden  Brown 
{Ann.  of  Surg.,  1899,  v°l«  *•  P-  755)*  Here  the  kidney  was  removed  and 
the  ureter  left  behind.  At  the  necropsy,  some  months  later,  the  ureter, 
previously  as  thick  as  the  thumb,  had  diminished  to  one-fourth  its  size. 

Eamsay 's  conclusions  on  this  point  are  as  follows  :  "  It  is  safest  to 
remove  the  ureter  with  the  kidney,  as  a  persistent  fistula  may  give 
trouble  if  it  is  allowed  to  remain  in  the  body  j"  and  again,  "that  a 
certain  proportion  of  these  fistulas  will  finally  disappear,  either  after  the 
removal  of  a  deep  suture,  or  because  of  the  slow  disappearance  of  the 
tubercular  disease  in  the  ureter,  which,  in  these  cases,  gradually  changes 
into  a  fibrous  cord." 

b.  Nephrectomy  by  an  Incision  in  the  Linea  Alba. — For  reasons 
already  given,  p.  209,  this  method  is  not  recommended,  that  of  Langen- 
biich,  already  fully  described,  being  preferable. 

14 — 2 


212  OPERATIONS  ON  THE  ABDOMEN. 

The  incision  in  the  linea  alba  will  not  materially  differ  from  that  for 
ovariotomy  or  abdominal  exploration,  and  the  same  precautions  are 
called  for  in  removing  a  kidney  by  this  method  as  in  that  through  the 
linea  semilunaris. 

C.  Nephrectomy  through  the  Abdominal  Wall,  but 
without  opening  the  Peritonaeum.— Having  made  use  of  the 
method  in  one  case  nine  years  ago,  and  being  much  struck  by  the  room 
afforded,  I  may  make  brief  mention  of  it : 

The  patient  was  a  woman,  aged  54,  the  subject  of  a  movable  kidney  on  the  right 
side,  the  kidney  being  also  the  seat  of  malignant  disease.  As  the  abdominal  walls  were 
thin,  and  as  the  kidney  could  easily  be  made  to  project  in  the  anterior  part  of  the  right 
lumbar  region,  I  made  a  longitudinal  incision  from  the  anterior  superior  spine  up  to  the 
eighth  rib.  The  different  layers  were  cut  through,  very  little  hemorrhage  being  met 
with  ;  when  the  peritoneum  was  reached,  this  was  then  stripped  up  out  of  the  iliac 
fossa,  upwards  and  inwards,  then  upwards  off  the  anterior  surface  of  the  kidney  until  its 
vessels  came  in  view.  No  difficulty  was  experienced  in  dealing  with  the  pedicle — 
first  the  ureter,  and  then  the  vessels.  The  vena  cava  was  seen  for  about  i£  inch  receiv- 
ing pulsation  from  the  aorta.  The  patient  never  rallied  thoroughly  from  the  operation,* 
and  sank  about  twenty-four  hours  after.  The  necropsy  showed  ligatures  firmly  tied ; 
one  of  those  on  the  renal  vein  had  slightly  puckered  in  the  inner  surface  of  the  vena 
cava.  A  clot  the  size  of  the  little  finger  constituted  all  the  bleeding  that  had  taken 
place.  The  kidney  was,  save  for  one  small  patch  at  the  lower  part,  entirely  converted 
into  encephaloid  carcinoma.  Two  or  three  of  the  aortic  glands  were  enlarged  ;  there 
were  no  other  secondary  deposits. 

Paterson  (Lancet,  vol.  i.  1903,  p.  729)  publishes  an  account  of  a  similar 
operation  and  strongly  recommends  it ;  his  patient  was  well  4^  years 
after  the  removal  of  a  carcinomatous  left  kidney  ;  there  was  no  sign  of 
a  ventral  hernia. 

Treves  is  probably  right  in  believing  the  risk  of  ventral  hernia  to 
be  considerable  after  this  operation. 

D.  Combination  of  Lumbar  and  Abdominal  Nephrec- 
tomy.— Dr.  Hume,  of  Newcastle,  made  use  of  this  method  in  a  case  of 
sarcoma  (Lancet,  vol.  i.  1893,  p.  196}  : 

An  incision  about  six  inches  long  was  first  made  in  the  linea  semilunaris,  and  the 
swelling  found  to  be  in  the  left  kidney.  A  lumbar  incision  was  then  made  from  the 
middle  of  the  first  cut,  dividing  all  the  structures  forming  the  abdominal  wall,  includ- 
ing the  peritonaeum.  The  intestines  were  pushed  to  the  right  and  protected  with  sponges. 
The  peritoneum  covering  the  kidney  was  then  separated  until  the  whole  growth  was 
exposed.  The  large  cavity  left  was  plugged  with  sublimate  gauze  dusted  with  iodoform, 
the  ends  of  the  strips  being  brought  out  through  an  opening  in  the  most  dependent  part 
of  the  loin.     The  strips  were  removed  in  thirty-six  hours.     The  patient  recovered. 

E.  Morris'  (Surgical  Diseases  of  the  Kidney  and  Ureter,  vol.  ii. 
p.  250)  Combined  Method  has  been  described  briefly  at  p.  200 ;  he 
recommends  it  for  the  removal  of  renal  growths. 

F.  Mr.  Knowsley  Thornton's  Combined  Method. — This  is 
given  at  p.  184. 

a.  Choice  between  Lumbar  and  Abdominal  Nephrectomy. — 
While  it  is  certain  that  all  kidneys  of  small  or  moderately  large  size 

*  I  think  that  the  thinness  of  the  abdominal  walls  prolonged  the  operation,  owing  to 
my  anxiety  not  to  wound  the  peritoneum.  As  has  been  said  above,  the  hemorrhage  waa 
very  slight,  and  I  was  careful  not  to  pull  upon  the  pedicle. 


NEPHRECTOMY.  213 

can  bo  easily  removed  by  a  lumbar  incision  sufficiently  enlarged 
(p.  173),  time  alone  will  show  whether  I  am  right  in  my  opinion  that 
before  the  lumbar  method  is  abandoned  a  trial  sin  mid  be  made  of  such 
a  free  incision  as  Konig's  (p.  205)  when  large  kidneys  have  to  be 
attacked.  And  this  leads  to  the  question  of  chief  importance:  How  far 
is  the  danger  really  increased  by  going  through  the  peritonaeum  to  get 
at  the  kidney  ?  I  am  strongly  of  opinion  that,  in  spite  of  all  the  recent 
improvements  in  abdominal  surgery  and  their  success  in  preventing 
peritonitis,  interference  with  and  handling  the  contents  of  the  perito- 
naeum, save  in  the  shortest  and  simplest  instances,  remains,  on  the  score 
of  shock,  as  grave  a  thing  as  ever  it  was.  I  am  quite  aware  that,  in  the 
hands  of  a  few  operators,  such  as  the  late  Sir  S.  Wells,  Mr.  K.  Thornton, 
and  Mr.  Malcolm,  removal  of  kidneys,  even  in  difficult  cases,  through 
an  abdominal  wound  involving  the  peritonaeum,  has  given  excellent 
results — results  perhaps  as  good  as,  or  better  than,  those  by  the  lumbar 
method.  But,  while  allowing  this,  it  cannot,  I  think,  be  lost  sight  of 
that  the  kidney  is  an  extra-peritonaeal  organ,  not  one,  like  the  uterus 
and  ovary,  within  the  peritonaeal  sac.  It  will  assuredly  never  come 
about  that  removal  of  the  kidney  will  pass,  like  oophorectomy  and 
removal  of  the  uterus  or  its  appendages,  into  the  hands  of  a  few 
operators,  however  specially  skilled  in  abdominal  surgery.  This  being 
so,  and  the  organ  in  question  being  one  behind  and  outside  the 
peritonaeum,  while  each  man  will  decide  for  himself  and  according  to 
his  special  experience  and  line  of  work,  the  majority  of  surgeons  will, 
I  think,  prefer  to  make  their  attacks  from  behind  whenever  this  is 
possible.     This  question  is  also  dealt  with  above  (pp.  187  and  200). 

Lumbar  Nephrectomy — Advantages: — 1.  The  peritonaeum,  save 
in  cases  of  exceptional  difficulty,  is  not  opened  or  contaminated. 
2.  Efficient  drainage  is  easily  provided.  3.  The  structures  interfered 
with  are  much  less  important.  4.  As  pointed  out  by  the  late  Mr. 
Greig  Smith,  "  in  the  case  of  its  being  unwise,  as  in  abscess,  or  in 
tumour  affecting  the  surrounding  tissues,  to  proceed  to  removal,  it  is 
less  serious  to  the  patient."  5.  If  the  kidney  is  firmly  matted  down, 
as  in  the  cases  given  at  p.  204,  such  dense  posterior  adhesions  are  most 
readily  dealt  with  by  the  lumbar  method.  6.  The  lumbar  incision,  if 
converted  into  a  T-shaped  one,  or  prolonged  forwards  by  Konig's  method, 
will  give  sufficient  room  for  meeting  most  of  the  conditions  which 
call  for  nephrectomy.     Thus  modified,  it  will  suffice  for  new  growths. 

Lumbar  Nephrectomy — Disadvantages  : — 1.  It  is  thought  by  some 
that  too  little  room  is  given  by  this  method  for  the  removal  of  large 
kidneys.  It  has  already  been  shown  (p.  173)  how  extensively  this  inci- 
sion can  be  enlarged.  It  is  doubtful,  therefore,  if  this  objection  holds 
good  for  any  cases,  even  those  of  unusually  long-chested  patients,  or 
those  with  spinal  deformity.  2.  In  a  fat  subject  the  organ  may  be 
difficult  to  reach,  even  when  well  pushed  up  from  the  front,  owing  to 
the  great  depth  of  the  wound.  3.  The  pedicle  is  less  easily  reached,* 
and  thus,  in  cases  of  difficulty,  bleeding  at  a  very  important  stage  of  the 
operation  is  less  easily  dealt  with.  4.  If  the  kidney  be  very  adherent, 
important  structures — e.g.,  the  peritonaeum  and  colon — may  be  opened, 
unless  great  care  is  taken.     5.  The  condition  of  the  opposite  kidney 

*  This  objection  and  the  next  can  be  met  by  a  very  free  incision  (p.  205). 


214  OPERATIONS  ON  THE  ABDOMEN. 

cannot  be  examined  into.  Possible  fallacies  bere  have  been  pointed 
out,  pp.  186,  209. 

Nephrectomy  by  Abdominal  Incisions  in  the  Linea  Alba,  or 
at  the  Edge  of  the  Rectus,  the  Peritoneal  Cavity  being 
opened — Advantages  : — 1.  Additional  room  in  case  of  large  kidneys. 
2.  More  easy  access  to  the  pedicle,  the  vessels  of  which  can  be  tied 
early  in  the  operation  to  lessen  haemorrhage  during  enucleation  ;  this  is, 
however,  not  always  possible,  for  large  gr5wths  may  overlap  the  vessels, 
and  in  inflammatory  cases,  there  may  be  much  confusion  from  matting 
and  adhesions.  3.  The  possibility  of  examining  the  condition  of  the 
other  kidney.  It  has  already  been  pointed  out  (pp.  186,  209)  that  this 
advantage  is  probably  overrated.  Thorough  examinations  along  the 
lines  laid  down  at  p.  149  are  far  more  reliable,  for  a  kidney  which  may 
seem  to  be  normal  to  the  touch,  may  be  insufficient  after  the  other  is 
excised.  4.  The  extent,  the  presence  or  absence  of  secondary  growths, 
and  the  wisdom  or  otherwise  of  attempting  nephrectomy  can  be  decided 
early  in  the  operation.  5.  The  diagnosis  can  be  made  between  renal 
enlargements  and  others  arising  in  the  colon  or  liver. 

Nephrectomy  by  Abdominal  Incisions  through  the  Peritonaeum 
— Disadvantages  : — 1.  The  peritonaeal  sac  is  opened.  2.  The  same 
sac  may  be  seriously  contaminated  if  a  kidney  containing  septic  matter, 
or  one  largely  converted  into  soft  growth,  is  ruptured  during  the 
needful  manipulations.  3.  The  intestines  may  be  difficult  to  deal 
with,  and  may,  by  crowding  into  the  field  of  operation  and  the  incision 
in  the  abdominal  wall,  prove  most  embarrassing.  4.  The  handling 
and  interference  with  the  contents  of  the  peritonaeum  may  cause  con- 
siderable shock.  5.  The  vitality  of  the  colon  may,  by  interference 
with  its  blood-supply,  be  endangered.  6.  It  is  more  difficult,  by  this 
method,  to  deal  with  any  dense  adhesions  which  may  exist  behind  the 
kidney.  7.  If  bleeding  follow  the  operation,  reopening  an  abdominal 
wound,  finding  the  bleeding  points  and  securing  them,  or  plugging  the 
wound,  will  be  attended  by  more  shock  than  the  adoption  of  the  same 
course  by  the  lumbar  method.  A  case  supporting  this  view  is  candidly 
reported  by  Mr.  Page,  of  Newcastle   (Lancet,   vol.  ii.  1893,  p.  1187). 

8.  Efficient  drainage  is  less  easily  provided  in  cases  of  any  contamina- 
tion of  the  peritonaeal  cavity,  or  of  oozing  after  the  kidney  is  removed. 

9.  The  after-complication  of  a  ventral  hernia  is  much  more  probable 
by  this  method,  though  it  must  be  allowed  that  the  free  lumbar  incision 
already  alluded  to  may  be  followed  by  the  same  result. 

Morris,  with  all  his  experience  (loc.  cit.)  advocates  the  use  of  the 
lumbar  operation  for  all  cases  except  for  tumours  of  very  large  size, 
injuries  of  the  kidney  which  may  be  complicated  by  other  injuries 
within  the  abdomen,  and  the  rare  cases  in  which  a  kidney  really  floats 
in  the  peritonseal  cavity  anchored  only  by  its  pedicle,  which  is  sur- 
rounded bjr  peritonaeum.  He  states  that  "  the  lumbar  operation  ought 
not  to  be  regarded  merely  as  the  operation  of  choice  ;  with  the  excep- 
tions stated,  it  is  the  only  operation  which  ought  to  be  considered 
justifiable.  The  kidney  as  an  extra-peritonaeal  organ  ought  to  be 
attacked  from  behind,  and  not  across  the  peritonaeal  cavity." 

Causes  of  Death  after  Nephrectomy. — 1.  Shock. — This  may  be 
induced  by  haemorrhage,  much  traction  on  the  pedicle,  and  thus, 
probably,  interference  with  the  solar  plexus,  injury  to  the  colon,  and, 


\t.nii;i:<  T<>MY. 


215 


where  the  peritonceal  sac  is  opened,  by  much  disturbance  of  its  contents. 
2.  Haemorrhage, — This  is  especially  to  be  dreaded  where  the  pedicle  is 
deep  and  difficult  to  command  ;  where  there  are  aberrant  renal  vessels; 
where  these  vessels  are  enlarged  and  perhaps  Boftened  ;  where,  owing 

to   too  much  tension   on  the  pedicle,  a  vessel  retracts  from  within  its 

loop  of  ligature  ;  where  the  kidney  capsule  and  tissue  are  broken  into. 
In  the  intra-peritonseal  method  there  is  the  additional  danger  of 
enlarg<  d  veins  within  the  meso-oolon.  Secondary  ha3morrhage  has 
been  alluded  to  above,  pp.  206,  208.  3.  Uraemia  and  Anuria. — These 
are  only  likely  to  occur  when  it  has  been  impossible  to  form  a  correct 
estimate  of  the  condition  of  the  opposite  kidne}',  or  where,  to  give  a 
patient  a  chance,  the  surgeon  operates  in  what  he  knows  to  be  a  doubt- 
ful case.  AVhere  there  is  reason  to  believe  that  the  suppression  of 
urine  may  be  due  to  a  calculus  in  the  opposite  kidney,  this  should  at 
once  be  cut  down  upon  in  the  hope  of  finding  a  calculus  that  can  be 
removed.  Mr.  Lucas's  brilliant  example  of  what  nephrolithotomy  may 
do,  when  such  peril  sets  in  at  a  later  date,  has  been  referred  to  at 
]>.  193.  4.  Peritonitis. — This,  if  septic,  is  due  either  to  mischief  intro- 
duced at  the  operation  or  from  the  kidney.  While  it  is  certainly  more 
likely  to  follow  the  intra-peritonreal  operation,  it  may  occur  after  that 
through  the  loin,  especially  when  much  difficulty  is  met  with  here, 
owing  to  numerous  adhesions,  or  to  working  in  a  wound  of  insufficient 
size.*  5.  Septic  trouble — Cellulitis — Erysipelas — Pyaemia. — These 
are  especially  likely  when  the  kidney  contains  septic  matter,  when  the 
soft  parts  are  much  bruised,  or  wdien  many  fingers  enter  the  wound. 
Other,  rarer,  causes  of  death  are — 6.  Pulmonary  Embolism.  7,  Em- 
pyema.— This  may  be  brought  about  by  an  extension  of  septic  cellulitis, 
or  by  removing,  during  the  operation,  a  portion  of  rib  in  order  to  get 
more  room — a  step  the  danger  of  which  Gannot  be  too  strongly  enforced 
(p.  180).  An  anatomical  predisposition  favouring  the  passage  of 
inflammation  from  the  kidney  to  the  pleura  has  been  pointed  out  by 
Dr.  Lange,  of  New  York.  This  authority  on  renal  surgery  found,  in 
one  subject,  an  enormous  gap  in  the  diaphragm,  the  muscle  fibres  being 
absent  from  the  ligamentum  arcuatum  internum  as  far  as  the  outermost 
part  of  the  eleventh  rib,  Between  these  two  points  the  fibres  of  the 
diaphragm  communicated  in  a  high  arch,  bounding  an  area  in  which 
the  fatty  tissue  about  the  kidney  was  in  direct  contact  with  the  pleura. 
8.  Intestinal  Obstruction. — -This  occurred  fatally  in  one  of  Mr. 
Thornton's  cases.  He  thought  it  was  brought  about  by  his  suturing 
the  two  edges  of  the  peritonaeum  over  the  kidney  together,  and  thus 
producing  kinking  of  the  large  intestine. 

Partial  Nephrectomy. — This  has  been  rendered  justifiable  by  the 
results  of  experiments  on  animals.  Morris  (loc.  supra  cit.)  says, 
'■'  Turner's  experiments  on  animals,  in  1888,  and  Barth's  histological 
researches  supply  ample  proofs  of  the  healing  power  of  the  kidney, 


*  During  a  nephrectomy  for  pyonephrosis  the  peritonaeum  was  injured  owing  to  the 
adhesions  of  the  renal  capsule.  As  it  was  thought  certain  that  some  septic  fluid  had 
escaped  into  the  peritomeal  cavity,  this  was  opened  by  a  small  incision  above  the  pubes 
after  the  lumbar  wound  had  been  closed.  Some  ounces  of  bloody  fluid  escaped,  the  cavity 
was  washed  out,  and  a  drainage-tube  placed  in  Douglas's  pouch.  The  patient  recovered. 
(F.  Page.  Lancet,  vol.  i.  1893,  P-  999-) 


2i6  OPERATIONS  ON  THE  ABDOMEN. 

and  the  process  by  which  healing  is  accomplished,  even  after  extirpa- 
tion of  considerable  portions.  Paoli,  of  Perugia,  performed  extra-peri- 
tomeal  operations  for  resection  of  the  kidney  upon  twenty-five  dogs, 
cats,  and  rabbits,  with  perfect  recovery." 

Morris  records  10  cases  of  partial  excision  for  disease — tuberculous 
foci,  traumatic  abscess,  containing  a  secondary  calculus,  a  cyst,  and  a 
fistula — he  has  excised  up  to  nearly  one-half  of  the  kidney  for  tubercle. 

All  the  10  cases  recovered  from  the  operations  but  one  recpuired  total 
nephrectomy  a  week  later  for  acute  general  pyelo-nephritis,  and  died 
3  months  afterwards  from  general  tuberculosis.  Another  needed 
nephro-ureterectomy  7  months  later,  and  in  another  symptoms  returned 
within  a  year.  The  rest  were  well  in  1900  except  one  who  had  died  of 
acute  broncho-pneumonia  3  years  after  the  operation. 

Morris  also  gives  uresumi  of  eleven  operations  (from  foreign  literature), 
three  for  cysts,  three  for  calculous  pyonephritis,  two  for  new  growths, 
and  one  each  for  puerperal  pyonephritis,  renal  fistula,  and  a  patch  of 
interstitial  nephritis  mistaken  for  malignant  disease. 

None  of  these  cases  died ;  nine  made  good  recoveries,  one  required 
nephrectomy,  and  in  one  fistula  resulted. 

Ramsay  {foe.  supra  cit.)  mentions  nine  cases  of  partial  nephrectomy 
for  tuberculous  disease  ;  in  only  two  of  these,  however,  was  the  result 
satisfactory.  One,  reported  by  Israel,  was  well  one  year  later  ;  the 
other,  by  Morris,  was  well  two  years  later. 

This  operation  may  also  be  performed  in  cases  of  laceration  of  the 
kidney  by  injury,  where  the  greater  part  of  the  organ  is  uninjured. 
Here  the  organ  will  very  likely  be  healthy,  and  removal  of  an  almost 
detached  part  may  be  sufficient  to  arrest  the  hemorrhage.  Mr.  Keetley 
has  recorded  a  case  of  this  kind  (Lancet,  vol.  i.  1890,  p.  134)  : 

A  young  man  had  been  crushed  by  a  waggon-wheel.  There  was  laceration.  Five 
or  six  hours  after  the  accident  he  showed  signs  of  serious  recurrent  haemorrhage. 
Through  an  incision  a  mass  of  blood-clot  was  scooped  out,  also  the  separated  lower 
end  of  the  kidney,  a  deep  bleeding  point  being  compressed  with  sponges,  which  were 
removed  in  twelve  hours.  Convalescence  was  rapid.  No  urinary  fistula  or  hydro- 
nephrosis resulted. 

It  may  be  said,  therefore,  that  where,  on  examination  of  the  kidney, 
a  suitable  opportunity  presents  itself,  partial  nephrectomy  may  be 
performed,  and  the  greater  part  of  the  kidney  in  this  way  saved. 
The  wound  in  the  kidney  may  be  sutured  or  the  haemorrhage  may  be 
arrested  by  means  of  plugging  with  iodoform  gauze,  suturing  being 
the  preferable  method  where  possible  ;  for  in  this  way  both  haemorrhage 
and  escape  of  urine  will  be  prevented,  and  rapid  healing  of  the  whole 
wound  thus  secured. 

In  view  of  the  unsatisfactory  results,  with  a  few  exceptions,  that  have 
attended  this  method  of  treating  tuberculous  disease,  and  of  the  great 
difficulty  there  must  be  in  making  certain  that  all  disease  has  been 
removed,  it  would  seem  wiser  to  remove  the  entire  kidney  in  such 
cases  if  the  opposite  organ  is  known  to  be  healthy.  Hurry  Fen- 
wick  (Med.  Ann.,  1906,  p.  296)  states  that  he  would  only  be  content 
with  a  resection  when  "  the  disease  was  evidently  limited  to  one  pole 
as  demonstrated  by  slitting  the  organ  from  end  to  end  and  down  into 
the  pelvis." 


NEPHRECTOMY. 


217 


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220  OPERATIONS  ON  THE  ABDOMEN. 

Results  of  Nephrectomy. 

The  foregoing  list  shows  twenty-three  cases  with  four*  deaths. 
Tubercular  cases,  where  the  mischief  is  advanced  and  the  adhesions 
extensive,  as  in  case  22  ;  malignant  growths  ;  and  cases  of  calculous 
pyelitis  where  both  kidneys  are  affected,  though  one  only  at  the  time 
of  operation  may  contain  stones,  will  alwa}Ts  keep  up  the  mortality  of 
nephrectomy. 

Mr.  H.  Morris  (Surgery  of  the  Kidney  and  Ureter,  vol.  ii.  p.  275)  gives 
the  following  statistics  of  his  cases  :  (a)  In  twenty-nine  nephrectomies 
for  calculous  disease,  there  were  five  deaths  ;  (b)  in  twenty-four  nephrec- 
tomies for  hydro-  and  pyonephrosis  there  were  three  deaths  ;  (c)  in 
twenty-two  nephrectomies  for  tuberculosis  there  were  five  deaths  ;  (<1)  in 
seventeen  nephrectomies  for  tumour  there  were  four  deaths  ;  (e)  in  three 
nephrectomies  for  fistula  there  were  no  deaths.  Thus,  there  were 
seventeen  deaths  out  of  ninety-five  cases. 

Tuffier's  statistics  published  in  1899  give  a  mortality  of  28*4  per  cent, 
in  200  lumbar  nephrectomies,  and  44*1  per  cent,  in  161  transperitoneal 
nephrectomies. 

NEPHRORRAPHY  OR  NEPHROPEXY. 

It  is  well  known  that  nephrorraphy  has  not  always  been  followed  by 
the  relief  expected.  This,  I  think,  is  due  to  one  or  more  of  the 
following  causes : 

1.  The  operation  has  been  performed  in  unsuitable  cases.  (A.)  Cases 
where  the  mobility  of  the  kidney  is  only,  in  reality,  a  small  part  of  the 
trouble.  Well-marked  instances  of  this  group  would  be  those  cases 
where  mobility  of  the  kidney  co-exists  with  a  markedly  neurotic 
tendency,  a  group  in  which,  were  it  not  for  the  above  tendency,  the 
mobility  of  the  kidney  would  be  little  complained  of;  a  group  in  which 
operation  has  been  resorted  to  far  too  often,  thus  bringing  much 
discredit  upon  it ;  a  group,  finally,  in  which  nephrorraphy  is  rarely  to 
be  resorted  to,  and  then  only  with  the  greatest  caution. f  In  dyspeptic, 
neurotic  women  approaching  the  menopause  the  operation  should  be 
avoided  altogether.  In  the  neurotic  tendency  lies  one  of  the  chief 
difficulties  with  regard  to  making  a  decision  on  the  question  of  opera- 
tion. The  frequency  with  which  a  highly  nervous  temperament  is 
present  suggests  the  obvious  question,  "Would  these  symptoms  have 
arisen  were  it  not  for  the  neurotic  tendency  ?  Any  honest  medical 
man  would  answer  that  in  the  majority  they  would  not.  In  a  certain 
number  the  mobility  of  the  kidney  determines  the  region  and  dis- 
tribution of  the  neurotic  trouble  ;  in  a  very  few  it  originates  and  causes 
the  neurotic  tendenc}r4     Care  should  be  taken  not  to  attribute  to  a 

*  I  have  included  No.  20,  as  I  performed  the  nephrectomy.  The  case  was.  however, 
admitted  under  the  care  of  another  surgeon,  and  I  was  only  called  to  it  at  the  very  end. 
On  the  other  hand,  case  15  ought,  perhaps,  to  be  accounted  a  fatal  case  of  nephrectomy. 

I  In  an  interesting  paper  by  Dr.  Drummond  (loo.  infra  cit.),  thirty  cases  of  movable 
kidney  are  given,  two  of  which  were  treated  by  nephrorraphy.  Both  relapsed.  In  a 
third  case,  the  details  of  which  were  supplied  to  Dr.  Drummond,  "  excision  of  the  movable 
kidney  was  practised  without  any  relief." 

%  As  in  the  rare  cases  where  a  man,  previously  active  and  healthy,  has  his  life  spoilt 
and  becomes  hypochondriacal  after  one  kidney  has  become  movable. 


NEPHRORRAPHY  OB  NEPHROPEXY.        221 

movable  kidney  symptoms  really  due  to  other  causes,  such  as 
dyspepsia,  appendicitis  or  gall  stones,  Cor  it  is  certain  that  many 
healthy  wcincii  have  freely  movable  kidneys.  Larrabee  {Boston 
Med.  and   Surg.  Jown.,    Nov.    26,   1903)    examined   272  women    for 

movable  kidney,  and  found  it  in  112  or  4i'5  per  cent.;  in  39  it  was 
merely  palpable  on  deep  inspiration  ;  in  49  it  could  he  kept  down 
during  expiration;  in  24  it  could  be  pushed  about  freely  ;  in  40  cases 
there  were  no  symptoms;  and  in  66  some  loss  of  weight;  only  6 
patients  gave  a  history  of  "  Dietl's  crises." 

Gordon  (Lancet,  1903,  vol.  i.  p.  1587)  relates  an  interesting  case  in 
which  a  movable  kidney  was  thought  to  be  the  cause  of  indigestion, 
constipation,  and  attacks  of  pain  in  the  right  side.  Nephropexy  failed 
to  give  relief,  and  later  a  simple  stricture  of  the  sigmoid  flexure  was 
discovered  during  an  exploration  for  intestinal  obstruction  which 
proved  fatal. 

Again,  where  the  mobility  of  the  kidney  is  associated  with  a  general 
proptosis  of  the  viscera,  especially  of  the  liver,  with  long-standing 
dyspepsia  or  constipation,  or  with  uterine  or  ovarian  trouble,  it  will  be 
useless  to  perform  nephrorraphy,  unless  the  other  ailments  can  be 
corrected — a  matter  of  no  little  doubt  and  difficulty  in  some  of  those 
patients  in  whom  we  meet  with  this  disorder.  (B.)  In  a  certain  pro- 
portion of  movable  kidneys — and  this,  perhaps,  a  larger  one  than  is 
usually  allowed — organic  disease  coexists  as  well.  I  have  met  with 
three  such  cases.  In  one  (Case  1,  Table,  p.  217)  the  kidney  was  the 
site  of  carcinoma  ;  in  a  second  (Case  8,  loc.  supra  cit.),  early  tubercular 
disease  must  have  been  present.  About  two  months  after  the  neph- 
rorraphy, pain  having  returned,  further  examination  showed  that  the 
urine,  which  had  before  been  found  normal,  contained  pus.  At  a 
second  operation  two  early  foci  of  tubercular  suppuration*  were  found 
and  the  kidney  was  removed.  Six  years  later  the  patient  was  alive  and 
well.  The  third  case  was  one  associated  with  hydronephrosis.  At 
this  time,  when  performing  nephrorraphy,  I  was  passing  nvy  sutures 
through  the  tissue  of  the  kidney  itself,  a  method  which  I  now  consider 
quite  unreliable,  and  I  am  doubtful  if  the  relief  given  in  this  case 
of  hydronephrosis  was  permanent.  The  question  of  nephrorraphy  in 
hydronephrosis  is  referred  to  below\ 

Mr.  F.  E.  Taylor  {Ann.  of  Surg.,  1904,  vol.  xl.  p.  215)  records  five 
cases  in  which  unsuspected  lesions  were  discovered  during  the 
operation  of  nephropex}\  Three  of  these  cases  occurred  in  a  series 
of  thirty  hospital  patients.  Renal  calculi  were  discovered  and  removed 
in  two  cases,  and  tuberculous  disease  in  two  others,  in  one  of  these  partial 
nephrectomy  of  the  lower  pole  was  performed,  and  in  the  other  neph- 
rectomy was  necessaiy.  The  fifth  case  was  one  of  hydronephrosis 
associated  with  movable  kidney,  and  probably  due  to  the  mobility. 

Taylor  concludes  that  an  operation  is  indicated  when  "  some  unusual 


*  My  silk  sutures,  with  which  the  kidney  had  been  fixed,  were  found  in  situ,  but  as 
the  collections  of  pus  were  on  the  inner  aspect  of  the  kidney,  I  do  not  think  they  dated 
to  the  stitching,  in  which  the  kidney  substance  had  been  boldly  taken  up.  The  early 
appearance  of  pus  after  the  nephrorraphy  is,  however,  suspicious,  and  it  is  quite  possible 
that  in  delicate  patients  the  injury  inflicted  by  suturing  might  be  the  starting-point  of 
tubercular  disease  of  the  kidney. 


222  OPERATIONS  ON  THE  ABDOMEN. 

or  unexplained  symptom  is  present,  and  still  more  if  any  tenderness 
or  enlargement  of  the  kidney  can  be  made  out."  He  also  pleads  for 
a  more  thorough  examination  of  the  kidney  during  the  operation, 
and  that  the  organ  should  always  be  brought  outside  the  loin  and 
carefully  palpated  and  inspected,  and  even  incised  if  any  doubtful 
spot  is  discovered. 

2.  Another  frequent  cause  of  nephrorraphy  failing  to  give  perma- 
nent relief  is  the  way  in  which  the  operation  is  performed.  Too 
much  reliance  has  been  placed  on  removing  some  of  the  fatty 
capsule  and  suturing  its  edges  to  the  lips  of  the  wound  with  gauze 
packing,  but  without  passing  any  sutures  through  the  fibrous  or  true 
capsule  of  the  kidney.  A  little  experience  was  sufficient  to  convince 
Hahn  that  this  method  which  he  introduced  was  insufficient.  Frequently 
the  kidney  is  already  movable  within  this  capsule,  and  no  good  results ; 
and  where  no  such  mobility  has  existed,  the  loose  fatty  tissue,  how- 
ever carefully  pulled  out,  tightened  and  stitched,  gradually  stretches 
and  ceases  to  fix  the  organ.  In  other  cases — and  this  is  very  frequent 
— the  kidney  tissue  itself  is  deeply  traversed  by  the  needle.  Now,  the 
friability  of  the  kidney  is  well  known.  Every  operator  wdio  has  passed 
sutures  in  this  way  is  familiar  with  their  tendency  to  cut  through 
before  or  just  as  they  are  finalhT  tightened  and  tied.  So  soft  is  the 
tissue  of  the  kidney,  especially  when  injured  and  inflamed — as  around 
a  suture — that  I  believe  that,  even  when  silk  sutures  thus  passed  have 
been  left  in  situ,  their  cutting  through  is  only  a  matter  of  time.  When 
unsuitably  prepared  catgut,  however  stout,  has  been  employed  the 
result  is  still  worse.  Like  silk,  it  is  very  liable  to  cut  its  way  through 
the  easily  lacerable  kidney  tissue  as  it  is  tied ;  if  it  does  not  do  so 
then  its  softening  takes  place  so  quickly  in  the  vascular  kidney  tissue 
that  any  permanent  anchoring  by  the  blending  of  this  material  wTith 
other  tissues  is  impossible.*  Moreover,  there  is  another  danger,  not 
altogether  a  fanciful  one,  which  may  follow  on  deeply  puncturing  the 
kidney.  A  German  surgeon,  Barth,  has  seen  a  necrotic  centre  caused 
in  the  kidney  owing  to  the  occlusion  of  one  of  the  arterial  centres  by 
the  anchoring  suture.  A  similar  condition  has  been  noted  as  the 
result  of  puncture.  One  of  the  large  arteries  was  obstructed,  hsemor- 
rhagic  infarction  took  place,  and  ultimately  necrosis  (M'Ardle,  Brit. 
Med.  Journ.,  vol.  i.  1894,  p.  526).  A  fourth  step  that  has  been 
advised,  scarifying  the  surface  of  the  kidney  and  scraping  the  adjacent 
muscles  and  fascise  does  not  commend  itself  to  me  as  satisfactory  at 
the  time  or  likely  to  be  of  permanent  utility  later.  Sometimes  the 
kidney  is  fixed  too  low  down,  hydronephrosis  or  pyonephrosis  resulting. 
Mr.  Bruce  Clarke  (Lancet,  1905,  vol.  i.  p.  8)  records  an  interesting  case 
of  this  kind  in  which  the  kidney  had  been  fixed  so  low  that  it  nearly 
touched  the  crest  of  the  ilium.  Hydronephrosis  developed  and 
Mr.  Bruce  Clarke  replaced  the  kidney  after  proving  that  there  was  no 
obstruction  in  the  ureter.  The  kidney  was  regaining  its  normal 
secreting  power,  and  the  patient  was  comfortable  when  last  seen  a 
few  weeks  after  the  operation. 

*  Dr.  Newman  drew  attention  to  this  fact  several  years  ago  (Lectx.  on  the  Surg.  Dig.  of 
the  Kidney,  p.  69)  :  "The  sutures  passed  into  the  kidney  became  destroyed  more  rapidly 
than  elsewhere  ;  the  living  renal  tissue  seems  to  have  an  unusual  power  of  absorption." 


KEPHRORRAPHY  OR  NEPHROPEXY.        223 

Indications. — To  speak  of  the  indications  more  exactly.  Where  an 
otherwise  healthy  kidney  is  very  movable,  especially  where  this  dates 
in  sensible  people  to  an  injury,  it"  the  Burgeon  is  in  doubt  as  to  an 
operation,  he  should  try  and  satisfy  himself  that  other  treatment, 
including  ;i  sufficient  trial  of  a  well-fitting  apparatus,41  has  tailed,  that 
the  pain,  whether  constant  or  paroxysmal,  is  bond  fide,  and  tliat  it 
really  cripples  and  sjwils  the  patient's  life.  Constipation  and  dyspepsia 
will  of  course  have  heen  treated,  tight  lacing  given  up,  and  a  trial 
made  of  a  well-fitting  truss  or  belt,  or  a  corset  coming  low  down  in 
front  and  so  fitted  as  to  gather  up  the  lower  part  of  the  abdomen  and 
its  contents.  Gallant  (Inter.  Joum.  of  Surg.,  Feb.,  1903)  strongly 
recommends  a  corset  of  this  kind.  Thus,  conditions  of  movable 
kidney  which  call  for  operation  are  : 

1.  Frequent,  severe,  and  spasmodic  attacks  of  pain,  or  more  or 
less  continuous  suffering  (Morris,  vol.  ii.  p.  221). 

2.  Dietl's  "crises"  consisting  chiefly  of  violent  attacks  of  colic, 
nausea  and  vomiting,  tenderness  and  distension  of  the  abdomen,  and 
sometimes  shivering  and  rise  of  temperature.  These  attacks  may  be 
due  to  torsion  of  the  vessels  or  nerves  of  the  pedicle  or  of  the  ureter, 
or  of  the  duodenum.  Obstinate  constipation  due  to  kinking  of  the 
colon  is  sometimes  relieved  by  fixing  the  kidney. 

3.  Renal  paroxysms  of  acute  abdominal  pain,  rigidity  of  the  abdomen 
over  the  kidney,  "faintness,  giddiness,  and  other  symptoms  of  collapse  " 
(Morris).  These  rare  attacks  are  probably  due  to  "  acute  renal 
dislocation  "  (Lancereaux),  and  torsion  of  the  pedicle. t 

4.  Another  strong  indication  for  nephrorraphy  is  early  hydrone- 
phrosis. Here  the  operation  is  resorted  to  not  only  to  save  the  patient 
from  the  pain  caused  by  the  movable  kidney,  but  to  "prevent  the 
organ  from  bringing  about  it  own  destruction  "  (Lucas).  Mr.  Lucas 
(Brit.  Med.  Joum.,  vol.  ii.  1891,  p.  1344)  relates  four  cases  in  which 
mobility  of  the  kidney  allowed  of  displacement  of  the  organ  on  its 
transverse  axis,  causing  bending  of  the  ureter,  +  and  thus  distension  of 
the  pelvis  with  urine.  Two  of  the  cases  were  treated  by  nephrorraphy, 
and  when  last  seen  remained  cured.  One  of  the  cases,  in  which  the 
hydronephrosis  was  undoubtedly  due  to  the  displacement,  seemed  to 

*  The  best  one  that  I  know  is  the  one  recommended  by  Sir  Frederick  Treves  (Pract., 
Jan.,  1905)  and  made  by  Ernst :  "  It  consists  of  a  thin,  carefully-padded  metal  plate, 
which  exercises  pressure  upon  the  abdominal  wall  by  means  of  two  springs.  The  pressure 
concerns  the  lower  and  inner  margins  of  the  plate,  so  that  the  kidney  is  forced  upwards 
and  outwards.-'  Since  1895  Treves  has  used  the  instrument  for  over  300  private  patients, 
in  95  per  cent,  of  whom  "  the  truss  has  proved  absolutely  efficient."  "  With  the  truss  on 
the  patient  has  been  able  to  take  active  exercise,  to  ride,  and  in  an  occasional  instance,  to 
hunt."  The  instrument  must  be  very  carefully  fitted,  and  must  be  applied  when  the 
patient  is  lying  down. 

t  Dr.  Weigall  (AustraleuAam  Med.  Gazette,  Nov.,  1903)  has  published  a  most  remark- 
able case  of  gangrene  of  the  right  kidney  following  torsion  of  the  pedicle.  The  organ 
was  removed  in  time  to  save  the  patient's  life. 

\  This  same  displacement  of  the  kidney,  which  occludes  for  a  time  the  ureter,  will 
also,  by  twisting  the  pedicle,  affect  its  vessels.  As  Mr.  Lucas  points  out,  the  vein  will 
suffer  more  from  pressure  than  the  artery,  thus  causing  turgescence  of  the  organ  generally 
as  well  as  distension  of  its  pelvis.  Thus  are  brought  about  the  nausea,  pain,  vomiting,  &c, 
which  have  been  described  as  strangulation  or  acute  dislocation  of  the  kidney.  (Bruce 
Clarke,  Trans.  Med.-Chir.  80c,  vol.  lxxvi.  p.  2G3  ;  Brit.  Med.  Journ.,  vol.  i.  1895,  p.  575.) 


224  OPERATIONS  ON  THE  ABDOMEN. 

show  that  the  destruction  of  the  kidney  may  occasionally  go  on  without 
any  severe  attacks  of  pain.  Mr.  F.  J.  Steward  (Lancet,  vol.  i.  1905, 
p.  1069)  related  two  similar  cases  hefore  the  Clinical  Society ;  the 
mobility  of  the  kidney  had  caused  kinking  of  the  upper  end  of  the 
ureter.  In  each  case  the  kink  was  easily  corrected  by  replacing  the 
kidney.  After  nephrorraphy  the  average  daily  excretion  of  urea 
increased  from  167  grains  to  277  grains  in  one  case.  The  other 
patient  had  had  her  hydronephosis  drained  sixteen  weeks  before  her 
admission  into  Guy's  Hospital.  The  fixation  of  the  kidney  was 
successful  in  both  cases. 

5.  Extreme  mobility,  not  restrained  by  any  apparatus  that  the 
patient  can  bear,  and  preventing  the  patient  from  taking  proper 
exercise  or  following  her  occupation. 

The  following  questions  arise  as  to  the  sutures.  (1)  What  is  the 
best  material?     (2)  What  tissues  are  to  be  taken  up  ? 

The  answer  to  each  of  these  questions  is,  in  my  opinion,  a  simple 
one.  (1)  Kangaroo-tail  tendon  is  an  excellent  material,  but  I  prefer  to 
use  catgut  suitably  prepared  to  resist  absorption  for  about  six  weeks. 
Silk,  which  is  easily  obtained  and  readily  sterilised,  with  a  little  care 
will  be  quite  efficient.  It  should  not  be  of  the  plaited  kind,  it  should 
be  of  medium  size  and  carefully  prepared.  Buried  as  it  is  deeply,  the 
use  of  silk  here  is  less  open  to  the  objections  to  which  I  have  alluded 
in  the  account  of  Radical  Cure  of  Hernia. 

(2)  In  answer  to  this  question  I  am  strongly  of  opinion  that  to 
ensure  a  permanent  cure  in  nephrorraplry,  the  sutures  should  take 
hold  of  the  proper  capsule  of  the  kidney  itself,  after  this  has  been 
carefully  peeled  off  in  two  flaps.  I  have  tried  other  methods,  e.g., 
inserting  them  through  the  substance  of  the  kidney  itself,  either 
fastening  them  to  each  side  of  the  wound  and  dropping  them  in,  or 
passing  them  from  one  lip  of  the  wound  through  the  kidney  and 
finally  through  the  other  lip  of  the  wound.  The  longer  I  watched  my 
cases  the  less  reason  had  I  to  be  satisfied,  though  the  earlier  results 
had  been  excellent. 

Methods  of  operating. — A  great  number  and  variety  of  operations 
have  been  invented  and  recommended  for  fixing  a  movable  kidney. 
Many  of  them  are  not  based  on  sound  anatomical  and  mechanical 
principles,  and  others  have  been  conceived  in  ignorance  of  Nature's 
ways  of  healing.  No  attempt  will  be  made  here  to  give  an  exhaustive 
account  of  all  the  ingenious  devices  that  have  been  too  often  hastily 
recommended  without  allowing  sufficient  time  to  elapse  for  observation 
of  the  after  results:  only  a  few  typical  methods  will  be  briefly  described. 
Operations  based  on  fixing  the  fatty  capsule  only  have  been  proved  to 
be  unsatisfactory.  There  is  little  doubt  from  experimental  and 
clinical  results  that  firmer  union  occurs  when  the  cortex  of  the  kidney 
is  bared,  than  when  sutures  which  pierce  the  friable  renal  tissues  are 
relied  upon.  Moreover  such  sutures  are  not  quite  devoid  of  danger, 
as  already  pointed  out,  and  there  are  at  least  five  cases  on  record  in 
which  these  sutures  have  caused  urinary  fistuhie  due  to  laceration  of 
the  kidney.  It  is  true  that  the  leakage  was  not  permanent,  but  it  was 
troublesome  and  avoidable ;  in  one  case  a  second  operation  was 
required  (Clayton  Greene,  Lancet,  1904,  vol.  ii.  p.  171 1).  It  is 
safer  and  better  to  pass  the  sutures  through  the  capsule  only,  unless 


NEPHRORRAPHY  OR  NEPHROPEXY.        225 

the   latter  is  too  tliin  to   be  relied  upon.      In  my  opinion  the  usual 
oblique  lumbar  incision  gives  more  room  and  far  better  access  to  the 

kidney  and  allows  a  more;  thorough  examination  of  the  pelvis  and 
ureter  than  the  vertical  incision  advocated  by  some  surgeons,  and 
my  experience  of  the  prone  position  has  not  impressed  me  favourably, 
for  it  certainly  embarrasses  the  breathing,  and  increasing  venous 
congestion  and  bleeding.  All  attempts  to  fix  the  kidney  through  the 
peritonaea]  cavity  are  to  be  condemned  as  futile  and  unnecessary. 
Passing  stitches  through  the  pleura  and  diaphragm  to  endeavour  to 
fix  the  upper  end  of  the  kidney  is  not  to  be  recommended,  because  it 
is  at  least  meddlesome  and  it  is  enough  to  secure  the  lower  two  thirds 
of  the  organ.  As  regards  the  parietes,  the  kidney  and  its  fibrous 
capsule  should  come  into  contact  with  the  raw  surfaces  of  the 
qnadratus  lumborum  muscle  and  the  deeper  part  of  the  parietal 
wound;  but  the  kidney  must  not  be  drawn  too  much  into  the  wound, 
where  it  will  be  exposed  to  injuries,  and  especially  liable  to  nephritis, 
soon  after  the  operation,  as  shown  by  Wolff  (Deutsche  Zeitscltrij't  fur 
Chirurgie,  Leipzig,  1897,  x^v^  P-  533) •  Fixation  of  the  lower  end 
of  the  kidney  only  in  the  attempt  to  get  it  into  a  high  position  may 
lead  to  anteversion  of  the  organ  or  to  stretching  of  the  adhesions, 
due  to  the  pressure  of  the  diaphragm  and  liver  on  the  upper  pole. 
On  the  other  hand,  fixation  at  too  low  a  level  may  lead  to  kinking  of 
the  ureter  and  hydronephrosis,  and  perhaps  to  pain  from  the  pressure 
of  the  corset  at  the  waist. 

For  the  average  operator  and  an  average  patient  it  must  be  unwise 
to  attempt  to  fix  both  kidneys  at  the  same  time,  although  Edebohls, 
with  his  great  experience,  has  not  found  this  heroic  practice  danger- 
ous. In  more  than  a  third  of  his  cases  the  double  operation  was 
performed. 

To  hope  to  get  very  firm  adhesions  from  the  granulation  tissue 
formed  as  a  result  of  gauze  packing,  scarification,  or  cauterising  of  the 
capsule  with  pure  carbolic  acid,  is  vain,  for  experience  has  proved  that 
such  adhesions  are  not,  in  the  end,  as  strong  as  those  obtained  by 
primary  union  between  raw  surfaces  kept  in  apposition  by  means  of 
sutures.  Carwardine  (Bristol  Med.-Chir.  Joum.,  March,  1905)  however 
advocates  the  use  of  carbolic  acid  and  gauze  packing  for  this  pur- 
pose. He  quotes  eight  cases  and  states  he  has  been  able  to  prove 
that  very  firm  adhesions  follow  his  method.  Rest  in  the  recumbent 
position  for  at  least  three  weeks  is  essential  for  the  success  of  the 
operation. 

Operation. — The  kidney  is  first  thoroughly  exposed  by  the  steps 
given  at  p.  172,  an  assistant  keeping  the  organ  well  pushed  up  into 
the  loin  while  the  surgeon  cuts  down  on  it.  I  may  here  say  that 
in  some  of  these  cases  of  very  movable  kidney  the  tissues  around 
are  so  loose  from  the  dragging  and  shifting  to  and  fro  of  the  kidney 
that  they  wrap  round  the  organ  very  closely,  and  thus  it  is  easj'  to 
injure  the  peritonaeum.  Thus,  in  one  of  the  patients  mentioned  above 
the  right  kidney  was  mobile  through  an  extremely  wide  range,  and  so 
loose  that  when  lying  on  her  left  side  the  patient  could  make  it  project 
as  a  convex  lump  in  the  left  iliac  fossa.  When  I  was  operating  on  this 
side  I  found  the  kidney  easily  reached,  but  not  easy  to  define,  owing  to 
the   extreme  looseness  of   the  folds   of   the    perinephritic   tissue   and 

s. — vol.  11.  15 


226  OPERATIONS  ON  THE  ABDOMEN. 

peritonaeum.*  This  latter  structure  I  opened  in  two  places,  the  thin 
edge  of  the  liver  appearing  at  one,  and  some  omentum  in  the  other. 
The  first  opening  was  clamped  and  tied  up  with  a  catgut  ligature, 
the  second  closed  with  a  continuous  suture  of  the  same.  Strict  aseptic 
precautions  were  taken,  and  not  the  slightest  ill  result  followed.  This 
accident,  which  I  have  seen  occur  twice  in  one  day,  can  be  avoided  by- 
taking  care  to  incise  the  fatty  capsule  at  the  upper  and  inner  part  of 
the  wound. 

The  kidney  itself  having  been  exposed,  it  is  gently  withdrawn  through 
the  wound,  and  thoroughly  examined  for  signs  of  disease,  and  the  upper 
part  of  the  ureter  is  also  palpated  for  stone.  Then  an  incision  is  made 
with  a  very  light  hand  all  along  the  convex  border  from  end  to  end. 
Unless  the  utmost  gentleness  is  taken  in  the  last  step  the  tissue  of  the 
organ  itself  will  certainly  be  incised,  causing  free  oozing.  With  the 
handle  of  a  scalpel  or  a  blunt  dissector,  flaps  of  capsule  are  then  deli- 
berately but  gently  stripped  off  the  kidney  up  to  a  point  about  halfway 
along  its  lateral  surfaces,  so  as  to  raise  sufficient  flaps  for  the  sutures  to 
find  a  holding  in.  The  flaps  having  been  raised  they  are  sutured  with 
medium-sized  sterilised  catgut  to  the  aponeurotic  and  muscular  edges 
of  the  wound.  To  get  a  firm  and  permanent  holding,  each  suture 
should  take  up  plenty  of  capsule  on  the  one  side  and  a  sufficient  grip 
of  the  lumbar  fascia  on  the  other.  I  generally  use  upwards  of  ten 
sutures,  perhaps  six  in  one  flap  and  four  in  the  other.  One  word 
of  caution  should  be  added.  This  method  of  anchoring  is  so  efficient 
that,  unless  care  is  taken,  it  is  possible  to  fix  the  kidney,  which  has 
been  drawn  out,  actually  between  and  not  beneath  the  lips  of  the  wound. 
After  one  row  of  sutures,  say  the  upper,  has  been  inserted,  tied  and  cut 
short,  and  the  second  merely  inserted,  care  should  be  taken  gently  to 
push  the  kidney  into  its  proper  place  in  the  loin,  just  under  the  wound  ; 
the  lower  sutures  are  then  also  tied,  cut  short,  and  dropped  in.  Any 
oozing  met  with  after  stripping  off  the  flaps  of  capsule  will  yield  to  firm 
sponge-pressure  kept  up  by  an  assistant  while  the  surgeon  is  putting  in 
his  sutures.  It  is  well  also  to  keep  a  sponge  in  the  lower  part  of  the 
wound,  to  be  removed  before  the  last  sutures  are  tightened.  If  when 
all  bleeding  is  arrested  the  wound  is  very  carefully  dried  out,  no  drain- 
age-tube will  be  required.  In  closing  the  wound  I  unite  the  edges 
of  the  muscles  and  fascia  with  buried  sutures  of  chromic  gut,  and  the 
skin  with  salmon  gut.  I  recommend  this  method  most  strongly  :  it  is 
both  easy  and  efficient,  and  sufficient  time  has  now  elapsed  in  several 
of  my  cases  for  me  to  be  able  to  say  that  no  injury  is  inflicted  on  the 
kidney  by  the  stripping  off  of  its  capsule.  Newman  ("  Surgical  Studies, 
Renal  case  ")  employs  a  very  similar  method  and  speaks  well  of  the 

*  This  was  not  a  mesonephron,  an  exceedingly  rare  condition.  I  find  that  Dr.  Drarn- 
mond,  of  Newcastle,  described  a  similar  condition  several  years  ago  ("  Clinical  Aspects  of 
Movable  Kidney,"  Lancet,  vol.  i.  1890,  p.  121)  :  "In  almost  every  instance  in  which  the 
kidney  has  been  found  to  be  freely  movable,  the  other  abdominal  organs  have  been  corre- 
spondingly loose  in  their  attachments — the  spleen,  liver,  cascurn,  stomach,  &c.  More  than 
once  a  distinct  mesonephron  was  present,  but  much  more  often  the  peritoneal  covering 
was  simply  loose,  so  that  the  organ  could  be  easily  placed  in  various  novel  positions.  At 
times  the  kidney  had  dragged  the  relaxed  peritoneum  so  far  from  the  abdominal  wall  as 
to  bring  into  close  conjunction  the  upper  and  lower  layers,  so  as  to  form  a  false 
mesonephron." 


NEPHRORRAPHY  oil  NEPHROPEXY. 


227 


results.  He  inserts  a  large  drainage-tube  between  the  kidney  and  the 
deeper  parts  of  the  wound  in  order  to  promote  adhesions  to  the  wound. 

Arbuthnot  Lane  (Clin.  80c.  Trans.,  vol.  xxv.  p.  203)  raises  about 
ten  triangular  Haps  of  the  capsule  of  the  posterior  surface  of  the  kidney  ; 
each  flap  is  twisted  and  tied  with  silk  brought  through  the  muscles  and 
fixed  by  tying  the  adjoining  ligatures. 

Blair  (interstate  Med.  Journ.,  May  4,  1904)  makes  use  of  a  very 
similar  plan,  but  he  only  raises  three  Haps,  two  of  which  have  their  bases 
at  the  outer  border  and  the  other  remains  attached  at  the  pelvic  border. 
These  are  drawn  untwisted  through  the  fatty  capsule,  the  lumbar  fascia 
and  the  muscles  of  the  back,  and  fastened  with  catgut  sutures.  "The 
peritonaeum  around  the  kidney  is  also  sutured  to  the  lumbar  fascia  so 
as  to  draw  it  taut  over  the  anterior  surface  of  the  organ,  as  an  additional 
Bupport. 

Edebohls'  Operation  (Ann.  of  Surg.,  1902,  vol.  xxxv.  p.  174). — The 
patient  is  placed  in  the  prone  position  with  an  air  cushion  (fourteen 


Fig.  64. 


Nephropexy  (After  Edebohls  ;  Ami.  of  Surg.).     The  suspension  sutures 
placed  in  the  fibrous  capsule. 

inches  long  and  eight  inches  in  diameter)  supporting  the  abdomen  and 
pushing  the  kidneys  well  back  into  the  loin.  Edebohls  maintains  that 
this  position  does  not  embarrass  the  breathing  or  render  anaesthesia 
difficult  or  dangerous;  it  greatly  facilitates  the  finding  and  delivery  of 
the  kidney. 

A  vertical  incision  is  made  along  the  outer  border  of  the  erector 
spime  from  the  last  rib  to  the  iliac  crest ;  the  fibres  of  the  latissimus 
dorsi  are  separated,  and  the  lumbar  fascia  is  incised  so  as  to  expose 
the  perirenal  fat,  and  sometimes  the  ileo  hypogastric  nerve  which  may 
be  drawn  aside  or  divided  and  reunited  later  on. 

The  anterior  lamella  of  the  lumbar  fascia  is  slit  vertically  and 
retracted  in  order  to  expose  freely  the  muscular  fibres  of  the  quadratus 
lumborum,  which  are  destined  to  form  an  adhesive  bed  for  the  kidney. 

The  kidney  is  sought  and  freed  by  the  fingers,  and  together  with  its 
fatty  capsule  it  is  brought  out  on  to  the  loin ;  if  the  incision  is  too 
small  to  allow  this,  more  room  may  be  obtained  by  incising  the  outer 
fibres  of  the  quadratus  near  the  ilium.  The  fatty  capsule  is  removed, 
and  the  kidney,  pelvis,  and  upper  part  of  the  ureter  are  thoroughly 
palpated  and  inspected,  or  even  incised  if  necessary.  The  fibrous  cap- 
sule is  nicked  at  the  middle  of  the  convex  border  and  slit  from  pole  to 
pole  along  a  grooved  director.     Anterior  and  posterior  flaps  are  raised  by 

'   15—2 


228 


OPERATIONS  ON  THE  ABDOMEN, 


blunt-dissectors,  so  as  to  denude  the  outer  half  of  the  cortex  ;  some  of 
the  flaps  may  be  removed  if  they  are  too  large. 

"Four  suspension  or  fixation  sutures  of  forty-day  catgut "  are  passed 
through  the  fibrous  capsule,  two  to  each  flap,  as  shown  in  Fig.  64. 
Each  suture  pierces  the  flap  near  its  base  and  also  the  attached  capsule 
under  which  it  runs  for  a  distance  of  two  to  three  centimetres  ;  a 
Hagedorn  needle  held  on  the  flat  is  used  to  pass  the  suture  to  avoid 
penetration  of  the  cortex  of  the  kidney. 

When  all  the  sutures  have  been  placed,  the  kidney  is  returned  into 
position,  and  the  anterior  and  posterior  sets  of  stitches  are  passed 
through  the  parietes  at  a  distance  of  about  ii  inches  from  each  other. 
The  inner  sutures  pierce  the  anterior  lamella  of  the  lumbar  fascia,  the 
quadratus  lumborum,  the  erector  spinas  and  the  latissimus  dorsi,  the 
outer  ones  pass  through  the  lumbar  fascia  and  the  latissimus  dorsi. 

Fig.  65. 


Nephropexy  (Edebohls).    The  suspension  sutures  piercing  the  muscles  ;  the 
fibres  of  the  latissimus  dorsi  have  been  separated  only. 

The  highest  stitches  are  close  to  the  last  rib.  The  parietal  wound  is 
closed  with  catgut  sutures  "  passed  in  such  a  manner  as  to  turn  the  raw 
surface  of  the  quadratus  towards  the  kidney,"  and  lastly  the  suspension 
sutures  are  tied  as  shown  in  Figs.  65  and  66.  The  wound  is  not  drained, 
but  is  completely  closed  by  means  of  the  intra-cuticular  suture. 

Edebohls  does  not  claim  that  the  kidney  is  fixed  as  high  as  the 
normal  position,  but  that  it  is  placed  high  enough  for  practical  purposes. 
Moreover,  he  maintains  that  it  is  not  wise  to  attempt  high  fixation, 
lest  the  liver  in  descending  lengthen  the  adhesions,  or  cause  anteversion 
of  a  kidney  which  has  only  been  fixed  at  its  lower  part,  which  is 
common  when  high  fixation  is  attempted. 

So  certain  is  he  that  other  diseases  frequently  co-exist  with  movable 
kidney,  that  he  often  opens  the  peritonaeum  to  the  outer  side  of  the  kid- 
ney, and  explores  the  gall  bladder  and  ducts,  the  duodenum  and  pylorus, 
and  especially  the  appendix,  which  he  often  removes  through  the  loin. 
He  then  closes  the  peritonaeum  and  proceeds  with  the  nephropexy. 


NKPIIKOIMIAIMIY    OK    NEPHROPEXY. 


229 


Tuffler's  Method  (Traitr  de  Ohirurgie,  Duplay  and  Reclus,  2nd  ed. 
1899,  tome  vii.) - — The  kidney  is  approached  through  a  slightly  oblique 
or  nearly  vertical  incision  extending  from  the  eleventh  rib  to  the  crest 
of  the  ilium.  The  fatty  capsule  is  separated  from  the  fibrous  one  on 
both  surfaces  and  the  outer  border. 

Two  thick  sutures  of  catgut  or  kangaroo-tendon  are  passed  through 
the  kidney,  one  near  the  lower  pole  and  the  other  about  4  centimetres 
below  the  upper  end.  A  third  suture  is  passed  between  these  two  when 
the  cortex  has  been  exposed  on  the  posterior  surface  and  outer  bolder 
by  dissecting  off  the  fibrous  capsule.  The  stitches  are  fixed  to  the 
parietes,  the  upper  one  to  the  periosteum  on  the  back  of  the  twelfth 
rib  and  the  others  to  transversalis  fascia.  Care  is  taken  not  to  tie 
them  so  tightly  as  to  lacerate  the  kidney,  which  they  serve  to  anchor 

Fig.  66. 


Nephropexy  (Edebohls).     The  four  suspension  sutures  tied,  and  the  wound 
closed  by  separate  suture. 

to  the  lumbar  wall  lower  than  the  normal   position.     The  wound  is 
closed  in  layers  by  buried  catgut  sutures,  no  drainage  being  used. 

Jonnesco's  Method  (Centralblatt  fur  Chirurgie,  No.  30,  1897). — 
Jonnesco,  having  tried  the  vertical  incision,  preferred  and  adopted  the 
oblique  one,  as  it  enabled  him  to  fix  the  kidney  to  the  ribs.  He  detaches 
the  true  capsule  along  the  whole  length  of  the  convex  border,  three 
silk  or  silver  wire  sutures  are  passed  through  the  skin  3  cm.  to  the 
inner  side  of  the  wound,  through  the  erector  spina?  and  the  lumbar 
fascia,  the  capsule,  the  posterior  surfaces  of  the  kidney  1^  cm.  from  the 
outer  border,  through  the  capsule  again  and  the  periosteum  of  the 
twelfth  or  eleventh  rib,  and  all  the  soft  parts  to  the  outer  side  of  the 
wound.  Two  sutures  are  passed  near  the  poles  and  the  other  at  the 
middle  of  the  kidney;  they  are  tied  so  as  to  suspend  but  not  to  lacerate 
the  organ.  The  stitches  are  removed  after  ten  days.  Jonnesco  claims 
that  his  method  is  simple  and  efficient,  that  the  sutures  do  not  tear 
out  because  they  pass  through  the  capsule  of  the  kidney,  and  that 


230 


OPERATIONS    ON    THE    ABDOMEN. 


being  removed  after  ten  days,  the)'  do  not  cause  unpleasant  after- 
effects like  pain,  suppuration,  fistula,  or  fibrosis  of  the  kidney  substance. 

In  this  operation  the  kidney  is  fixed  with  its  axis  turned  out  of  the 
normal  and  parallel  to  the  last  rib. 

Fullerton's  Operation  (Brit.  Med.  Journ.,  Dec.  24,  1904). — The 
kidney  is  approached  through  the  usual  oblique  incision,  and  "it  is 
pushed  up  to  but  not  out  of  the  wound."  A  large  flap  of  the  true 
capsule  is  then  raised  from  the  posterior  surface  and  outer  border  of 
the  kidney,  the  base  of  the  flap  being  "  just  above  the  centre  of  the 
horizontal  axis  of  the  kidney."  The  inner  border  of  the  flap  is  made 
longer  than  the  outer,  to  preserve  the  inward  tilt  of  the  upper  end  of 


Fig.  67. 


The  kidney  from  behind  (Fullerton). 
L.A.E.,  is  shown.     Q.L.- 


The  ligamentum  arcuatum  externum, 
-Quadratus  Lumborum. 


the  organ.  The  finger  is  now  insinuated  deep  to  the  ligamentum 
arcuatum  externum,  which  is  easily  found  stretching  horizontally  from 
the  lower  border  of  the  last  rib  near  its  tip  to  the  transverse  process  of 
the  first  lumbar  vertebra  in  front  of  the  quadratus  lumborum.  The 
tissues  on  the  anterior  surface  of  the  ligament  are  pushed  up  "  so  as  to 
get  rid  of  the  pleura  should  it  descend  lower  than  usual.  "While  the 
finger  thus  protects  the  pleura,  an  incision  is  made  about  a  third  of  an 
inch  or  more  above  the  lower  margin  of  the  ligament,  and  parallel  to 
its  fibres  for  the  whole  available  distance  between  the  quadratus 
lumborum  and  the  tip  of  the  last  rib.-' 

By  means  of  forceps  the  flap  of  capsule  is  drawn  backwards 
through  the  slit  in  the  ligament,  spread  out  and  sewn  "  to  the  ligament 
and  neighbouring  parts  with  catgut  or  silk."  "  Other  stitches  may 
be  used  to  unite  the  capsule  at  the  margins  of  the  raw  surface  to  the 


Ni:riii;oi;i;Ai'iiv  OB   NEPHROPEXY. 


231 


Fig.  68. 


lumbar  fascia  at  the  sides  and  below  if  considered  necessary  "  (vide 

.  67  and  68). 

Mr.  F ullerton  does  not  claim  that  the  kidney  is  replaced  in  its  normal 
position,  but  believes  that  "  it  is  fixed  a  little  lower  than  normal,  hut  it, 
is  slung  by  its  own  capsule,  and  for  all  practical 
purposes  it  is  in  excellent  position." 

At  the  time  of  writing  his  paper  Mr.  Fuller- 
ton  had  performed  the  operation  three  times  on 
the  living  subject.  The  following  criticisms  may 
be  made.  No  mention  is  made  of  the  removal 
of  any  of  the  perirenal  fat,  and  as  the  kidney  is 
not  brought  out  of  the  wound,  a  co-existing 
lesion  of  the  kidney  may  easily  be  overlooked. 

In  answer  to  my  enquiries,  Mr.  Fullerton 
kindly  wrote  in  October,  1906,  that  he  has  seen 
some  of  the  cases  nearl}-  two  years  after  opera- 
tion, and  that  the  kidneys  remain  fixed.  His 
senior  colleague,  Air.  Mitchell,  has  adopted  the 
operation  in  preference  to  all  others. 

Morris'  Operation  {Surg.  Diseases  of  the 
Kidney  and  Ureter,  1901,  vol.  ii.  p.  231). — 
Morris  exposes  the  kidney  through  his  usual 
oblique  lumbar  incision,  and  removes  a  considerable  part  of  the  perirenal 
fat,  but  he  does  not  believe  it  to  be  necessary  to  interfere  with  the  fibrous 
capsule  in  any  way.     He  passes  three  silk  sutures  "  into  the  posterior 

Fie.  69. 


Diagram  of  right  kidney 
and  flap  (Fullerton). 


Nephropexy  (Morris'  Operation).     Left  kidney  shown.     The  sutures  are 
represented  in  the  figure  too  near  the  hilum  (Morris). 

surface  of  the  kidney,  one  nearer  the  upper,  the  other  nearer  the  lower 
end,  and  the  third  midway  between  the  other  two,  but  nearer  the  hilum. 
Each  suture  is  buried  for  a  length  of  three-quarters  of  an  inch  within 


232 


OPERATIONS    ON    THE    ABDOMEN. 


Fig.  70. 


the  renal  substance,  and  penetrates  about  half  an  inch  into  the  thick- 
ness of  the  organ."  The  sutures  are  then  passed  through  the  edges  of 
"  the  shortened  adipose  capsule,  the  transversalis  fascia,  and  the  deeper 
layers  of  muscles,  and  tied  to  them  as  shown  in  figure  69. 

Only  one  of  the  sutures  serves  to  narrow  the  parietal  wound,  which 
is  closed  by  silk  sutures  passing  through  all  the  layers  including  the 
skin.  A  drainage  tube  is  often  used.  The  wound  usually  heals  in  a 
week,  but  the  patient  is  kept  in  bed  for  from  four  to  five  weeks. 
Mr.  Morris  sometimes  uses  Vulliet's  method  in  severe  cases  in  young 
women  and   speaks  highly  of  it ;  he   also  raises   capsular  flaps  from 

edges  of  the  renal  wound  when  an 
exploration  of  the  kidney  has  been 
considered  necessary. 

He  considers  that  M'Ardle  has  ex- 
aggerated the  risk  of  sepsis  and  phle- 
bitis involved  by  sutures  penetrating 
the  renal  tissues,  and  also  that  the 
danger  of  including  one  of  the  large 
renal  arteries  (Barth)  is  avoided  by 
passing  the  sutures  only  from  the  pos- 
terior surface  and  not  through  the  thick- 
ness of  the  organ.  Morris  has  operated 
on  more  than  eighty  cases  without  a 
death. 

Goelet's  Operation  (Ann.  of  Surg., 
1903,  vol.  xxxviii.  p.  769). — The  kidney 
is  exposed  as  in  Edebohls'  operation 
(p.  227),  and  the  fatty  capsule  is  dragged 
downwards  and  opened  at  the  upper 
and  inner  angle  of  the  wound  to  avoid 
opening  the  peritonaeum  or  injuring  the 
colon.  Traction  is  made  on  the  fatty 
capsule,  and  the  kidney  is  delivered  into 
the  wound.  The  fatty  capsule  is  com- 
pletely separated  from  the  kidney,  and  thus  the  duodenum  and  colon 
are  detached  from  the  anterior  surface.  The  pelvis  and  ureter  are 
searched  for  stone. 

The  capsule  is  neither  detached  nor  split,  as  Goelet  believes  this  to 
be  unnecessary  for  firm  union  granting  that  non-absorbable  ligatures, 
which  do  not  stretch,  are  used,  and  that  these  are  tied  so  that  they 
cannot  become  loose  by  cutting  into  the  tissues.  Goelet  uses  silk- 
worm gut  made  pliable  by  boiling  and  preserving  in  3  per  cent. 
Lysol. 

Two  sutures  are  inserted  into  the  posterior  aspect  of  the  free  border 
kidney,  one  at  the  junction  of  the  middle  and  lower  third,  and  the 
other' about  the  centre  of  the  kidney  (vide  Fig.  70).  "  A  small  fully 
curved  needle  one  inch  long  is  used  to  pass  the  sutures. — The  lower 
one  pierces  the  true  capsule  at  a  and  passes  beneath  it  for  half  an  inch 
to  b  superficially  to  it  for  nearly  half  an  inch  to  c,  deep  to  it  for  half  an 
inch  from  c  to  d,  and  superficially  from  d  to  c,  deeply  from  c  to  /. 
Goelet  maintains  that  the  strain  upon  the  sutures  "is  in  a  direction 
parallel  to  the'surface  of  the  kidney  and  its  capsule,  and  not  at  right 


Nephropexy  (After       Goelet  ; 

Ann.   of   Surg.').  The    suspension 

sutures  placed  in  the  true  capsule. 
(Posterior  view.) 


NEPHRORRAPH?  OB  NEPHROPEXY. 


233 


angle  to  it,"  as  in  all  other  forms  of  suture  used  ;  therefore  it  requires 
great  tension  to  make  the  stitch  tear  out. 

All  redundant  fatty  capsule  is  torn  off  or  excised  with  scissors,  due 
care  being  taken  not  to  injure  the  bowel  or  open  the  peritonaeum.  The 
kidney  is  then  replaced,  and  the  sutures  are  then  passed  through  all 
the  parietes  near  the  upper  end  of  the  wound,  by  means  of  a  long 
curved  perinaeal  needle  {vide  Fig.  71).  They  are  tied  over  a  roll  of 
gauze  placed  longitudinally.  This  forms  a  cushion  for  the  suture 
loop  to  rest  upon,  and  prevents  the  sutures  from  cutting  through  the 
skin  and  consequent  loosening  of  the  loop.  A  gauze  drain  is  packed 
around  and  below  the  lower  pole  of  the  kidney  to  keep  back  the  fat 
which  has  not  been  removed.  The  wound  is  sewn  up  in  layers,  except 
at  the  lower  angle  where  the  gauze  packing  protrudes.     The  sustaining 

Fig.  71. 


Nephropexy  (After  Goelet ;  Ann.  of  Surg.).     The  suspension  sutures  being 
passed  through  the  whole  thickness  of  the  parietes. 


sutures  are  not  removed  until  the  twentieth  day,  and  the  patient  is 
allowed  to  get  up  next  day. 

Goelet  lays  great  stress  on  the  importance  of  complete  removal  of 
the  fatty  capsule,  and  especially  upon  the  detachment  of  the  duodenum 
and  colon  to  prevent  these  from  dragging  on  the  kidne^y.  He  also 
seems  to  think  that  he  can  prevent  these  structures  from  re-adhering 
to  the  kidney  by  means  of  gauze  packing,  and  early  stimulation  of 
intestinal  movements.  He  claims  that  he  has  had  no  recurrence  in 
171  operations  on  134  patients,  37  of  these  having  both  kidneys  fixed 
on  the  same  day. 

It  may  be  objected  that  these  cases  had  not  been  observed  long 
enough  for  the  conclusions  to  be  final,  for  the  first  of  the  operations 
was  only  performed  about  three  years  before  Dr.  Goelet's  paper  was 
read. 

The  Method  of  Vulliet  (Revue  Medicale  de  la  Suisse  Bomande, 
20  Juin,  1895,  p.  326). — The  kidney  having  been  exposed  and  freed 
in  the  usual  way,  another  short  vertical  incision  is  made  close  to  the 


234 


OPERATIONS  ON  THE  ABDOMEN. 


spinous  process  of  the  last  lumbar  vertebra,  and  a  tape-like  slip  of  the 
tendon  of  the  erector  spinas  is  pulled  out  but  left  attached  at  its  lower 
end.  Thomas  (Brit.  Med.  Joum.,  Nov.  8,  1902)  uses  a  swivel  to 
aid  him  in  detaching  a  suitable  length.  The  slip  should  be  about  ten 
inches  long  and  a  quarter  of  an  inch  wide.  It  is  passed  by  means  of  a 
long  straight  blunt  needle  in  a  handle  and  with  a  large  eye  near  the 
extremit}',  through  the  muscular  tissues  of  the  erector  spinas  and 
quadratus  lumborum.  "It  is  made  to  underrun  the  fibrous  capsules 
of  the  kidney  upon  its  posterior  surface  and  near  the  external  border, 
it  is  then  passed  back  again  and  fixed  to  the  erector  spinas  muscle  by 
means  of  a  suture  of  fine  silk  "  (Morris,  vide  Fig.  72). 

Morris  sometimes  modifies  this  operation  when  too  short  a  length 

Fig.  72. 


Last  rib , 


Deflected  tendon  slip,  showing  its 
course  through  the  muscular  mass 
and  beneath  the  renal  capsule  .     . 

Spinous  process  first  lumbar  vertebra 
Muscular  mass 


Vulliet's  method  of  fixing  the  kidney.  A  side  view,  showing  the  spinous 
processes,  as  well  as  the  side  of  the  bodies  of  those  bones.  The  kidney  is  in 
situ,  but  the  suture  is  made  to  appear  to  enter  on  the  anterior  instead  of  the 
posterior  face.     Diagrammatic,  copied  from  Vulliet's  paper  (Morris). 

of  tendon  tears  out  by  splitting  the  latter  and  passing  the  two  through 
the  muscles  to  the  kidney,  and  one  of  them  under  the  capsule.  The 
two  strands  are  then  tied  firmly  together.  Morris  recommends  Vulliet's 
operation,  but  states  that  patients  complain  of  pain  in  the  back  for  a 
short  time.     Thomas  (loc.  eit.)  reports  10  successful  cases. 

The  Mortality  of  Nephropexy. — Morris  reports  80  operations  with- 
out a  death,  and  Tuffier  75  with  2  deaths.  The  latter  has  also 
collected  173  records  with  a  mortality  of  4*4  per  cent,  for  all  operators 
(Morris,  loc.  cit.,  vol.  ii.  p.  236). 

Edebohls  collected  records  of  836  operations  by  surgeons  with 
experience  of  at  least  15  operations  each  ;  the  mortality  was  1*65  per 
cent.  Edebohls  himself  (loc.  cit.)  reports  193  operations  with  3 
deaths,  a  mortality  of  1*55  per  cent.  More  than  a  third  of  these 
patients  had  bilateral   operations,  and   in  52  the  appendix  was  also 


NEPHRORRAPHY  OR  NEPHROPEXY. 


235 


removed.      In  2  nephrectomy  was   performed   on    the   opposite  side 
at  the  8am e  operation  (a  most  hazardous  proceeding). 

Goelet  records  171  operations  on  134  patients  without  a  death 
(loc.  cit). 

Edebolils  has  also  operated  on  135  successive  cases  without  a  death, 
and  he  quotes  Johnston  as  having  operated  107  times  without  a  fatality. 
It  may  he  stated  that  at  the  present  time  the  mortality  should  not  lie 
more  than  I  to  2  per  cent,  for  skilful  and  aseptic  surgeons. 

Death  may  occur  from  sepsis,  peritonitis,  tetanus,  pulmonary 
embolism,  broncho-pneumonia,  uncontrollable  vomiting.  Pulmonary 
embolism  is  a  common  cause  of  death  and  is  probably  due  to  throm- 
bosis of  the  renal  vein,  which  may  occur  when  the  kidney  has  not 
been  pierced  by  any  suture  ;  it  may  be  due  to  laceration  of  the  lining  of 
the  vein  during  forcible  attempts  to  deliver  the  kidney  combined  with 
the  enforced  rest  that  must  follow  the  operation.  As  far  as  I  know, 
the  clot  has  not  been  proved  to  be  septic  in  origin. 

Accidents  that  may  happen  during  the  operation.  Laceration  of  the 
kidney  may  occur  during  its  delivery,  but  it  is  more  common  as  the 
result  of  tension  on  sutures  which  pierce  the  kidney.  Edebolils 
{Ann.  of  Surg.,  1902,  vol.  xxxv.  p.  157)  reports  a  case  in  which  a 
fistula  persisted  for  three  and  a  half  months,  and  he  refers  to  three 
other  cases. 

Clayton  Greene  {Lancet,  1904,  vol.  ii.  p.  171 1)  has  reported  an 
interesting  case,  which  is  probably  unique.  A  fistula  followed  the  use 
of  deeply  penetrating  catgut  sutures.  It  closed  after  the  removal  of 
some  deep  sutures,  but  six  months  later  another  operation  was 
required  for  pain  and  swelling.  A  clear  fluid,  presumed  to  be  urine, 
was  found  within  a  greatly  thickened  true  capsule,  which  was  detached 
from  the  kidney,  except  at  the  hilum.  Mr.  Clayton  Greene  calls  this 
condition  external  hydronephrosis. 

The  peritonaeum  may  be  opened,  because  the  liver  may  be  mistaken 
for  the  kidney.  The  colon  may  be  wounded,  and  the  pleura  has  been 
opened  causing  temporary  pneumothorax.     The  ureter  has  been  torn. 

Complications. —  Septic  infection,  nephritis,  neuralgia  from  section 
or  involvement  of  nerves  in  the  scar. 

Hernia  may  occur,  but  Edebohls  was  only  able  to  discover  records 
of  nine  cases. 

Results. — It  is  to  be  regretted  that  some  of  the  energy  devoted  to 
inventing  and  publishing  new  methods  is  not  spent  on  following  cases 
and  recording  ultimate  results. 

Very  few  statistics  are  of  any  great  value,  because  the  patients  have 
not  been  examined  after  a  sufficient  length  of  time;  it  is  absurd  to 
claim  cures  after  a  few  months  only,  for  it  is  well  known  that  fibrous 
adhesions  often  stretch,  and  even  vanish  in  time.  The  scar  that 
follows  free  drainage  for  suppurative  peritonitis  seems  firm  enough  for 
some  months,  but  a  ventral  hernia  appears  as  a  rule  sooner  or  later. 

Goelet  (loc.  supra  cit.)  claims  that  he  has  only  had  one  partial  failure 
after  171  operations,  but  his  cases  could  not  have  been  observed  long 
enough  to  justify  this  optimism,  for  the  first  of  the  operations  was 
performed  only  three  years  before  the  results  were  published. 

Edebohls  (loc.  supra  cit.)  maintains  that  not  a  single  one  of  the 
kidneys  which  he  has  anchored  has,  to  his  personal  knowledge,  again 


236  OPERATIONS  ON  THE  ABDOMEN. 

become  movable.  Everyone  knows,  however,  that  it  is  practically 
impossible  to  trace  all  cases,  especially  failures,  which  often  go  else- 
where. The  following  figures  are  of  more  value,  being  more  definite  : 
In  1898,  Edebohls  personally  examined  55  of  his  patients  which  had 
been  operated  upon  from  one  to  eight  years  previously.  In  50  the 
kidney  was  firmly  fixed ;  in  five  the  adhesions  had  stretched  more  or 
less,  but  none  of  the  kidneys  could  be  pushed  up  under  cover  of  the 
ribs,  as  in  an  ordinary  movable  kidney.  Edebohls  therefore  asserts 
that  they  are  not  detached.  One  seemed  to  be  movable  enough  to 
require  a  second  operation,  which  showed  that  the  kidney  was  fixed, 
and  could  not  be  detached  without  tearing  the  renal  tissues.  Keen, 
quoted  by  Treves,  gives  the  results  of  116  operations.  After  three 
months  only  578  per  cent,  were  regarded  as  cured,  and  12*9  per  cent, 
improved,  and  19*8  per  cent,  were  considered  to  be  failures. 

Mc Williams  (Med.  News,  Oct.  4,  1902)  records  61  cases,  of  which 
42  were  traced  ;  22,  or  52  per  cent,  were  considered  to  be  cured, 
and  15,  or  35*7  per  cent,  benefited,  and  5  cases,  or  10  per  cent,  not 
benefited.  Of  19  simple  cases,  12,  or  63  per  cent,  were  cured.  Out 
of  23  complicated  cases,  10,  or  43  per  cent,  were  cured  ;  2  of  the  61 
died,  giving  a  mortality  of  3*2  per  cent. 

The  results  must  be  judged  by  a  more  important  test  than  that  of 
mobility;  it  is  far  more  essential  to  know  if  the  patient  has  or  has  not 
obtained  relief  from  her  symptoms.  The  relief  of  symptoms  will 
generally  prove  both  the  accuracy  of  the  diagnosis  and  the  efficiency  of 
the  treatment.  It  is  poor  consolation  to  know  that  a  kidney  has  been 
fixed  when  symptoms  supposed  to  have  been  due  to  its  mobility  still 
persist.  On  the  other  hand,  it  matters  little  if  a  kidney  become 
slightly  too  movable  if  the  patient  does  not  suffer  from  it.  It  is  to  be 
hoped  that  more  prominence  may  be  given  to  these  points  in  future 
statistics. 

THE   SURGICAL   TREATMENT   OP  BRIGHT'S   DISEASE. 

Mr.  Reginald  Harrison  (Brit.  Med.  Journ.,  1896,  vol.  ii.  p.  1125)  was 
the  first  to  advocate  surgical  treatment  for  nephritis  ;  he  suggested 
that  the  improvement  which  may  follow  chance  operations  upon 
kidneys  which  are  in  a  state  of  chronic  nephritis  might  be  due  to  the 
relief  of  tension  within  the  capsule  of  the  kidney.  Harrison  therefore 
practised  and  recommended  renipuncture  for  Bright's  disease,  later  he 
performed  capsulotomy  and  nephrotomy. 

Israelii!  1899  drew  attention  to  the  disappearance  of  symptoms  of  renal 
disease  after  negative  explorations  for  stone,  but  he  did  not  recommend 
surgical  interference  for  Bright's  disease  (La  Sem.  Med.,  Feb.  5,  1904). 
Ferguson,  Edebohls,  and  Pousson,  in  1899,  advocated  surgical  interven- 
tion in  certain  cases  of  nephritis,  including  chronic  Bright's  disease. 

In  view  of  the  grave  prognosis  of  this  disease  under  medical  treat- 
ment, it  is  certainly  worth  while  to  consider  the  advisability  or  otherwise 
of  seeking  aid  from  surgery,  but  it  remains  to  be  proved  that  opera- 
tions are  either  hopeful  or  even  justifiable  in  any  cases  of  genuine 
Bright's  disease  (vide  p.  162). 

Two  operations  require  consideration. — 1.  Harrison's  operation 
(Lancet,  1901,  vol.  ii.  p.  330).     The  patient  having  been  anaBsthetised, 


THE   SURGICAL    TREATMENT   OF    BRIGHT'S    DISEASE.     237 

the  kidney  is  exposed  through  the  usual  oblique  lumbar  incision  (vide 
p.  172);  the  fatty  capsule  is  opened,  and  an  assistant  pusbes  the 
kidney  towards  the  operator.  It  is  not  necessary  to  deliver  the  organ 
on  to  the  loin  unless  the  diagnosis  is  uncertain,  and  a  thorough 
examination  is  indicated  on  that  account. 

The  fibrous  capsule  is  exposed  and  incised  along  the  convex  border 
for  a  distance  of  about  2  or  3  inches.  In  some  cases  Harrison  punc- 
tures the  kidney  in  various  directions,  avoiding  the  pelvis  ;  in  others 
he  incises  the  cortex  more  or  less  freely. 

The  wound  is  only  partly  closed,  a  drainage  tube  being  inserted  and 
left  in  position  for  a  week  or  ten  days.  Drainage  is  considered  to  be 
an  essential  part  of  the  treatment.  In  a  case  of  nephritis  it  does  not 
matter  which  kidney  is  selected  for  the  operation,  unless  pain  is  present 
on  one  side. 

"  Both  organs  are  usually  involved  in  the  inflammatory  condition, 
though  perhaps  it  may  turn  out  not  to  the  same  degree.  In  double 
nephritis,  the  relief  of  tension  in  the  one  organ  aids  the  other,  and 
thus,  as  I  have  noticed  on  several  occasions,  the  normal  amount  and 
constitution  of  the  urine  becomes  re-established." 

The  Indications  for  the  operation  as  given  by  Mr.  Harrison,  at  the 
International  Congress  at  Lisbon,  1906  {Lancet,  1906,  vol.  i.  p.  1202) 
are  as  follows  : — 

"  (1)  Progressive  signs  of  kidney  deterioration  as  shown  by  the 
persistence  or  increase  of  albumen  when  it  should  be  disappearing  from 
the  urine,  as  in  the  natural  course  of  inflammatory  disorders  ending  in 
resolution. 

(2)  Actual  or  threatened  suppression  of  urine. 

(3)  Where  marked  disturbance  of  the  heart  and  circulatory  system 
occurs  in  the  course  of  inflammatory  renal  disorders." 

A  consideration  of  the  pathology  of  Blight's  disease,  of  the  experi- 
mental evidence  (vide  p.  239),  and  of  the  theory  of  renal  tension,  does 
not  commend  this  operation  to  me  ;  it  is  almost  certain  that  any  relief 
that  may  be  derived  from  an  operation  may  be  obtained  with  far  less 
risk  by  medical  treatment. 

The  following  remarks  made  by  Mr.  Henry  Morris,  after  a  vast 
experience  of  diseases  of  the  kidney,  show  how  dangerous  operations 
may  be  in  Blight's  disease  : — "Surgical  operations  and  more  especially 
operations  upon  the  urinary  organs,  if  it  be  possible  to  postpone  them, 
should  never  be  undertaken  during  the  existence  of  acute  or  sub-acute 
interstitial  nephritis,  or  any  form  of  '  congestive '  urinary  fever " 
(Surgical  Diseases  of  the  Kidney  and  Ureter,  vol.  i.  p.  316).  When  a 
series  of  consecutive  cases  treated  by  operation  is  published  and  the 
results  are  found  to  compare  favourably  with  those  obtained  by  less 
heroic  measures,  physicians  may  no  longer  shrink  from  submitting 
their  patients  to  operation,  but  until  then  discretion  is  certainly  the 
best  part  of  valour. 

2.  Renal  Decapsulation. — Edebohls  "originally  devised,  proposed 
and  performed  "  this  operation  for  the  treatment  of  chronic  Blight's 
disease  (Med.  Rec,  Dec.  21,  1901,  pp.  961-970,  and  Med.  News,  April  22, 
1899).  He  exposes  the  kidney  through  the  vertical  incision,  which  has 
already  been  described  under  nephropexy  at  p.  227,  and  the  patient  is 
placed  in  the  prone  position  with  an  air  cushion  supporting  the  abdomen. 


238  OPERATIONS  ON  THE  ABDOMEN. 

Both  kidneys  are  therefore  accessible  without  changing  the  patient's 
position.  The  following  description  is  taken  from  Dr.  Edebohls  paper  in 
the  Brit.  Med.  Joimi.,  1902,  vol.  ii.  p.  1507  :  "  If  possible,  next  deliver 
the  kidney  into  the  wound  or  out  upon  the  skin  of  the  back,  a  pro- 
cedure which  greatly  facilitates  further  operative  procedures  in  both 
renal  decapsulation  and  nephrotomy.  When  such  delivery  of  the  kidney 
is  impossible,  the  rest  of  the  work  must  be  done  at  a  great  disadvantage 
with  the  kidney  well  up  underneath  the  lower  ribs  and  with  the  fatty 
capsule  constantly  overlapping  the  organ  to  a  greater  or  less  extent." 
By  adopting  the  usual  oblique  incision  it  is  much  easier  to  bring  the 
kidney  into  the  wound,  especially  in  men  and  in  patients  with  a  small 
interval  between  the  last  rib  and  the  iliac  crest,  and  the  risk  of  hernia 
is  very  small  if  the  muscles  are  sutured  carefully. 

"  In  performing  renal  decapsulation  the  operator  next  proceeds  to 
bluntly  separate  the  fatty  capsule  from  the  capsule  proper,  the  dissec- 
tion being  continued  on  either  aspect  and  around  both  poles  of  the 
kidney  until  the  renal  pelvis  is  reached.  Now  and  then  the  fatty 
capsule  may  be  found  so  thickened  and  adherent,  as  the  result  of 
chronic  perinephritis,  that  the  scissors  or  knife  may  be  required  to 
separate  it  from  the  capsule  proper.  The  kidney  with  its  capsule 
proper  is  next  lifted  from  its  fatty  capsule  bed,  and  if  possible  delivered 
into  or  through  the  wound.  The  capsule  proper  is  divided  on  a 
director  along  the  entire  length  of  the  convex  external  border  of  the 
kidney  and  clear  around  the  extremity  of  either  pole.  Each  half  of 
the  capsule  proper  is  in  turn  stripped  from  the  kidney  and  reflected 
toward  the  pelvis  until  the  entire  surface  of  the  kidney  lies  raw  and 
denuded  before  the  operator.  In  separating  the  capsule  proper  from 
the  kidney  care  must  be  taken  not  to  break  or  tear  away  parts  of  the 
kidney  substance,  which  is  often  very  friable  and  veiy  firmly  connected 
with  the  capsule  proper,  especially  in  the  presence  of  chronic  interstitial 
nephritis.  I  have  found  the  smooth  surface  of  the  index  finger  of  the 
rubber  gloved  hand  the  best  instrument  for  safely  effecting  separation 
of  the  capsule  proper  from  the  kidney.  The  stripped-off  capsule  is 
next  cut  away  entirely,  close  to  its  junction  with  the  pelvis  of  the 
kidney,  and  removed.  Delivery  of  the  kidney  into  the  bottom  of  or 
out  of  the  wound  greatly  facilitates  the  decapsulation  part  of  the  opera- 
tion, whereas  if  the  kidney  cannot  be  readily  reached,  the  operation 
sometimes  becomes  very  difficult.  In  the  latter  event  the  entire 
kidney  capsule  proper  may  have  to  be  peeled  off  at  a  finger's  length 
on  the  bottom  of  the  wound  beyond  the  reach  of  sight."  All  the 
capsule  should  be  excised  if  possible,  but  if  this  is  not  practicable  the 
small  remainder  should  be  separated  and  everted  towards  the  root  of 
the  kidney. 

The  kidney  is  dropped  back  and  the  wound  closed  without  drainage 
except  under  exceptional  circumstances.  Both  kidneys  are  operated 
upon  at  one  sitting  so  as  to  avoid  the  dangers  of  two  ansesthetics,  which 
is  important  in  these  cases  of  nephritis.  "  Decapsulation  of  both 
kidneys  for  chronic  Blight's  disease  requires  for  its  performance  from 
half  an  hour  to  one  hour  from  the  first  incision  to  complete  closure  of 
both  wounds  and  the  application  of  dressings."  ..."  Decapsulation 
of  one  kidney  is,  in  itself,  less  serious  than  either  nephropexy, 
nephrotomy,  resection  of  the  kidney  or  nephrectomy." 


THK    sriKJICAL    TREATMENT    OF    BRIGHTS    DISEASE.     239 

Edebohls  has  performed  his  operation  qoI  only  for  cases  of  Blight's 
disease,  but  also  for  acute  pyelo-nephritis  with  miliary  abscesses, 
hydronephrosis,  pyonephrosis,  polyc3Fstic  kidney,  and  puerperal 
eclampsia.* 

It  is  probable,  as  be  admits,  that  the  cases  of  ascending  suppurative 
nephritis  would  have  recovered  without  operation.  In  two  eases 
decapsulation  was  only  used  in  addition  to  nephropexy,  for  mobility, 
and  the  benefit  undoubtedly  derived  from  the  combined  operation  was 
almost  certainly  due  to  the  fixation,  which  may  perhaps  have  been 
made  more  secure  by  the  removal  of  the  capsule  {Brit.  Med.  Journ., 
1902,  vol.  ii.  p.  1507). 

From  observations  which  were  made  during  three  secondary 
explorations  upon  kidneys,  which  had  previously  been  fixed,  Edebohls 
concludes  that  decapsulation  allows  anastomoses  to  occur  between  the 
vessels  of  the  perinephritic  tissues  and  those  of  the  kidney,  and  that 
this  may  provide  an  additional  blood  supply  to  the  organ.  An  increase 
of  blood  supply  may  lead  to  absorption  of  the  inflammatory  products, 
and  to  the  removal  of  pressure  upon  the  tubules  and  glomeruli,  which 
may  then  resume  their  normal  function.  It  is  not  claimed  that  improve- 
ment is  rapid,  but  that  it  is  progressive,  the  albumen  only  disappear- 
ing after  from  one  to  twelve  months. 

Edebohls  (New  Tori,:  Med.  Journ.,  May  21,  1904)  states  that  decapsu- 
lation for  chronic  Blight's  disease  has  been  performed  in  200  to  300 
cases.  He  recommends  the  operation  for  every  case  of  chronic  Bright's 
disease  which  has  a  reasonable  expectation  of  life  of  not  less  than  one 
month  without  an  operation,  if  no  contra-indication  to  any  operation 
is  present  and  if  the  services  of  a  surgeon  of  experience  can  be  obtained. 
He  does  not  regard  cardiac  complications  as  contra-indications  unless 
the  heart  is  dilated  and  weak,  but  albuminuric  retinitis  is  considered 
to  be  an  absolute  objection,  for  of  all  the  nine  patients  having  this  com- 
plication, not  one  survived  the  operation  for  a  year. 

Edebohls  had  operated  upon  72  patients  up  to  the  end  of  1903.  Of  these  47  survived 
and  had  been  traced  for  periods  varying  from  6  months  to  12  years,  19  of  them  suffered 
from  chronic  diffuse  nephritis,  17  from  chronic  interstitial  nephritis,  7  from  chronic 
parenchymatous  nephritis,  and  4  had  chronic  interstitial  nephritis  of  one  kidney 
and  chronic  diffuse  inflammation  of  the  other.  21  of  the  patients  were  cured,  and  only 
6  were  not  improved  to  some  extent,  the  greatest  improvement  occurring  in  the  cases  of 
chronic  interstitial  nephritis,  and  the  least  in  the  chronic  diffuse  nephritis. 

Edebohls  states  that  strict  asepsis  is  essential  for  success  as  the  subjects  of  nephritis  do 
badly  if  their  wounds  suppurate. 

Walker  Hall  and  G.  Herxheimer  (Jtrif.  Med.  Journ.,  April  9,  1904)  found  that  a  new 
capsule  thicker  than  the  old  one  forms  within  about  three  weeks  in  rabbits.  Johnson  was 
unable  to  find  any  anastomoses  between  the  renal  and  perirenal  vessels  in  dogs,  and 
Turner  (Presse  Med.,  April,  1905)  arrives  at  the  same  conclusion,  after  failing  io  induce  any 
anastomosis  by  tying  the  renal  vein  and  constricting  the  renal  artery  of  the  decapsulated 
kidney. 

Claude,  Balthasard,  Jaboulay,  and  Gilford  (J/erZ.  Rec.  July,  1904)  did  not  find  any 
marked  anastomoses  between  the  decorticated  kidney  and  the  adherent  tissues  of  rabbits  ; 
acute  nephritis,  induced  by  injection  of  neutral  ammonium  chromate,  was  not  influenced 
by  decortication  undertaken  three  days  later  (Hall  and  Herxheimer).  Decapsulation  has 
been  even  shown  to  induce  interstitial  nephritis  in  some  rabbits.  If  decapsulation  does 
any  good,  it  probably  acts  by  relieving  tension  and  congestion. 

*  Two  successful  cases  (Boston  Med.  and  Surg.  Journ.,  June  2,  1904). 


240  OPERATIONS  ON  THE  ABDOMEN. 

Hubbard  (Boston  Med.  and  Surg.  Journ.,  Jan.  28,  1904)  reports  7  cases  of  decapsulation  of 
the  kidney,  but  albuminuria  did  not  cease  in  any  of  the  patients,  and  5  of  them  died  within 
6  months  of  the  operation,  2  within  ig  days.  Freeman  (Ann.  of  Surg.,  vol.  xxxix.,  1904, 
p.  370)  records  a  case  of  unilateral  hematuria  for  which  decapsulation  was  performed  ; 
the  surface  of  the  kidney  "  was  granular  and  mottled  yellowish  grey,  and  the  fibrous 
capsule  adherent."  A  small  piece  was  removed  and  examined ;  the  glomeruli  and  inter- 
stitial tissues  were  inflamed.  No  return  of  hsematuria  occurred  during  the  7  months  of 
observation  before  publication.  A  cure  should  not  be  claimed  in  this  short  time,  for  the 
man  had  suffered  from  attacks  of  hsematuria  on  and  off  for  twenty  years. 

Baker  (Zeut.  f.  Chir.,  1904,  No.  14)  has  endeavoured  to  improve  the  operation  by 
bringing  a  piece  of  omentum  backwards  through  a  peritonaeal  perforation  and  wrapping 
it  round  the  kidney.  A3  the  omentum  is  far  more  vascular  than  the  perirenal  fat,  a  freer 
anastomosis  is  expected  to  form.     Tuffier  (loc.  sup.  cit.)  found  even  this  to  be  of  no  avail. 

Berg  (Med.  Rpc,  June  18,  1904)  advises  decapsulation  in  cases  of  nephritis  which 
have  reached  a  stationary  stage,  and  in  which  me<lical  treatment  is  of  no  more  avail. 
He  believes  that  nephritis  due  to  sclerosis  of  the  vessels  or  to  chronic  suppuration  is  not 
benefited  by  the  operation. 

Ramon  Guiteras  (New  York  Med.  Jbum.,  Nov.  7,  1903)  found  that  the  leading 
American  surgeons  are  about  equally  divided  for  and  against  the  operation  of  decapsula- 
tion for  chronic  nephritis.  Of  120  cases  which  he  collected  16  per  cent,  were  cured,  40 
per  cent,  improved,  n  per  cent,  unimproved  and  33  per  cent.  died.  The  mortality  in 
chronic  interstitial  nephritis  was  26  per  cent,  and  that  of  chronic  diffuse  nephritis 
75  per  cent. 

H.  J.  Whitacre  (Journ.  Amer.  Med.  Assoc,  May  23,  1903)  records  a  case  of  suppression 
of  urine  which  had  lasted  for  eight  days,  and  was  then  relieved  by  decapsulation  of  both 
kidneys,  but  suppression  is  occasionally  relieved  without  any  operation. 

Whether  decapsulation  will  ever  become  a  recognised  method  of 
treatment  of  intractable  cases  of  chronic  Bright's  disease  is  uncertain. 
So  far  it  lias  not  found  favour  with  English  surgeons  and  physicians. 

Theoretically  there  is  little  to  recommend  it,  for  a  free  vascular 
anastomosis  can  hardly  be  expected  to  form  between  the  kidney  and 
the  anaunic  fatty  capsule  which  surrounds  it.  The  tension  within  the 
fibrous  capsule  cannot  be  high  for  any  length  of  time,  for  the  capsule 
is  thin  and  delicate  in  cases  of  chronic  nephritis,  and  it  is  quite 
capable  of  stretching,  as  is  shown  by  the  rapid  enlargement  of  the 
kidney,  which  occurs  in  acute  nephritis,  and  in  some  cases  of  hydro- 
nephrosis. Moreover,  the  kidneys  of  chronic  interstitial  nephritis  are 
usually  smaller  than  normal,  and  still  it  is  in  these  cases  that  decap- 
sulation is  claimed  to  do  most  good.  It  would  be  far  more  reasonable 
to  take  away  or  incise  the  dense  and  thick  tunica  albnginea  from  an 
inflamed  testicle  for  the  relief  of  tension,  than  it  is  to  remove  the  thin 
capsule  which  invests  a  shrunken  and  chronically  inflamed  kidney.  In 
acute  nephritis,  incision  of  the  capsule  might  really  be  expected  to 
relieve  tension,  but  decapsulation  has  not  been  at  all  successful  in 
these  cases,  although  a  few  recoveries  have  followed  operation  for  actual 
or  threatened  suppression  of  urine  in  scarlatinal  nephritis.  These 
results  were  not  necessarily  due  to  the  interference,  but  muy  have 
occurred  in  spite  of  it. 

Is  it  to  be  expected  that  decapsulation  may  arrest  a  renal  degenera- 
tion and  vascular  sclerosis,  that  have  gradually  increased  for  years,  in 
the  majority  of  the  subjects  of  chronic  Bright's  disease  ? 

Experimental  evidence  lends  but  little  if  any  support  to  the  advocates 
of  this  operation,  and  it  fails  to  demonstrate  any  real  anatomical  reason 
for  its  supposed  success.  The  literature  of  the  subject  is  full  of  vague- 
ness,  inaccuracy  and  confusion.     Cases   of  movable   kidney,   with  or 


OPERATIONS   ON    THE    URETER. 


241 


without  nephrectasis,  have  been  frequently  classified  as  instances  <>f 
Bright's  disease,  and  even  cases  of  ascending  nephritis  have  been 
included.  No  one  denies  that  decapsulation  and  fixation  of  a  movable 
kidney  may  do  good,  and  that  the  hydro-nephrosis  and  transient, 
albuminuria  which  may  be  secondary  to  it  maybe  cured  by  nephropexy. 

Newman  drew  attention  to  this  fact  ten  years  ago  (Lancet,  January, 
1886,  ]>.  166).  These  cases  should  not  be  confused  and  classed  with 
those  of  the  bilateral  and  far  more  serious  disease  which  was  described 
by  Bright. 

Many  writers  seem  to  forget  that  patients  not  uncommonly  recover 
from  Bright's  disease  without  operation,  and  particularly  that  spon- 
taneous improvement  may  occur  and  last  for  a  long  time,  only  to  be 
followed  by  relapse  after  months  or  years.  Recorded  cases,  with  few 
exceptions,  have  not  been  followed  up  for  a  sufficient  length  of  time 
to  justify  their  classification  as  cures.  It  may  be  seriously  doubted 
whether  the  results  in  patients  who  survive  the  operation  are  any  better 
than  those  obtained  in  the  same  time  and  with  far  less  risk  by  medical 
treatment.  Suppuration  is  apt  to  occur  in  the  wound  even  when  every 
care  is  taken  to  avoid  sepsis,  and  Edebohls  lays  stress  on  the  dangers 
of  the  aiuesthetic  in  these  patients. 

The  operation  is  very  dangerous  in  acute  nephritis,  and  it  should 
not  be  undertaken  in  patients  with  cardiac  dilatation  and  anasarca. 
Albuminuric  retinitis  is  an  absolute  contra-indication. 

It  may  be  stated  in  conclusion  that  published  facts  do  not  lead  us 
to  hope  for  favourable  results  from  surgical  interference  in  Bright's 
disease.  In  suppression  and  perhaps  in  grave  cases  of  eclampsia,  an 
operation  may  not  be  more  dangerous  than  leaving  well  alone,  and 
time  and  experience  may  prove  that  incision  of  the  renal  capsule  may 
give  relief.  In  some  cases  of  chronic  interstitial  and  chronic  parenchy- 
matous nephritis,  which  have  been  medically  treated  without  avail,  the 
patients  should  be  given  the  opportunity  of  declining  or  accepting  an 
operation  which  may  offer  a  faint  hope  of  relief ;  but  all  the  dangers 
and  chances  of  the  operation  should  be  explained  to  the  patients  and 
their  relations.  Decapsulation  of  both  kidneys  offers  the  best  prospect, 
but  this  should  not  be  undertaken  except  by  a  skilful  and  aseptic 
surgeon,  and  under  the  most  favourable  circumstances. 


OPERATIONS  ON  THE  URETER. 

There  are  two  main  conditions  in  which  operations  on  the  ureter  are 
necessary  : 

A.  Ureteral  Obstruction. 

B.  Injuries  to  the  Ureter. 

A.  Ureteral  Obstruction. — This  in  the  great  majority  of  cases  is  due 
to  the  impaction  of  a  calculus  in  the  ureter ;  in  others,  however,  it  has 
been  found  to  be  due  to  a  valvular  formation  at  the  opening  of  the 
ureter  into  the  renal  pelvis  or  to  a  stricture  of  the  ureter.  These 
conditions  will  be  considered  separately. 

I.  Ureteral  Calculus. — There  can  be  no  doubt  whatever  that  in 
many  cases,  where  a  renal  calculus  has  been  diagnosed  and  no  calculus 
found,  the  stone  has  really  been  in  the  ureter. 

s. — vol.  11.  16 


242  OPERATIONS  ON  THE  ABDOMEN. 

Morris  (Surgical  Diseases  of  the  Kidney  and  Ureter,  vol.  ii.  p.  448) 
during  his  first  twenty  years'  experience  of  renal  surgery  "had  six  cases 
in  which  a  stone  must  have  been  present  in  the  ureter  at  the  time  of 
the  operation,  although  the  kidney  was  explored  with  a  negative  result 
in  each  case."  Five  of  these  patients  subsequently  passed  a  calculus, 
and  the  other  one  died  about  a  year  later,  and  a  stone  was  found  near 
the  lower  end  of  the  ureter.  Other  surgeons  have  had  the  same 
experience,  but  in  many  cases  the  stone  has  been  fortunately  found  in 
the  ureter  near  the  kidney.  At  the  present  day  there  is  less  excuse  for 
this  error,  which  was  unavoidable  in  the  past,  for  the  introduction  and 
the  perfection  of  systematic  examination  of  all  the  urinary  organs  by 
means  of  the  X-ray  screen  has  provided  the  surgeon  with  a  means  of 
almost  accurately  localising  calculi  before  any  operation  is  undertaken 
for  their  discovery  and  removal. 

Whenever  possible  such  an  examination  by  a  trustworthy  radio- 
grapher should  precede  all  explorations  of  the  kidney  and  ureter.  This 
will  enable  the  surgeon  to  reach  the  calculus  by  the  most  suitable 
route,  with  the  least  possible  amount  of  injury  to  the  patient,  and  also 
to  avoid  many  an  unnecessary  exploration  on  the  one  hand,  or  an 
incomplete  operation  on  the  other. 

The  rays  may  show  calculi  on  both  sides,  either  in  the  kidneys  or 
ureters  or  both.  Tenney  (Bost.  Med.  and  Surg.  Joum.,  February  4, 
1904),  from  an  analysis  of  134  cases  of  ureteral  calculi,  found  that  they 
w7ere  multiple  in  one-eighth  of  the  cases. 

It  should  not  be  forgotten,  however,  that  minute  calculi,  especially 
if  they  consist  chiefly  of  uric  acid,  may  be  overlooked ;  and  yet  that 
these  may  be  large  enough  to  produce  a  fatal  anuria.  In  rare  cases, 
other  things,  such  as  blood,  inspissated  pus,  or  hydatid  cysts,  may  do 
the  same.  Moreover,  a  positive  X-ray  result  may  mislead ;  cretaceous 
mesenteric  glands,  atheromatous  patches  in  the  arteries,  phleboliths, 
calcifying  centres  in  the  pelvic  ligaments,  may  occasionally  lead  to  error. 
Fenwick  has  several  times  avoided  these  mistakes  by  passing  into  the 
ureter  a  bougie,  which  is  opaque  to  the  Rontgen  rays  (Brit.  Med. 
Joum.,  June  17,  1905).  Leonard  (Lancet,  June  17,  1905),  however, 
in  330  examinations  for  renal  and  ureteral  calculi  found  the  negative 
and  positive  errors  to  amount  to  less  than  3  per  cent.  After  51  negative 
results  with  the  rays,  the  surgeon  discovered  no  stones  upon  exploration 
in  47 ;  but  stones  were  either  passed  or  found  at  operation  in  4  cases. 

Abdominal  and  vaginal  or  rectal  palpation  of  the  ureter  also  should 
be  practised  more  frequently  for  diagnostic  and  localising  purposes.  A 
prolapsed  ovary  has  been  mistaken  for  a  calculus,  however,  but  this 
mistake  may  be  avoided  by  remembering  that  a  calculus  in  the  lower 
ureter  will  be  placed  nearer  the  surface  and  antero-externally  to  the 
vagina,  whereas  a  prolapsed  ovary  is  softer,  and  placed  behind  the 
vagina  (Cullingworth,  quoted  by  Morris,  loc.  cit.). 

Intra-vesical  palpation  has  served  to  discover  a  stone  low  down  in 
several  cases  in  the  male  and  female  (vide  infra). 

During  operation  upon  the  kidney  and  ureter,  when  there  is  any 
suspicion  of  the  existence  of  a  calculus  or  of  any  obstruction  in  the 
course  of  the  ureter,  it  is  always  wise,  if  not  imperative,  to  pass  a 
ureteral  catheter,  bougie,  or  sound  into  the  bladder,  and  also  up  into 
the  pelvis  of  the  kidney  if  the  ureter  only  is  exposed.      The  surgeon 


OPERATIONS  ON  THE  URETER.  243 

may  thus  discover  a  second  stone  or  some  other  obstruction  which 
might  be  otherwise  easily  overlooked  and  render  the  operation  incom- 
plete or  useless,  whether  the  X-rays  have  been  used  or  not. 

Impaction  of  a  calculus  may  take  place  at  almost  any  point  in  the 
course  of  the  ureter,  although  in  most  east's  impaction  occurs  at  or 
near  one  of  the  three  following  narrow  places  : — 

(a)  About  two  and  a  half  inches  below  the  hilum  of  the  kidney,  or 
about  an  inch  below  the  junction  of  the  renal  pelvis  and  the  ureter; 
here  the  diameter  is  about  one-seventh  of  an  inch  (Deaver,  Ann.  of 
Sun/.,  vol.  i.  1906,  p.  yii). 

(b)  Near  the  pelvic  brim ;  here  the  diameter  is  about  a  quarter 
of  an  inch. 

(c)  At  or  near  the  vesical  orifice ;  at  the  orifice  the  diameter  is  only 
one-tenth  of  an  inch. 

Tenney  (Bost.  Med.  and  Surg.  Joum.,  February  4,  1904)  found  that 
35  stones  were  arrested  at  the  upper  constriction,  18  only  at  the  middle, 
and  7 3  at  the  lower  one.  Bovee  (Washington  Med.  Annals,  1905, 
vol.  iv.  p.  233)  records  22,  17,  and  18  at  these  sites  respectively. 
Morris  in  44  operation  records  found  that  19  were  impacted  near  the 
kidney,  10  at  the  pelvic  brim,  and  15  at  the  extremity  of  the  ureter 
(Lancet,  December,  1899).  Since  then  the  same  authority  has  operated 
upon  4  and  collected  12  more  cases;  in  11  of  these  16  cases  the 
impaction  was  at  the  lower  end,  and  two  others  were  found  within 
three  inches  of  the  bladder. 

It  may,  therefore,  be  concluded  that  most  stones  will  be  arrested  at 
the  lower  constriction,  and  that  many  more  will  be  found  at  the  upper 
constriction  than  near  the  pelvic  brim. 

A  calculus  placed  within  the  renal  pelvis,  acting  as  a  ball  valve,  may 
obstruct  the  orifice  of  the  ureter  and  even  cause  fatal  anuria  ;  but  it 
must  not  be  regarded  as  a  "  ureteral  "  calculus  in  the  sense  which  is 
attributed  to  this  word  here. 

Indications  for  Operation  : — 

(a)  When  the  ureter  of  the  only  active  kidney  is  obstructed  and 
anuria  exists,  an  immediate  operation  is  imperative  (vide  p.  190). 

(b)  When  only  one  ureter  is  obstructed,  there  is  not  the  same  urgent 
need  for  treatment,  for  it  is  a  matter  of  common  experience  that 
many  ureteral  calculi  are  passed  naturally.  Leonard  (loc.  cit.)  states 
that  26  of  his  40  patients  passed  the  stones  which  had  been  demon- 
strated by  the  X-rays.  If  a  calculus  is  known  to  be  small  from  an 
examination  with  the  screen,  and  especially  if  it  is  shown  to  have 
descended  between  two  examinations,  and  colic,  but  no  complications, 
exist,  expectant  treatment  may  be  tried  for  a  few  days,  as  recommended 
by  Leonard.  Large  quantities  of  any  alkaline  mineral  water  may  be 
given  with  the  idea  of  increasing  the  volume  and  pressure  of  the  urine, 
and  urotropin  or  helmitol  may  be  given  with  the  object  of  keeping  the 
urine  aseptic.  It  is  known  that  the  kidney  may  resume  its  normal 
function  after  being  obstructed  more  or  less  completely  for  weeks. 

Immediate  operation  is  demanded  when — 

(a)  Another  calculus,  which  is  too  large  to  travel  along  the  ureter,  is 
detected  in  either  kidney,  or  the  other  ureter. 

(b)  When  the  calculus  in  the  ureter  is  large  and  is  really  impacted 
and  not  merely  passing  down  the  duct,       When  the   obstruction  is 

16 — 2 


244  OPERATIONS    OX    THE    ABDOMEN". 

complete  or  nearly  complete,  as  shown  by  the  small  volume  of  the  urine 
and  an  examination  of  the  separated  urines,  operation  should  not  be 
delayed,  lest  the  kidney  be  irreparably  damaged. 

(c)  When  there  is  evidence  of  any  septic  complication  or  of  nephrec- 
tasis,  as  shown  by  fever,  pyuria,  and  enlargement  of  the  kidney  or  great 
tenderness  in  the  region  of  the  calculus. 

Operation. — i.  Impaction  of  a  Calculus  at  or  above  the  Brim  of 
tlie  Pelvis. — In  these  cases  the  ureter  can  be  sufficiently  exposed  by 
prolonging  tbe  incision  already  made  for  exploring  the  kidney  as  above 
described  (vide  p.  176). 

In  some  cases  the  dilatation  of  the  ureter  above  the  site  of  impaction 
will  allow  of  the  calculus  being  pushed  gently  along  the  ureter  either 
up  to  the  kidney  or,  at  any  rate,  to  some  more  accessible  part  of  the 
ureter.  Tuffier  (Duplay  and  Reclus,  Traitc  de  Chirurgie,  t.  vii.  1892), 
during  a  lumbar  nephrolithotomy,  in  which  examination  of  the  kidney 
revealed  no  stone,  detected  a  hard  oval  bod}-  about  three  centimetres 
long,  where  the  ureter  crossed  the  pelvic  brim.  The  stone  was 
movable  and  was  pushed  up  into  the  pelvis  of  the  kidney,  and  removed 
by  an  incision  into  the  convex  border.     Tbe  patient  recovered. 

If  the  stone  cannot  be  pushed  up  as  far  as  the  kidney,  or  is  so 
tightly  impacted  that  it  cannot  be  moved,  it  should  be  removed  through 
a  longitudinal  incision  in  the  ureter.  Tbe  incision  in  the  ureter  may 
be  sutured  with  fine  silk  or  catgut,  passing  through  the  outer  coats, 
or  it  may  be  left  without  sutures.  Deaver  (loc.  cit.)  uses  two  layers  of 
sutures  :  catgut  for  the  deep  layer  and  silk  for  the  outer  coats. 
Mitchell  and  Corson  (loc.  cit.)  pass  the  sutures  before  incising  the 
ureter.  Should  inflammatory  thickening  or  ulceration  of  the  ureter 
be  present,  it  would  seem  wiser  not  to  insert  sutures.  A  number  of 
successful  cases,  both  with  and  without  sutures,  have  been  recorded. 
The  following  case,  described  by  Dr.  Kirkham  (Lancet,  March  16, 1899), 
is  an  illustrative  one,  and  is,  I  believe,  the  first  case  in  which  a  patient 
has  been  saved  from  death  from  suppression  of  urine  by  the  removal 
of  a  calculus  low  down  in  the  ureter  : 

The  patient  was  58.  He  had  twice  suffered  from  right  renal  colic,  and  had  passed  a 
small  calculus.  May  24,  left  renal  colic  came  on.  No  urine  was  passed  from  this  date 
till  after  the  operation.  May  30.  the  patient  was  drowsy,  with  prostration  and  muscular 
twitchings.  Dr.  Kirkham  then  explored  the  kidney  in  the  hope  that  if  no  calculus  was 
removed  life  might  be  saved  by  affording  an  outlet  to  the  urine  by  an  incision  into  the 
pelvis  of  the  kidney.  An  incision  was  made  from  the  tip  of  the  last  rib  towards  the 
anterior  superior  spine.  No  stone  being  found  in  the  kidney,  the  exploration  was  con- 
tinued along  the  ureter,  in  which  a  stone  was  distinctly  felt  about  half  an  inch  above 
where  the  ureter  crosses  the  external  iliac.  There  was  a  little  difficulty  in  reaching  the 
ureter  in  this  part  of  its  course,  but  after  enlargement  of  the  wound  a  calculus  about  the 
size  of  a  date-stone  was  removed.  A  little  urine  escaped  from  the  incision  into  the  ureter. 
No  sutures  were  placed  in  this.  Half  an  hour  after  the  operation  an  ounce  and  a  half  of 
urine  was  passed  naturally.  Very  little  escaped  from  the  wound  in  the  ureter,  and  the 
patient  made  an  excellent  recovery. 

When  it  has  not  been  possible  to  localise  the  calculus  before  the 
operation,  experience  shows  that  the  lumbar  incision  is  the  best  to 
adopt.  In  28  out  of  44  cases  recorded  by  Henry  Morris,  this  incision 
was  used  under  the  impression  that  the  disease  was  renal,  and  in 
25  of  these  cases  the  calculus  was  accessible.     There  is,  therefore,  a 


OPERATIONS  ON  THE  DRETER  245 

fair  chance  of  finding  th<'  calculus  and  also  of  removing  it  through  this 
incision. 

Moreover,  the  kidney  can   be  examined  and  removed   it'  necessary, 

and  it'  the  other  kidney  is  known  to  he  healthy.    In  three  of  the  25  ca 
quoted  by   Morris  nephrectomy  was  adopted.      In  any   case  a  fistula 
can  be  established,  and  the  kidney  given  a  chance  to  recover. 

If  the  stone  cannot  he  found  in  the  upper  ureter,  it  should  be  sought 
with  the  ureteral  sound,  passed  through  an  incision  in  the  renal  pelvis. 

Should  the  stone  be  thus  localised,  it  may  he  removed  at  once  by 
prolonging  the  incision,  or  by  making  a  separate  anterior  wound,  it'  the 
stone  is  in  the  pelvis  ;  the  liability  of  ventral  hernia  is  thus  diminished 
and  an  easier  and  more  direct  access  obtained. 

In  some  cases  it  may  be  wise  to  delay  the  removal  of  the  calculus, 
for  the  latter  may  be  passed  naturally  after  a  few  days,  when  the  kidney 
has  resumed  its  normal  function.  The  condition  of  the  patient  may  be 
too  critical  to  allow  a  prolongation  of  the  operation,  and  the  surgeon 
may  then  reluctantly  remain  content  with  establishing  a  temporary 
urinary  fistula  in  the  loin. 

2.  Impaction  of  a  Calculus  in  the  Pelvic  Portion  of  the  Ureter. — In  the 
male,  the  greater  part  of  the  pelvic  ureter  can  be  exposed  by  a  prolonga- 
tion of  the  lumbar  incision  already  made  for  exploring  the  kidney,  as 
recommended  by  Morris  {vide  pp.  173,  176  and  192). 

Should  the  patient,  however,  be  fat,  and  the  lumbar  incision  already 
very  deep,  this  method  will  be  found  to  be  extremely  difficult.  In  such 
cases,  and  also  in  the  female,  the  abdomen  should  be  opened  by  an 
incision  in  the  semilunar  line  or  through  the  rectus  sheath.  In  most 
cases  it  will  then  be  found  possible  to  push  the  calculus  along  the  dilated 
ureter  up  to  or  near  the  kidney,  when  its  removal  can  be  accomplished 
through  the  lumbar  incision,  and  the  abdominal  wound  closed.  This 
plan  was  first  carried  out  by  Lane  in  the  following  case  (Lancet,  1890, 
vol.  ii.  p.  967)  : 

A  woman,  aged  23,  had  had  symptoms  of  renal  stone  for  twenty  years,  but  there  was 
nothing  to  point  to  the  fact  that  the  stone  was  in  the  ureter  and  not  in  the  kidney, 
except  that,  associated  with  her  renal  pain,  she  complained  at  times  of  pain  in  the  lower 
part  of  the  abdomen  on  the  same  side,  which  did  not  appear  to  be  reflected.  The  kidney 
was  explored  by  the  lumbar  incision,  and  nothing  found  either  in  this  organ  or  in  those 
parts  of  the  ureter  which  could  be  reached  from  above  or  per  rectum.  The  pain  having 
returned  with  its  original  severity,  the  abdomen  was  opened  along  the  left  linea  semilunaris, 
and  in  the  portion  of  the  ureter  which  had  not  been  explored  at  the  previous  operation  a 
small  stone  was  felt.  This  was  forced  upwards  along  the  ureter  to  the  crest  of  the  ilium,  and 
by  means  of  a  small  incision  in  the  side  the  ureter  was  exposed  and  the  stone  removed.  The 
aperture  in  the  ureter  was  sewn  up  by  a  fine  continuous  silk  suture.  Xo  leakage  took  place 
from  the  ureter,  and  the  woman  recovered  completely,  losing  all  her  pain  and  discomfort. 

Witherspoon  (New  York  Med.  Journ.,  May  21,  1904)  has  modified 
Lane's  method.  Through  the  lower  part  of  the  rectus  he  opens  the 
peritonaeum  and  examines  both  ureters  and  kidneys,  and  having 
localised  the  stone,  he  sews  up  the  peritonaeum  accurately,  and  peels 
it  away  from  the  parietes,  so  as  to  enable  him  to  extract  the  stone 
extraperitonaeally. 

I  strongly  recommend  this  incision,  but  with  modern  methods  of 
localisation,  and  of  determining  the  condition  of  the  other  kidney,  it 
will  be  rarely  necessary  to  open  the  peritonaeum  for  exploratory  purposes. 


246  OPERATIONS    ON    THE    ABDOMEN. 

Moreover,  the  fallacies  of  this  method  have  been  already  dealt  with 
(p.  193). 

The  rectus  incision  has  the  following  advantages  : 

It  gives  a  very  good  view,  which  is  unspoilt  by  haemorrhage.  It  is 
extra-peritonseal,  at  least  as  regards  the  incision  into  the  ureter.  It  is 
not  very  difficult  to  anyone  with  a  sound  knowledge  of  anatomy.  The 
risks  of  hernia  and  of  injury  of  the  cord  are  less  than  after  the  oblique 
inguinal  incision  mentioned  below.     Drainage  is  easily  established. 

The  ureter  is  to  be  sought  in  the  mesial  aspect  of  the  wound,  attached 
to  the  displaced  peritonaeum.  The  finger  of  an  assistant  or  a  bougie  in 
the  rectum  or  vagina  and  a  sound  in  the  bladder  may  give  valuable  aid. 
Thus  the  stone  may  be  more  easily  found,  and  the  ureter  containing 
it  may  be  pushed  upward  into  a  more  accessible  position.  Gentle 
endeavours  may  be  made  to  push  the  stone  upward  into  a  more  dilated, 
healthy,  and  visible  part  of  the  ureter.  Care  must  be  taken,  however, 
not  to  use  force,  lest  the  ureter  be  damaged ;  in  one  of  Israel's  cases 
(quoted  by  Morris)  the  duct  was  torn  across.  Attempts  to  crush  the 
stone  are  not  likely  to  succeed,  and  may  injure  the  ureter.  The  stone  can 
rarely  be  pushed  on  into  the  bladder  because  of  the  very  small  size 
of  the  vesical  orifice,  and,  moreover,  it  would  be  difficult  to  tell  whether 
the  calculus  had  really  reached  the  interior  of  the  bladder  or  had  merely 
passed  into  the  submucous  parts  of  the  ureter.  Sutures  are  not 
essential,  and  sometimes  it  may  be  a  very  difficult  and  tedious  task  to 
insert  them ;  but  whenever  possible  the}r  should  be  used,  for  the  leak- 
age maj'be  at  least  diminished,  if  not  prevented  entirely,  in  some  cases. 
The  risks  of  extravasation  and  delay  of  recovery  may  thus  be  avoided. 
Mitchell  and  Corson  pass  the  sutures  before  incising  the  ureter,  and 
take  advantage  of  the  stone  as  a  guide  and  support.  Before  sewing  the 
longitudinal  incision  in  the  ureter,  a  bougie  must  be  passed  down  into 
the  bladder  and  up  to  the  kidne}\  In  any  case  drainage  of  the  wound 
is  essential,  for  it  is  difficult  to  close  the  tube  accurately  in  the  depth  of 
the  wound,  and  leakage  may  occur  even  after  the  most  careful  suturing. 

Gibbon  (Ann.  of  Surg.,  1906,  vol.  xliii.  p.  742)  has  adopted  a  similar 
method  except  that  he  does  not  suture  the  parietal  peritonaeum  until 
he  has  extracted  the  stone,  which  he  pushes  uj)  into  the  extra-peri- 
tonaeal  wound  by  means  of  a  finger  within  the  peritoneal  cavity.  He 
records  two  cases  in  which  he  successfully  adopted  this  method,  after 
discovering  ureteral  stones  during  exploration,  in  patients  who  had 
been  sent  to  him  supposed  to  be  suffering  from  appendicitis.  The 
appendix  and  the  stone  were  removed  in  each  case,  and  both  patients 
did  well,  but  there- is  little  doubt  that  it  is  safer  to  sew  up  the  peri- 
tonaeum (if  opened  at  all)  before  incising  a  tube  which  has  septic 
contents  in  most  cases  of  calculous  obstruction. 

Mr.  Betham  Robinson  (Lancet,  vol.  i.  1905,  p.  495)  has  successfully 
removed  a  stone  situated  close  to  the  bladder  of  a  boy  of  only  three 
years  of  age.  He  used  an  extra-peritonaeal  incision  similar  to  the  one 
commonly  employed  for  tying  the  external  iliac  artery.  From  an 
experience  of  this  and  two  successful  cases  in  adults,  he  concludes  that 
the  operation  is  much  easier  in  the  child,  because  of  the  absence  of 
much  fat  in  the  abdominal  wall  and  the  small  size  of  the  child's  pelvis, 
with  the  abdominal  position  of  the  bladder,  so  that  the  finger  in  the 
rectum  was  able  to  push  the   ureter  and  the  stone  well  up  into  the 


OPERATIONS  ON  THE  URETER.  247 

wound.     Caic  must  be  taken  not  to  lacerate  the  thin  peritonsBum  of 
the  child. 

Freyer  (Lancet,  vol.xi.  1903,  p.  584)  and  a  number  of  othersurg 

have  also  used  this  method,  and  speak  well  of  it. 

I>r.  Fowler  (Ann.  of  Surg.,  vol.  xl.  1904,  p.  943)  recommends  this 
incision  even  for  stones  impacted  very  low  in  the  pelvis. 

Sampson  (.1///;.  of  Surg.,  1905,  vol.  xli.  p.  217)  approaches  the  lower 
ureter  through  a  low  gridiron  or  muscular  separation  incision  in  the 
groin  and  recommends  the  adoption  of  either  this  or  the  incision 
through  the  rectus. 

In  no  case  is  it  wise  or  safe  to  remove  a  calculus  from  the  ureter 
through  the  peritonaeum,  for  however  carefully  the  latter  may  he 
protected  from  soiling  with  urine  during  the  operation,  and  however 
carefully  and  skilfully  the  surgeon  may  attempt  to  close  the  incision  in 
the  diseased  ureter,  it  is  the  rule  for  the  urine,  which  is  usually  septic 
in  these  cases,  to  leak  at  the  line  of  suture.  Therefore  it  is  an  accepted 
rule,  that  drainage  of  the  neighbourhood  of  the  sutures  is  essential  to 
guard  against  probable  urinary  extravasation.  Such  drainage  cannot 
be  safely  established  across  the  peritonaeum,  and  when  the  peritonaeum 
covering  the  ureter  is  sewn  up,  extravasation  may  still  occur  into  the 
undrained  extra-peritonaeal  tissues  and  set  up  pelvic  cellulitis. 

These  remarks  are  made  with  full  knowledge  that  the  trans-peritonseal 
method  has  been  entirely  successful  in  a  few  cases,  of  which  the 
following  is  a  brilliant  instance,  recorded  by  Mr.  F.  J.  Steward 
(Clin.  Soc.  Trans.,  vol.  xxxiv.) : 

The  patient  was  admitted  for  hematuria  and  painful  micturition,  which,  in  the 
absence  of  pain  or  tenderness  over  either  kidney  or  ureter,  were  thought  to  be  due  to 
a  vesical  calculus.  As  the  sound  detected  nothing,  the  bladder,  after  being  distended 
with  air,  was  opened  above  the  pubes.  Nothing  was  found  in  the  bladder,  but  through  its 
walls  a  stone  could  be  felt  in  the  lower  part  of  the  right  ureter.  As  the  stone  could  not 
be  worked  down  towards  the  bladder,  the  wound  was  closed.  Eight  days  later  an  incision 
about  five  inches  long  was  made  in  the  lower  part  of  the  right  linea  semilunaris,  and  the 
peritoneal  sac  opened.  The  stone  was  easily  felt,  and  was  gently  manipulated  up  the 
ureter  as  far  as  a  point  a  little  above  the  iliac  vessels.  As  it  would  go  no  further,  the 
peritona3um  and  then  the  ureter  were  incised  and  the  stone,  weighing  nine  grains, 
removed.  The  ureter  was  then  closed  with  a  fine  silk  suture,  taking  up  the  outer  coats 
only  ;  the  peritonaeum  was  then  sutured  in  like  manner,  and  the  wound  closed,  with  the 
exception  of  a  small  part  through  which  a  gauze  drain  was  brought.  No  leakage 
occurred,  and  the  patient  made  a  satisfactory  recovery. 

3.  Impaction  at  or  near  the  Vesical  Orifice. — In  these  cases  the 
symptoms  may  very  closely  resemble  those  of  stone  in  the  bladder  or 
cystitis.  Judicious  use  of  the  cystoscope  and  bimanual  pelvic 
examination  may  prevent  the  error  in  some  cases.  The  mistaken 
diagnosis  may  be  confirmed  by  the  use  of  the  sound  alone,  for  the 
projecting  part  of  the  calculus  may  be  touched.  Freyer  (loc.  cit.) 
relates  three  cases  of  this  kind. 

The  vesical  route  is  the  best  in  these  cases,  the  urethra  being  dilated 
in  the  female.  Successful  results  have  been  recorded  by  Emmet,  Berg, 
Richmond,  Czerny,  Sanger,  Thornton,  Freyer,  and  others.  Millet 
evaginated  the  ureteral  orifice  through  the  female  urethra,  by  means 
of  a  finger  in  the  vagina,  and  he  was  then  able  to  extract  the  stone 
(Deaver,  loc.  cit.). 


248  OPERATIONS   ON   THE   ABDOMEN. 

In  the  male  the  stones  are  best  removed  by  suprapubic  cystotomy. — 
Morris  refers  to  five  cases  in  which  this  method  was  successfully 
adopted.  Tuffier  has  also  removed  stones  in  this  position  twice  by 
suprapubic  cystotomy.  Crawford  {Amer.  Med.,  vol.  ii.  1904,  p.  791) 
succeeded  in  extracting  a  calculus  measuring  if  inches  in  diameter  in 
this  way.  Freyer  (loc.  cit.)  removed  ureteral  stones  in  two  cases 
through  a  perineal  lithotomy  wound,  undertaken  for  the  removal  of 
vesical  stones,  for  which  the  calculi  had  been  mistaken,  by  the  use  of 
the  sound. 

After  several  attempts  Freyer  (loc.  cit.)  was  able  to  grasp  and  remove 
a  stone  from  the  ureteral  orifice  of  a  man  b}r  means  of  a  lithotrite, 
which  w<as  then  used  to  crush  it.  The  calculus  had  been  localised  by 
means  of  the  cystoscope. 

It  may  be  necessary  to  incise  the  mucous  membrane  or  even  the 
muscular  wall  of  the  bladder  in  order  to  free  the  calculus,  but  as  long 
as  the  incision  is  not  carried  upwards  for  more  than  an  inch  the 
peritonaeum  will  not  be  endangered.  While  trying  to  grasp  the  stone 
with  forceps,  a  finger  placed  in  the  vagina  or  rectum  should  be  used  to 
prevent  the  stone  from  slipping  upwards  out  of  reach. 

4.  Impaction  loiu  in  the  Pelvis,  but  not  accessible  from  the  Bladder. — 
Until  lately  it  used  to  be  believed  that  stones  situated  low  down  in 
the  pelvis  could  not  be  reached  or  removed  through  the  iliac  or  other 
extra-peritonaeal  route,  especially  in  the  female. 

The  experiences  of  Israel,  Young  (loc.  infra  cit.),  Finney,  Betham, 
Robinson,  and  others,  have  proved  that  it  is  possible  to  remove  a 
calculus  from  any  part  of  the  ureter  down  to  the  bladder  wall  through 
an  iliac  incision.  It  may  not  be  always  wise  to  choose  this  route, 
however,  for  it  may  not  be  the  easiest  or  the  safest  method  to  adopt 
in  certain  cases  for  various  reasons.  In  most  cases  it  should  be 
adopted,  however,  because  the  kidne}7  and  ureter  can  be  examined  at 
the  same  time.  Ceci  records  a  fatal  case  in  which  he  removed  a 
calculus  through  the  rectum ;  this  route  is  not  to  be  recommended  on 
account  of  the  danger  of  ascending  suppurative  nephritis. 

The  Vaginal  Route. — Emmet,  Cabot,  Israel,  Garceau,  and  others, 
have  successfully  removed  ureteral  calculi  through  the  vagina.  It  may 
be  suitable  for  some  cases  in  which  the  calculus  is  not  more  than  two 
inches  from  the  bladder. 

Garceau  (Boston  Med.  and  Surg.  Journ.,  April  21,  1904)  removed  a 
stone  impacted  about  three  inches  from  the  vesical  orifice  by  incising 
the  anterior  vaginal  cul  de  sac,  and  pushing  awa}7  the  peritonaeum  from 
between  the  bladder  and  the  uterus,  and  then  everting  the  broad  ligament 
backwards,  and  hooking  the  calculus  and  the  ureter  downwards  and 
forwards  towards  the  vagina.  A  small  vaginal  incision  was  then  made, 
and  the  calculus  squeezed  out,  and  the  incision  was  closed  with  sutures, 
which  took  up  the  outer  coats  of  the  ureter.  The  operation  took  only 
ten  minutes,  and  was  entirely  successful,  no  fistula  resulting.  The 
stone  was  a  large  one,  having  a  diameter  of  three-eighths  of  an  inch. 

This  method  carries  the  risk  of  pelvic  cellulitis,  which  occurred  in  a 
case  recorded  by  Freyer  (Lancet,  vol.  ii.  1903,  p.  584). 

In  this  case  Freyer  was  unable  to  extract  the  calculus,  because  it 
slipped  up  out  of  his  reach ;  but  it  came  away  into  the  dressings. 
Pelvic  cellulitis  supervened  and  delayed  the  recovery  of  the  patient. 


ol'KKATIONS    ON    TIIK    URETER. 


249 


A  temporary  or  permanent  uretero-vaginal  fistula  may  also  arise  after 
tliis  operation.  Israel  (quoted  by  Young),  although  he  was  able  to 
remove  two  stones  by  this  route,  failed  in  two  other  eases,  and  had  to 
resort  to  the  iliac  incision,  which  proved  successful.  Therefore  Esrael 
did  not  attempt  the  vaginal  operation  in  his  two  next  cases. 

Fenwick  {Clin.  Sue.  Trans.,  vol.  xx.  p.  240)  has  removed  a  calculus 
located  two  to  three  inches  from  the  bladder  through  a  small  transverse 
perineal  incision,  but  this  method  is  not  recommended  for  the  reasons 
given  by  Young  in  his  able  article  on  the  surgery  of  the  lower  ureter 
{Ann.  of  Surg.,  1903,  vol.  xxxvii.  p.  682).  He  states  that  the  wound 
is  narrow  and  deep ;  and  that  Regnier  failed  to  reach  the  stone,  and 
had  to  adopt  the  iliac  method.  Moreover,  the  peritonaeum  may  be 
opened  unawares,  and  the  kidney  and  ureter  cannot  be  examined ;  and 
the  incision  in  the  latter  cannot  be  sutured. 

The  Sacral  Route. — Henry  Morris  {Surgical  Diseases  of  the  Kidney 
a)id  Ureter,  vol.  vi.  p.  469)  in  February,  1900,  removed  a  calculus, 
which  was  impacted  two  to  two  and  a  half  inches  from  the  orifice  of  the 
left  ureter,  through  the  "sacral  route."  Morris  considered  the  calculus 
to  be  too  high  for  removal  by  the  vaginal  method.  He  made  an  incision 
five  inches  long  parallel  with,  and  to  the  left  of,  the  vertebral  spines,  and 
two  inches  from  the  middle  line.  It  extended  from  the  level  of  the 
third  sacral  spine  to  a  distance  of  one  and  a  half  inches  beyond  the  tip 
of  the  coccyx.  The  gluteus  maximus  and  the  great  sacro-sciatic  liga- 
ment were  divided  and  retracted.  Bougies  were  inserted  in  the  vagina 
and  rectum,  and  a  sound  was  passed  into  the  bladder.  "After  some 
trouble  the  left  ureter  was  found,  and  the  part  containing  the  impacted 
stone  was  pushed  into  the  wound."  The  stone  was  removed,  and 
three  Lembert  sutures  were  used  to  close  the  ureteral  incision.  A 
fistula  lasted  for  nearly  four  weeks  ;  but  the  patient  made  a  good 
recovery. 

In  another  case  Mr.  Morris  adopted  this  method  for  the  removal  of 
the  lower  part  of  the  ureter  of  a  patient  whose  corresponding  kidney 
and  upper  part  of  the  ureter  had  been  removed  for  calculous  pyo- 
nephrosis three  weeks  earlier.  The  part  of  the  ureter  removed  by  the 
sacral  route  contained  nine  stones. 

This  method,  which  was  first  suggested  by  Cabot  in  1892  (Amer. 
Journ.  Med.  Sci.,  1892,  p.  43),  deserves  attention  because  it  has  been 
adopted  and  recommended  by  so  eminent  an  authority  as  Henry 
Morris  ;  but  it  is  open  to  the  following  criticisms.  It  is  unnecessarily 
severe,  difficult,  and  destructive,  and  it  does  not  allowr  a  proper  examina- 
tion of  the  kidney  and  ureter,  so  that  extensive  disease  of  the  one  and 
a  stricture  of  the  other  may  be  overlooked.  It  is  practically  certain 
that  any  stone  in  the  pelvis  can  be  reached  either  by  the  abdominal 
extra- peritonaeal  route  or  by  the  vaginal  or  vesical  routes. 

Prognosis. — Extra-peritonaeal  uretero-lithotomy  is  a  very  successful 
operation,  which  has  a  brilliant  future.  With  earlier  and  more  accurate 
diagnosis,  the  operation  will  not  only  have  a  lower  mortality,  but  will 
also  save  more  kidneys  from  destruction  by  long-continued  backward 
pressure  and  sepsis. 

Tenney  (loc.  sujJra  cit.)  gives  the  mortality  of  23  in  122  cases. 
Fowler  (loc.  cit.)  mentions  three  deaths  in  21  operations,  and  Deaver 
(loc.  cit.)  two  deaths  in  25  cases. 


250 


OPERATIONS  OX  THE  ABDOMEN. 


In  44  cases  recorded  by  Morris  (loc.  cit.)  nephrectomy  was  necessary 
in  four. 

II.  Valvulak  Obstruction. — Simon,  in  1876,  gave  theoretical 
directions  for  the  relief  of  this  condition.  The  first  successful  operation 
was,  however,  performed  by  Fenger,  of  Chicago,  in  1892.  The  method 
of  dealing  with  the  condition  may  be  gathered  from  the  following  r/mm/ 
of  Fenger's  case  (Ann.  of  Surg.,  vol.  xx.  1894).  The  patient  was  a 
woman,  aged  28,  with  intermittent  hydronephrosis  due  to  a  movable 
kidney.     The    pelvis  and    calyces  were    first    explored    and    no  stone 


IV. 


Showing  Kiister's  operation.  (Morris.)  I.  Sac  wall ;  c,  transverse  section  of 
ureter.  II.  b,  c,  the  ureter  in  transverse  section,  split  on  anterior  side  ;  at  b  and 
c,  eleven  sutures  which  connect  the  wings  of  the  split  ureter  to  the  wall  of  the 
sac.  III.  a,  the  upper  mouth  of  the  ureter  running  in  the  wall  of  the  sac, 
a,  b  ;  a,  c,  split  line  of  the  same  in  the  anterior  part  of  the  canal.  IV.  The  cleft 
walls  of  the  canal  pulled  apart  and  fixed  at  a,  b,  c,  inside  the  wall  of  the  sac. 

found.  As  the  ureter  could  not  be  catheterised,  a  small  opening  was 
made  in  the  posterior  wall  of  the  infundibulum,  when  a  valvular 
obstruction  was  found  at  the  upper  end  of  the  ureter  where  it  joined 
the  renal  pelvis.  The  valve  was  divided  vertically,  and  the  ends  of 
the  longitudinal  incision  united  by  sutures,  so  as  to  convert  the 
incision  into  a  transverse  one.  The  incision  in  the  infundibulum 
was  then  closed  with  sutures,  and  the  kidney  fixed  in  the  loin,  a 
bougie  being  passed  through  the  wound  in  the  renal  parenchyma 
and  retained  in  position  in  the  ureter  for  two  days.  The  patient 
recovered  without  a  fistula,  and  subsequently  had  no  return  of  the 
hydronephrosis. 


OPERATIONS   ON    THE    URETER. 


25' 


Monis  {lor.  cit.,  vol.  ii.  p.  435)  does  not  recommend  leaving  the 
bougie,  for  there  is  little  fear  of  stenosis  resulting,  if  the  ureter  be  of 
normal  calibre  :  "  It  delays  healing,  and  it  is  Liable  to  be  followed  by  a 
temporary  fistula.  It  is  apt  to  excite  ureteritis,  and  there  may  be 
marked  difficulty  in  removing  it  owing  to  deposit  of  urinary  salts 
upon   it." 

If  the  ureter  be  found  to  be  adherent  to  the  dilated  pelvis,  and 
opening  into  the  latter  too  high  for  efficient  drainage,  a  plastic  opera- 
tion should  be  undertaken.  The  valve  or  bridge  between  the  lower 
end  of  the  pelvis  and  the  ureter  should  be  incised  from  within  the 
pelvis,  which  should  be  opened  by  a  posterior  vertical  incision. 

Recurrence  of  the  malformation    should  be  prevented  by  carefully 

Fig.  74. 


Abnormal  position  of  ureter  to  hydronephrotic  infundibulum  of  kidney 
before  operation.  (Morris.)  The  bougie  could  not  be  passed  into  the  ureter 
through  the  kidney  wound,  therefore  an  incision  was  made  in  the  pelvis. 


suturing  the  edges  of  the  incision  in  the  septum  in  a  longitudinal 
direction,  as  recommended  by  Mynter  (Aim.  of  Surg.,  December,  1893), 
or  by  sewing  the  flaps  to  the  inner  surface  of  the  sac  (Ktister).  The 
simplest  way,  however,  is  to  join  the  extremities  of  the  longitudinal 
wound  and  thus  convert  it  into  a  transverse  one,  as  recommended  by 
Fenger  and  Morris.  The  exploratory  incision  in  the  pelvis  should 
then  be  closed  with  fine  catgut  sutures,  which  should  not  pierce  the 
mucous  lining,  and  should  be  prepared  to  last  for  about  twenty  days, 
so  that  they  may  not  become  absorbed  before  firm  union  has  occurred. 
If  the  method  recommended  above  is  not  practicable  because  the 
ureter  is  not  adherent  to  the  dependent  part  of  the  hydronephrotic  sac, 
an  iucision  may  be  made  at  the  lowest  point  of  the  sac,  and  its  edges 


252 


OPERATIONS  ON  THE  ABDOMEN. 


joined  to  a  longitudinal  wound  made  in  the  ureter.  The  sutures 
should  only  pierce  the  outer  coats  of  the  sac  and  ureter.  This 
method  is  not  applicable  when  a  narrow  stricture  exists  in  the  ureter 
below  the  lower  end  of  the  sac,  and  then  a  portion  of  the  ureter  may 
have  to  be  resected  and  the  healthy  end  joined  to  the  lower  part  of  the 
sac,  as  in  Kuster's  classical  case.  Kuster's  patient  had  a  hydronephrosis 
of  his  only  kidney  draining  in  the  loin,  and  Kuster  found  first  a 
valvular  and  elevated  ureteral  orifice,  which  he  slit  open  ;  then  he 
discovered  a  slight  stricture  in  the  ureter  2  cm.  below  the  sac.  As 
this  was   not  remediable,   it  was  resected,   and  the   healthy  end  was 

Fio.  75- 


Ureter  in  its  improved  position  to  the  infundibulum  after  resection  of  the 
upper  end  of  the  ureter,  and  its  reunion  with  the  renal  pelvis.     (Morris.) 

attached  to  the  lower  end  of  the  hydronephrotic  sac,  as  shown  in 
Fig.  j$.  It  will  be  noticed  that  the  outer  surface  of  the  ureter  is 
attached  to  the  denuded  inner  surface  of  the  sac. 

The  patient  ultimately  improved  wonderfully  in  his  general  health 
and  comfort.  The  fistula  closed,  although  pus  was  present  in  the  urine 
six  months  later. 

Figures  (74  and  75)  from  Mr.  Morris'  well-known  work  illustrate  his 
case,  in  which  he  slit  open  the  pelvis  from  the  point  of  insertion  of 
the  ureter  to  the  lower  end  of  the  sac,  and  then  joined  the  healthy  end 
of  the  ureter  to  the  margins  of  the  lower  part  of  the  incision.  The 
end  of  the  ureter  was  enlarged  by  slitting  to  prevent  subsequent  con- 
traction. Morris  himself  states  that  lateral  anastomosis  would  do  well 
for  cases  of  this  kind.     Certainly  it  would  be  much  simpler,  and  the 


Or  EH  AT  IONS    ON    THE    UltETEl 


253 


danger  of  leakage  at  the  "  angle  of  suture  "  would  be  avoided.  The 
stump  of  the  ureter  attached  to  the  pelvis  could  be  turned  in  by  a 
purse-string  suture. 

Morgan  (Ann.  of  Surg.,  1902,  vol.  xxxvi.p.  528)  has  published  a  unique 
case  of  valvular  obstruction  situated  about  one  and  a  half  inches  above 
the  bladder.  This  malformation  was  probably  due  to  kinking,  which  was 
again  due  to  peri-ureteral  adhesions,  such  as  induce  a  similar  condition  in 
the  oesophagus.  Morgan  divided  the  valve  through  an  incision  made 
extra-peritonseally  into  the  pouch.  A  suprapubic  cystotomy  was  per- 
formed to  pass  catheters  into  the  ureter  to  prevent  recurrence  and 
establish  drainage.     The  patient  ultimately  made  a  good  recovery. 

III.  Stricture  of  the  Ureter. — Various  plans  have  been  adopted 
by  different  surgeons  to  remedy  strictures  of  the  ureter,  the  chief  being 

Fig.  76. 


FRONT 


FRONT 


SIDE 

Illustrating  Fenger's  operation  for  stricture  of  the  ureter.     (Morris.) 


the  plastic  method  of  Fenger  (loc.  supra  cit.),  dilatation  by  bougies 
(Alsberg),  and  resection  of  the  strictured  portion  (Kiister).  The  first  of 
these  plans  only  will  be  described  here,  as  it  will  probably  be  found 
applicable  to  the  greatest  number  of  cases.  Moreover,  this  method 
has  been  successfully  carried  out  by  Fenger,  Morris,  Mynter,  and 
others. 

The  details  of  the  operation  can  be  very  well  made  out  by  reference  to 
the  three  illustrations  in  Fig.  76.  The  strictured  portion  of  the  ureter  is 
first  divided  longitudinally  ;  sutures  of  fine  silk  are  then  passed  on  either 
side  of  this  in  order  to  draw  the  two  extremities  of  the  incision  together 
and  thus  convert  it  into  a  transverse  one,  after  the  manner  of  the 
Heineke-Mickulicz  operation  for  stenosis  of  the  pylorus.  Further 
sutures,  passing  through  the  outer  coats  only,  now  bring  the  edges  of 
the  rest  of  the  incision  together,  thus  folding  the  ureter  on  itself  to 
some  extent. 


254  OPERATIONS  ON  THE  ABDOMEN. 

The  following  short  account  of  Fenger's  case  well  illustrates  the 
brilliant  success  of  the  operation  : 

"  Traumatic  stricture  of  ureter  close  to  entrance  into  pelvis  of  kidney  ; 
intermittent  pyonephrosis  for  twenty-four  years ;  increased  frequency  of 
attacks;  nephrotomy;  no  stone  in  sacculated  kidney  ;  ureteral  entrance 
could  not  be  found  ;  longitudinal  ureterotomy  revealed  stricture  at 
upper  end  of  ureter ;  longitudinal  division  of  stricture  and  plastic 
operation  on  ureter;  recovery  without  fistula." 

Before  performing  any  plastic  operation  upon  the  ureter  or  the 
pelvis,  it  is  very  important  to  decide  (a)  if  the  kidney  is  in  a  recoverable 
condition,  and  (b)  if  the  ureter  is  patent  throughout  the  rest  of  its 
course  up  and  down.  Much  may  have  been  learnt  about  the  functional 
capacity  of  the  kidney  from  an  examination  of  the  separated  urines,  but 
the  only  reliable  evidence  is  an  examination  of  the  kidney  from  the 
wound.  The  patency  of  the  ureter  must  be  determined  by  means  of  a 
bougie  or  ureteral  catheter.  These  must  be  used  at  the  beginning  of 
all  plastic  operations,  and  before  completing  all  nephrolithotomies  and 
uretero-lithotomies.  If  these  precautions  are  not  taken  the  surgeon 
may  waste  time  and  energy  in  performing  useless  operations,  or  fail  to 
relieve  his  patients  by  incomplete  ones.  It  should  be  remembered  that 
stones  and  strictures  of  the  ureter  are  often  associated.  The  stone  may 
be  either  the  result  or  the  cause  of  the  stricture.  Carcinomatous 
stricture  may  develop  at  or  near  an  impacted  stone  (Deaver,  loc.  tit.). 

In  cases  of  extensive  or  multiple  strictures  of  the  ureter,  and  in  those 
due  to  tuberculous  or  malignant  disease,  nephro-ureterectomy  may 
be  the  only  suitable  treatment  if  the  other  kidney  is  known  to  be 
sufficiently  healthy.  Failing  this,  a  fistula  may  be  established  in  the 
loin. 

Ureteral  Catheterisation  and  dilatation  through  the  bladder  has 
been  successfully  performed,  and  cases  have  been  published  by  Kelly, 
Pawlik,  Casper,  and  others.  Morris  condemns  the  treatment  as  a 
difficult,  tedious,  and  painful  process,  which  is  moreover  uncertain  and 
revolting.  Pawlik  had  to  pass  the  instrument  thirty  times  in  his  cases 
of  pyonephrosis.  Symptoms  of  fever  and  pain  may  be  aggravated  by 
each  introduction. 

Strictures  of  the  lower  ureter  may  be  approached  through  an  extra- 
peritoneal abdominal  incision  and  treated  in  one  of  various  ways. 

Young  (Ann.  of  Surg.,  1903,  vol.  xxxvii.  p.  688),  after  removing  a 
calculus  impacted  1 J  cms.  above  the  bladder,  was  able  to  dilate  a  stric- 
ture which  had  developed  below  the  calculus.  In  another  case  of  the 
same  kind,  Dr.  Young  removed  a  large  calculus  from  the  ureter  just 
above  the  wall  of  the  bladder.  He  then  discovered  an  impervious 
intra-mural  stricture  which  he  was  not  able  to  dilate.  He  therefore 
exposed  the  lateral  wall  of  the  bladder  from  the  same  iliac  wound,  and 
having  retracted  the  vas  deferens,  he  opened  the  bladder.  With  the 
aid  of  digital  counter-pressure  at  the  ureteral  orifice,  he  was  able  to 
force  the  point  of  a  small  urethral  dilator  into  the  bladder  and  then 
to  divide  the  stricture  from  within  the  bladder  by  means  of  a  long- 
handled  scalpel.  The  patient  made  a  rapid  recovery,  and  the  ureteral 
orifice  was  seen  to  be  patent  six  months  later  by  means  of  the 
C}^stoscope. 

Israel  (quoted  by  Young)  having  performed  a  nephrolithotomy  on  a 


OPERATIONS   ON    THE    URETER. 


255 


woman,  and  discovered  a  stricture  in  the  pelvic  ureter,  attempted  to 
dilate  the  stricture  from  the  bladder;  but  failing,  lie  exposed  the  ureter 
extra-peritonseally,  and  found  a  stricture  about  3  cms.  long  ending  at 
the  bladder  wall.  He  then  resected  the  stricture  and  joined  the 
healthy  end  of  the  ureter  to  an  incision  made  on  a  sound  high  up  on 
the  posterior  wall  of  the  bladder.  The  ureter  was  cut  obliquely,  and  its 
mucous  membrane  sutured  to  that  of  the  bladder  at  one  angle  of  the 
wound,  which  was  then  closed.  The  lumbar  fistula,  which  had  existed 
for  eight  months,  soon  closed.  Before  it  closed  Israel  proved  that  fluid 
introduced  into  the  bladder  did  not  flow  back  through  the  new  ureteral 
orifice,  but  a  catheter  could  be  passed  from  the  fistula  along  the  ureter 
into  the  bladder. 

Extra-peritoneal  uretero-vesical  anastomosis  is  far  preferable  to 
making  a  uretero-vaginal  fistula  for  the  purpose  of  dilating  the  stricture, 
for  the  fistula  may  not  close,  and  the  stricture  may  recontract. 
Nephrectomy  is  better  than  a  permanent  urinary  fistula  either  in  the 
loin  or  vagina,  if  the  other  kidney  is  healthy. 

Aberrant  renal  vessels  causing  and  obstructing  the  ureter  may 
be  ligatured  and  divided.  Morris  {Lancet,  1905,  vol.  ii.  p.  158)  dis- 
covered this  condition  in  a  woman  whose  symptoms  had  not  been 
relieved  by  a  nephropexy  performed  elsewhere  four  years  earlier. 
Sixteen  calculi  were  also  discovered  in  the  kidney,  and  were  probably 
secondary  to  the  ureteral  obstruction. 

B.  Injuries  to  the  Ureter. — These  may  be  met  with  either  in  the 
form  of  traumatic  ruptures,  or  of  accidental  division  or  removal  of  a 
piece  of  the  ureter  during  the  course  of  certain  abdominal  operations, 
such  as  hysterectomy  or  the  removal  of  a  pelvic  tumour. 

Traumatic  rupture  of  the  ureter  has  not  yet  been  treated  by  direct 
suture.  This  is  owing  doubtless  to  the  extreme  difficulty  in  the 
diagnosis  of  this  condition  in  the  early  stages,  for  most  of  the  cases 
have  not  been  recognised  until  an  accumulation  of  urine,  blood,  or  pus 
has  formed  and  has  been  opened.  The  tumour  due  to  the  accumulation 
may  not  be  noticed  for  some  time,  two  to  three  weeks  (Stanley,  Page, 
Barker,  Hicks),  thirty-nine  days  (Croft),  and  in  one  case  (Stanley's) 
not  until  seven  weeks  after  the  injury. 

Mr.  Henry  Morris  (vol.  ii.  p.  330)  was  onky  able  to  discover  records 
of  12  cases  of  rupture  of  the  ureter  as  distinguished  from  rupture  of  the 
renal  pelvis.  Should  a  traumatic  rupture  be  discovered  during  an 
exploration,  it  should  be  treated  by  suture  or  anastomosis. 

The  accumulated  fluid  in  the  loin  has  been  aspirated  in  some  cases 
several  times  with  ultimate  recovery,  but  it  is  questionable  whether 
the  absence  of  reaccumulation  has  not  been  due  to  atrophy  of  the 
kidney. 

Lumbar  incision  is  far  preferable,  and  thus  drainage  at  least  will  be 
established  to  prevent  further  extravasation  and  suppuration.  In  some 
of  these  late  cases  it  may  be  possible  to  perform  a  plastic  operation  on 
the  ureter.  If  it  be  known  that  the  opposite  kidney  is  in  good  wrorking 
order,  a  secondaiy  nephrectomy  may  be  performed  for  suppuration  in 
and  around  the  kidney,  or  for  persistent  fistula. 

Primary  nephrectomy  is  not  justifiable,  for  the  kidne}'  and  ureter 
may  recover  their  functions,  and  knowledge  is  first  needed  concerning 
the  secreting  power  of  the  other  kidney,  if  an}r. 


2=56 


OPERATIONS    OX    THE    ABDOMEN", 


For  accidental  division  or  removal  of  a  piece  of  the  ureter  during 
the  course  of  an  abdominal  operation,  a  very  large  number  of  different 
operations  have  been  performed.  It  is  impossible  here  to  mention  or 
describe  all  these  operations.  An  attempt  will,  however,  be  made  to 
indicate  the  methods  which  are  likely  to  be  found  most  suitable  to  the 
various  conditions  that  may  be  met  with. 

In  the  great  majority  of  instances  it  will  be  found  possible  to  directly 
unite  the  divided  ends  of  the  ureter.  The  results  that  have  so  far 
attended  the  various  methods  of  bringing  this  about  clearly  show  that 
it  should  be  done  wherever  possible.  Bovee  (Ann.  of  Surg.,  August, 
1900)  mentions  twenty-seven  published  cases  with  only  two  deaths, 
and  not  in   one   was  there   failure  to   unite.     If  the  ureter  has  been 


Fig.  77- 


Ureteroureterostomy  :  Van  Hook's  method.     (Morris.) 

simply  divided  without  loss  of  substance,  and  if  both  the  ends  are 
accessible,  and  the  upper  end  will  not  reach  the  bladder,  then,  because 
it  is  the  most  simple  method  to  cany  out,  and  because  it  is  the  least 
likely  to  be  followed  by  stricture,  the  following  operation,  devised  by 
Van  Hook  (vide  Fig.  yy),  should  be  performed.  The  following  are  the 
steps  of  the  operation  as  given  by  Fenger  (loc.  supra  cit.): 

"  (1)  Ligate  the  lower  portion  of  the  tube  one-eighth  or  one-fourth 
of  an  inch  from  the  free  end.  Silk  or  catgut  ma}'  be  used.  Make  with 
fine  sharp-pointed  scissors  a  longitudinal  incision,  twice  as  long  as  the 
diameter  of  the  ureter,  in  the  wall  of  the  lower  end,  one-fourth  of  an 
inch  below  the  ligature. 

"  (2)  Make  an  incision  with  the  scissors  in  the  upper  portion  of  the 
ureter,  beginning  at  the  open  end  of  the  duct  and  carrying  it  up  one- 
fourth  of  an  inch.     This  incision  ensures  the  patency  of  the  tube. 

"(3)  Pass  two  very  small  cambric  sewing  needles  armed  with  one 


OI'KKATIONS    OX    THK    L'KKTKK. 


257 


thread  of  sterilised  catgut  through  the  wall  of  the  upper  end  of  the 
ureter,  one-eighth  ofaD  inch  from  the  extremity,  from  within  outward, 
the  needles  being  from  one-sixteenth  to  one-eighth  of  an  inch  apart, 

and  equidistant  from  the  end  of  the  duct.     It  will  be  seen  that  the 

loop  of  catgut  between  the  needles  firmly  grasps  the  upper  end  of 
the  ureter. 

"  (4)  These  needles  are  now  carried  through  the  slit  in  the  side  of 
the  lower  end  of  the  ureter  into  and  down  the  tube  for  one-half  an  inch, 
where  they  are  pushed  through  the  wall  of  the  duct  side  by  side. 

"  (5)  It  will  now  be  seen  that  traction  upon  this  catgut  loop  passing 
through  the  wall  of  the  ureter  will  draw  the  upper  fragment  of  the  duct 


Fig.  78. 


Fig.  79. 


Uretero-ureterostomy.  To  illustrate 
the  oblique  method  of  Bovee. 
(Morris.) 


Implantation  of  the  ureter  into  the  bladder 
(Witzel's  method).  The  dotted  lines  show  the 
bladder  pulled  into  its  new  position  with  the 
ureter  sutured  into  it.     (Morris.) 


into  the  lower  portion.  This  being  done,  the  ends  of  the  loop  are  tied 
together  securely,  and  as  the  catgut  will  be  absorbed  in  a  few  days, 
calculi  do  not  form  to  obstruct  the  passage  of  the  urine. 

"  (6)  The  ureter  is  now  enveloped  carefully  with  peritonaeum." 
If,  however,  a  portion  of  the  ureter  has  been  accidentally  removed, 
and  the  upper  end  will  not  reach  the  bladder,  it  will  probably  be  found 
that  there  will  not  be  sufficient  length  of  ureter  available  for  per- 
forming Van  Hook's  operation.  In  this  case  the  ends  must  be  united 
by  end-to-end  suture,  or  by  the  oblique  method  of  Bovee  (vide  Fig.  78). 
Stricture  is  not  so  likely  to  follow  as  after  transverse  end-to-end  or  end- 
in-end  methods  of  Schopf  and  Poggi  respectively. 

Kelly  (Journ.  Amer.  Med.  Assoc,  Oct.  6th,  1900)  has  used  a  hammer 
similar  to  the  one  introduced  by  Halstead  for  gall  duct  operations. 
Near  the  end  of  the  hammer  there  is  a  circular  groove  over  which  the 

S. VOL.    II.  17 


258 


OPERATIONS  ON  THE  ABDOMEN. 


distal  end  of  the  ureter  is  temporarily  tied.     This  may  be  found  useful 
in  anastomosis  of  the  lower  ureter. 

TJretero-Vesical  Grafting. — Should  it  be  found  that  the  upper  end 
of  the  divided  ureter  will  reach  the  bladder,  implantation  into  this 
organ  is  preferable  to  all  other  procedures.  This  may  be  carried  out 
by  some  modification  of  the  method  of  Paoli  and  Busachi  (Annates  des 
Maladies  des  Organes  Genito-urinaircs,  1888),  which  consists  in  split- 
ting the  distal  end  of  the  ureter  and  uniting  it  by  sutures  to  an  incision 
in  the  bladder,  or  by  a  modification  of  the  operation  of  Van  Hook  for 
uretero -ureterostomy,  the  cut  end  of  the  ureter  being  invaginated  into 

Fig.  80. 


Technique  of  the  grafting  of  the  ureter  on  to  the  bladder  with  Boari's 
button.  (Morris.)  A,  Enlarged  view  of  button  ;  B,  Enlarged  view  of  button, 
showing  the  spriDg  compressed  by  the  stiletto  ;  C,  The  ureter  fastened  on  to  the 
button  ;  D,  The  grafting  on  to  the  bladder  by  means  of  the  button. 


the  bladder.  This  method  has  been  adopted  by  Penrose  and  others 
(Med.  News,  vol.  lxiv.  1894,  p.  470).  If  possible  the  operation  should 
be  performed  extra-peritonseally  as  in  AVitzel's  operation  (Centralblattfiir 
Gynakologie,  1896,  No.  ii.  p.  289).  Witzel  displaced  and  fixed  the 
bladder  into  the  iliac  fossa,  in  order  to  enable  him  to  bury  the  ureter 
for  a  distance  4  cm.  in  the  bladder  wall  as  shown  in  the  figure.  The 
mucous  membranes  of  the  incision  in  the  bladder  and  of  the  oblique 
opening  in  the  ureter  were  joined  with  interrupted  catgut  sutures,  and 
the  external  coats  were  also  joined  with  sutures  (Vide  Fig.  79). 


ol'KKATIoNS    ON    Till:    IIMlTKIt. 


259 


In  some  cases  Boari's  *  button,  if  available,  may  shorten  the  dura- 
tion of  the  operation,  but  the  button  has  to  be  removed  later  by  the 
urethra  in  the  female  and  Bupra-pubically  in  the  untie. 

Boari  (Inc.  cit.)  has  described  and  figured  an  ingenious  plan  of 
raising  an  extra-peritonaea!  flap  from  the  anterior  wall  of  the  bladder  and 
joining  its  edges,  and  implanting  the  ureter  into  the  tube  thus  formed. 
This  method  may  be  found  useful  when  displacement  of  the  bladder 
i^  not    enough    to    allow  of   union   without    tension.     Van   Hook  has 

Pio.  81. 


Boari's  operation.     A  flap  from  the  anterior  wall  of  the  bladder  is  used  as  a 
substitute  for  the  lower  part  of  the  ureter.     (Morris.) 

described  a  similar  method ;  the  ureter  had  been  previously  implanted 
upon  the  skin  of  the  abdomen. 

Finally,  should  such  a  length  of  ureter  have  been  removed  as  to 
render  both  direct  union  of  the  two  ends  and  implantation  into  the 
bladder  impossible,  the  proximal  end  must  be  either  implanted  into 
the  bowel  or  on  the  skin.  The  results  of  both  these  plans  have  so  far 
been  on  the  whole  extremely  unsatisfactory,  owing  to  infection  of  the 
ureter  and  kidney  in  the  case  of  implantation  into  the  bowel,  and  to 
discomfort  and  constant  irritation  of  the  skin  when  the  implantation  is 
made  on  the  skin.  For  these  reasons  a  secondary  nephrectomy  will 
often  be  necessary  in  such  cases. 


*  Ann.  des  Malad.  des  Organ.  Ge/iitu-urinairea,  1896,  p.  I. 

17 — 2 


CHAPTER  V. 
OPERATIONS    ON    THE   INTESTINES. 

ACUTE  INTESTINAL  OBSTRUCTION.  —  APPENDICITIS.  — 
INFLAMMATION  OP  MECKEL'S  DIVERTICULUM.  — 
PERFORATING  ULCER  OF  STOMACH— OF  DUODENUM 
— OF  INTESTINE  AFTER  TYPHOID  FEVER.— SUPPURA- 
TIVE PERITONITIS.  —  TUBERCULAR  PERITONITIS.  — 
ENTEROSTOMY. — FORMATION  OF  ARTIFICIAL  ANUS.— 
SUTURE  OF  INTESTINE. — RESECTION  OF  INTESTINE. 
— ENTERECTOMY.— COLECTOMY.— INTESTINAL  ANAS- 
TOMOSIS AND  SHORT  CIRCUITING.  —  INTESTINAL 
OCCLUSION. — ENTEROPLASTY.  —  CLOSURE  OF  ARTI- 
FICIAL   ANUS    AND    F^ICAL    FISTULA. 

ACUTE    INTESTINAL    OBSTRUCTION. 

Considered  generally,  without  reference  to  the  causation  of  the 
obstruction,  the  successful  treatment  of  acute  intestinal  obstruction 
depends  largely  on  two  points  :  (a)  The  Question  of  Operation,  and 
(b)  The  Question  of  the  Extent  of  Interference  that  is  indicated 
in  any  given  Case. 

(a)  The  Question  of  Operation. — Although  cases  of  so-called 
"spontaneous  cure"  have  from  time  to  time  been  recorded,  the  number 
of  these  is  so  small,  and  the  correctness  of  the  diagnosis  in  many  of  them 
so  doubtful,  that  for  all  practical  purposes  it  is  wiser  to  leave  them 
entirely  out  of  consideration.  For,  apart  from  these  and  the  small 
number  of  cases  of  intussusception  that  have  survived  the  sloughing  of 
the  intussusceptum,  as  Sir  F.  Treves  says,  "  there  is  no  avoiding  the 
fact  that  acute  intestinal  obstruction,  if  unrelieved,  ends  in  death " 
(Intestinal  Obstruction,  p.  475).  This  being  so,  it  clearly  becomes  the 
duty  of  the  surgeon  to  operate  on  every  case  of  acute  intestinal 
obstruction.  The  operation,  moreover,  should  be  performed  at  the 
earliest  possible  moment  after  the  diagnosis  has  been  made,  for,  serious 
as  the  operation  is  in  itself,  it  is  not  nearly  so  serious  as  delay,  since 
the  mortality  rises  extremely  rapidly  as  the  period  between  the  onset 
of  the  s}rmptoms  and  the  time  of  operation  increases.  Neither  should 
uncertainty  of  diagnosis  be  allowed  to  debay  the  operation,  for  of  the 
many  conditions  that  simulate  acute  intestinal  obstruction — e.g., 
appendicitis,  peritonitis  from  different  causes,  thrombosis  of  mesenteric 
veins,  acute  pancreatitis,  enteritis,  &c. — in  some  an  operation  may  be 
beneficial,  while  as  to  the  others  it  would  be  better  that  an  exploratory 


ACUTE   INTESTINAL   OBSTRUCTION.  26i 

operation,  as  long  as  it  is  done  by  skilled  hands,  took  place  needlessly 
than  that  a  remediable  condition  should  be  left  untouched.  Here, 
again,  the  valuable  opinion  of  Sir F.  Treves  maybe  quoted.  He  says: 
"  Operation  in  these  cases  is  too  often  regarded  as  a  last  resource.  It 
should  be  theirs*  resource,  as  it  certainly  is  the  only  resource." 

The  mortality  of  all  cases  of  acute  intestinal  obstruction,  as 
shown  by  Gibson  {Ann.  of  Surg.,  Oct.  1900)  in  a  collection  of  cases 
operated  upon  between  1888  and  1898,  is  about  47  per  cent.,  his 
list  including  646  cases  with  312  deaths  ;  and  although  this  is 
without  doubt  a  vast  improvement  upon  former  times,  it  is  still 
to  be  hoped  that  in  the  near  future  earlier  recognition  and  more 
immediate  operation  will  do  much  to  bring  about  still  further  improve- 
ment. Even  then  the  mortality  will  probably  always  be  high,  and 
this  owing  to  the  frequently  complicated  nature  of  the  cause  of  the 
obstruction,  the  peculiar  vitality  of  the  parts  which  have  to  be  handled, 
and  the  readiness  with  which  these  pass  into  a  condition  beyond 
recovery.  Bearing  in  mind,  however,  the  essentially  fatal  character  of 
the  condition,  apart  from  relief  by  operation,  eveiy  successful  operation 
should  be  looked  upon  rather  as  a  life  saved,  than  every  fatal  one  as  a 
life  lost.     The  results  have  considerably  improved  in  the  last  few  years. 

(b)  The  Extent  of  Interference  that  is  indicated  in  a  given  Case. 
— The  operation  must  be  according  to  the  state  of  the  patient.  These 
cases  of  acute  intestinal  obstruction  are  not  to  be  grouped  together  as 
all  equally  fit  for  operation,  or  as  all  certain  to  be  relieved  by  operation 
as  long  as  this  is  undertaken  early.  In  some  the  condition  of  the 
patient  is  good,  the  abdomen  is  undistended  and  a  prolonged  search 
may  be  made.  In  others  a  precisely  opposite  condition  is  present, 
any  prolonged  exploration  is  out  of  the  question,  and  all  that  can 
be  done,  if  the  cause  is  not  found  at  once,  is  to  open  one  of  the  most 
distended  coils,  as  low  down  as  possible,  and  drain  the  intestines 
{ride  infra). 

I  propose  to  describe  the  operation  generally  first,  and  then  to  allude 
to  its  application  to  the  chief  forms  of  acute  intestinal  obstruction. 

Operation. — The  bladder  is  first  emptied,  and  the  abdominal  wall 
shaved  and  cleansed.  A  water-bed  should  be  filled  with  hot  water, 
and  if  the  patient's  condition  is  bad,  a  hot  port  wine  enema  should  be 
given. 

The  question  of  anaesthetics  in  these  cases  is  a  very  important  one, 
and  should  be  well  considered.  The  impeded  respiration  due  to  the 
abdominal  distension  is  liable  to  make  the  administration  of  a  general 
anaesthetic  difficult  and  dangerous.  The  tendency  to  vomit  is  another 
grave  danger,  a  sudden  attack  during  the  administration  having 
frequently  caused  immediate  death  from  choking. 

Apart  from  these  two  considerations,  the  administration  of  a  general 
anaesthetic  seems  to  have  special  dangers  of  its  own  in  cases  of  acute 
intestinal  obstruction,  for  it  undoubtedly  often  produces  a  complete 
and  sudden  change  in  the  whole  aspect  of  a  case,  a  patient  thought  to 
be  in  good  condition  and  well  able  to  bear  an  operation  becoming 
suddenly  moribund  within  a  few  minutes  of  the  commencement  of  the 
administration. 

For  all  these  reasons  it  is  advisable,  wherever  possible,  and 
especially  in  very  bad  cases,  to  make  use  of  local  anaesthesia  only,  the 


262  OPERATIONS  ON  THE  ABDOMEN. 

infiltration  method  of  Schleich  with  cocaine,  or  ft  eucaine,  being  the 
most  suitable. 

Should  it,  however,  be  deemed  inadvisable  to  operate  without  general 
anaesthesia,  the  stomach  should  be  previously  washed  out  if  vomiting 
has  been  severe,  and  saline  infusions,  either  intra-venous  or  into  the 
cellular  tissue  of  the  axilla,  should  be  made  during  the  preparation  for 
the  operation,  and  repeated  or  continuous  infusion  may  be  of  great 
benefit  after  the  operation. 

The  operation  to  be  performed  will  necessarily  vary  according  to  the 
general  condition  of  the  patient,  and  the  mode  of  procedure  will  be 
described  under  two  heads  :  (A)  Early  Cases,  or  where  the  condition 
of  the  patient  is  good ;  and  (B)  Late  Cases,  or  where  the  condition 
of  the  patient  is  very  serious. 

A.  Early  Cases. — The  surgeon  makes  an  incision  five  inches  long 
through  the  right  rectus  muscle  close  to  the  middle  line,  and  beginning 
two  inches  above  the  level  of  the  umbilicus.*  The  anterior  wall  of  the 
rectus  sheath  is  incised,  and  one  of  its  edges  is  separated  from  the  muscle 
(Winslow)  ;  the  muscle  fibres  are  then  either  separated  or  drawn  out- 
wards ;  the  transversalis  fascia  and  the  peritonaeum  are  then  separated 
from  the  deep  surface  of  the  rectus,  and  incised  with  care. 

I  strongly  advise  the  surgeon  to  give  himself  plenty  of  room,  so  as 
to  quickly  get  his  hand  in  and  explore  efficiently.  A  short  median 
incision  below  the  umbilicus,  and  the  introduction  of  a  couple  of 
fingers,  is  usually  futile.  The  abdominal  wall  in  these  cases  is  not 
thinned  and  overstretched  as  in  ovariotomy  ;  hence,  if  inadequately 
opened,  it  grips  the  hand  most  embarrassingly.  If  the  case  has  been 
allowed  to  go  on  until  the  intestines  are  distended,  the  search  for  the 
cause  of  the  mischief  will  be  rendered  all  the  more  difficult,  and  there 
must  be  sufficient  room  to  introduce  the  hand  freely.  If  an  assistant 
skilfully  keeps  the  edges  of  the  wound  together  where  this  is  not 
occupied  by  the  inserted  wrist,  the  intestines  will  not  escape. 

The  peritonaeum  should  always  be  well  lifted  up  before  it  is  opened, 
especially  if  there  is  distended  bowel  beneath.  The  opening  is  then 
enlarged  with  blunt-pointed  scissors,  two  fingers  with  the  palmar 
aspect  turned  upwards  serving  now  as  the  best  director. 

The  late  Mr.  Greig  Smith  advised,  where  the  peritonaeum  is  thin, 
that  it  be  pinched  up  between  the  finger  and  thumb,  and  rolled  about 
to  see  that  no  bowel  is  included. t 

The  surgeon  should  now  decide  which  mode  of  exploration  he  will 
make  use  of.  The  following  is  as  useful  as  any  :  If  the  parts  are  not 
much  distended,  three  possible  sites  of  strangulation  should  be  first 
looked  to.      (i)  The  caecum,!  which  will  give  twofold  evidence,  first,  its 

*  In  those  extremely  rare  cases  where  the  obstruction  can  be  localised  to  one  or  other 
side  of  the  abdomen,  a  lateral  incision  may  be  made  use  of,  either  over  the  swelling,  if 
any  be  present,  or  in  the  linea  semilunaris. 

t  If  much  fluid  is  present,  it  now  often  shows  itself  through  the  peritonaeum. 

J  If  the  caecum  can  be  made  out  to  be  empty,  tracing  up  empty  coils  from  this  will 
very  likely  lead  to  the  obstruction.  The  more  marked  the  evidence  of  collapsed  small 
intestine,  the  greater  the  probability  of  the  obstruction  being  high  up,  and  the  less  fit 
the  case  for  enterostomy  (p.  344)  (R.  Jones,  Brit.  Med.  Jburn.,  vol.  i.  1S94,  p.  1123). 
In  this  case  a  band  was  found  and  successfully  dealt  with.  Here  the  obstruction  had  been 
incomplete  at  first,  one  of  incarceration  followed  by  strangulation.  I  have  mentioned  a 
similar  successful  case  on  p.  350. 


ACUTE    INTESTINAL   OBSTRUCTION.  263 

distension  or  emptiness  telling  whether  the  obstruction  is  above  or 
below  it;  and  secondly,  the  state  of  its  appendix,  whether  normal  or 

adherent,  whether  empty  or  containing  some  concretion.  (2)  Next, 
the  internal  inguinal,  the  femoral,  and  obturator  rings  are  explored,  to 
make  sure  that  no  tiny  hernia  exists,  imperceptible  from  the  outside. 
The  fingers  are  next  swept  upwards  towards  the  (3)  umbilicus,  in  the 
hope  of  finding  one  of  the  diverticular  bands  mentioned  at  p.  266.  If, 
up  to  this,  the  search  has  been  fruitless,  the  brim  of  the  pelvis  is  next 
examined,  as  bands  of  omenta  are  often  fixed  hereabouts,  and  also 
because,  in  women,  local  peritonitis,  originating  about  the  uterus  or 
its  appendages,  and,  in  either  sex,  about  the  appendix  ca3ci,  is,  not 
infrequently,  the  cause  of  the  obstruction.  If  an  empty  coil  of  small 
intestine  be  fortunately  discovered,  it  should  be  followed  up  to  the 
obstruction,  which  will  probably  be  not  far  away.  This  method  is  far 
easier  than  following  a  distended  coil. 

If  the  search  fail — and  it  often  will  when  distension  is  present, 
embarrassing  the  fingers  in  their  movements,  and  obscuring  the  relation 
of  parts — one  or  two  of  the  loops  which  lie  nearest  to  the  wound  should 
be  carefully  scrutinised.*  These  should  be  followed  in  the  direction  of 
increasing  congestion  and  distension,  thus  leading  to  the  obstruction. 
Fixity  of  a  coil  may  be  another  aid.  Where  there  is  ground  to  believe 
that  the  case  may  be  one  of  acute  supervening  upon  chronic  obstruction, 
the  sigmoid  and  colon  should  be  first  investigated. 

If  this  prove  fruitless  in  cases  where  there  is  not  much  distension, 
the  plan  adopted  by  Mr.  Cripps  (Clin.  Soc.  Trans.,  vol.  xi.  p.  225)  is 
the  simplest — i.e.,  to  draw  out  some  inches  of  intestine  at  a  time,  bit 
by  bit,  from  the  upper  part  of  the  wound,  passing  it  in  again  into  the 
belly  through  the  lower  part,  in  such  a  wa}r  that  at  no  time  are  more 
than  five  or  six  inches  of  intestine  exposed.  After  drawing  out  and 
replacing  some  feet  of  intestine  in  this  wa}T,  it  is  probable  that,  owing 
to  the  increasing  congestion  or  resistance,  the  surgeon  will  reach  the 
obstruction.!  This  is,  however,  a  tedious  method,  and  one  only  to  be 
adopted  when  the  condition  of  the  patient  is  good. 

An  assistant  should  hold  the  coil  from  which  the  surgeon  starts  in 
the  lower  angle  of  the  wound  under  a  hot  sponge,  so  as  to  save  the 
surgeon  going  over  the  ground  a  second  time. 

If  a  search  for  ten  minutes  has  failed  |  to  find  the  cause  of  obstruction 
the  following  courses  remain  open  :  (a)  Kummell's  plan  of  allowing  the 
small  intestines  to  prolapse  under  hot  aseptic  towels  ;  (/?)  emptying  the 
most  distended  coil,  and  either  closing  the  opening  later,  or  (y)  inserting 
in  it  a  Paul's  tube  ;   (8)   "  short-circuiting." 

*  The  late  Mr.  Greig  Smith  said  that  as  the  most  distended  coils  will  rise  nearest  the 
surface,  and  the  greater  amount  of  bowel  is  within  three  inches  of  the  umbilicus,  there  is  a 
probability  that  the  most  dilated  coils  will  be  in  sight. 

t  If  he  find  that  the  bowel  is  getting  healthier  and  emptier,  the  surgeon  must  reverse 
the  direction  of  his  search. 

%  "  The  difficulty  of  finding  the  obstruction  in  some  cases  is  well  shown  by  Madelung, 
who,  in  several  cases  where  the  seat  of  obstruction  could  not  be  located  during  life 
requested  the  pathologist,  when  he  made  the  post-mortems,  to  locate  the  obstruction  by 
introducing  his  hand  through  an  incision,  allowing  him  from  ten  to  twenty  minutes  for 
the  exploration  ;  in  every  instance  he  failed  to  find  the  obstruction  within  the  specified 
time  "  (Senn,  toe.  supra  tit.*). 


264  OPERATIONS   ON   THE   ABDOMEN. 

(a)  The  objection  to  this  method  is,  of  course,  that  it  is  often 
exceedingly  difficult  to  get  the  distended  coils  back  into  their  home, 
and  that  the  necessary  manipulations  and  exposure  must  produce 
shock,  and  may  inflict  serious  damage.  If,  however,  the  condition  of 
the  patient  is  satisfactory  and  the  amount  of  distension  not  great,  it  is, 
if  done  properly,  and  with  care  to  prevent  undue  exposure  of,  and 
damage  to,  the  intestines,  perhaps  the  wisest  course  to  pursue.  This 
practice  is,  moreover,  recommended  by  no  less  an  authority  than 
Sir  F.  Treves,  who  considers  that  the  damage  done  to  the  intestines, 
by  the  amount  of  exposure  necessary,  is  probably  less  than  that 
caused  by  prolonged  manipulations  within  the  abdominal  cavity.  The 
abdominal  incision  should  be  made  very  free,  and  the  intestines  then 
allowed  to  escape  between  smooth-surfaced  sterile  towels,  wrung  out 
of  salt  solution  at  a  temperature  of  no0  F.  In  this  Tay  the  intestines 
can  be  immediately  covered  with  the  towels,  and  the  further  search 
for  the  cause  of  obstruction  conducted  with  very  little  exposure  or 
interference.  Usually  the  seat  of  obstruction  will  be  quickly  indicated 
by  fixity  of  some  loop  of  intestine,  wdiich  thus  will  not  leave  the 
abdomen. 

(J3)  Should,  however,  the  amount  of  distension  be  considerable,  it  is 
wiser  to  relieve  this  condition  before  proceeding  further.  To  this  end  a 
different  method  must  be  adopted  according  to  the  seat  of  greatest  dis- 
tension. Should  this  be  the  large  intestine,  for  instance,  in  a  case  of 
volvulus,  the  distended  loop  may  be  emptied,  either  by  oblique  puncture 
with  a  very  fine  hydrocele  trocar  if,  which  is  rare,  they  contain  only  gas, 
or  b}r  incision  if  liquid  fasces  are  present  as  well.  Both  these  steps  are 
often  disappointing.  Two  conditions  must  be  present  to  allow  puncture 
with  the  finest  hydrocele  trocar  to  be  safe.  The  coats  of  the  intestine 
must  be  sufficiently  healthy,  neither  infiltrated  nor  paralysed,  to  allow 
the  peritoneal  and  muscular  coats  to  close  the  opening  in  the  mucous 
bj'  gliding  over  it,  otherwise  a  fatal  leakage  will  take  place  guttatim 
unless  every  puncture  is  closed  by  a  fine  parietal  suture.  The  second 
condition  is,  that  gas  only  must  be  present ;  liquid  faeces  being  almost 
invariably  present  as  well.  A  wiser  course  is  to  incise  and  evacuate 
the  most  distended  coils.  The  patient  being  turned  on  to  one  side, 
the  most  distended  loop  is  drawn  out  over  a  basin,  incised  parallel  to 
its  long  axis  at  a  point  most  distant  from  the  mesentery,  the  rest  of 
the  coils  being  kept  within  the  abdomen,  and  the  one  withdrawn 
carefully  isolated  by  tampons  of  iodoform  gauze  or  hot  aseptic  towels. 
As  the  escape  of  gas  and  fluids,  owing  to  the  paralysis  of  the  intestine, 
will  probably  be  very  slow,  it  will  be  wise  to  follow  Dr.  Senn,  and 
"  resort  to  pouring  out  the  contents,  as  it  were,  by  seizing  the  gut 
several  feet  above  and  below  the  incision,  and  elevating  it,"  a  large 
quantity  of  fluid  fasces  being  thus  poured  out.  This  emptying  of  dis- 
tended coils  will  not  only  facilitate  reduction,  but,  as  first  urged  by  the 
late  Mr.  Greig  Smith  (Abdom.  Surg.,  p.  436),  it  will  diminish  the 
harmful  effects  of  a  greatly  distended  abdomen,  viz.,  dyspnoea,  palpita- 
tion, and  abdominal  shock,  and,  as  regards  the  bowels  themselves,  the 
danger  of  continued  distension,  paralysis,  and  absorption  of  toxic 
products.  When  the  evacuation  has  been  made  as  complete  as 
possible,  the  next  step  will  depend  upon  the  condition  of  the  patient. 
If  this  be  good,  and  the  relief  of  the  distension  has  been  sufficient  to 


ACUTE  INTESTINAL   OBSTRUCTION.  265 

justify  further  exploration,  the  Burgeon  closes  hia  incision  in  the 
intestine  by  Lembert's  sutures,  taking  care  to  effect  real  inversion  of 
the  edges,  and,  leaving  one  or  two  of  the  sutures  Long,  keeps  tins  bit 
of  intestine  outside,  entrusted  to  an  assistant,  while  he  continues  his 
search  for  the  cause  of  the  obstruction.  If  this  be  found  and  removed, 
the  opened  and  sutured  part  of  the  intestine  must  again  be  inspected, 
and  its  exact  closure  made  sure  of  before  it  is  returned ;  any  sutures 
left  long  having  been  first  cut  short.  Before  finally  closing  the  wound 
the  question  of  cleansing  the  peritonseal  cavity,  irrigation,  and  the 
insertion  of  a  drain  into  Douglas's  pouch  may  arise. 

If,  on  the  other  hand,  it  is  found  that  the  small  intestine  is  the  seat 
of  most  distension,  then  very  little  advantage  will  be  gained  by  either 
puncture  or  incision,  for  the  acute  flexures  caused  by  the  distension 
will  prevent  more  than  a  very  small  portion  of  the  gut  being  emptied 
by  each  incision.  In  this  case  it  is  wiser  to  drain  the  intestine  for  a 
time  by  performing  enterostomy,  as  described  below  (p.  344),  and  to 
search  for  and,  if  possible,  remove  the  cause  of  obstruction  after  the 
worst  of  the  distension  has  been  relieved. 

(y  and  8)  AY  here  the  patient's  condition  makes  any  further  search 
impossible,  or  where  there  is  great  distension,  a  temporary  or 
permanent  artificial  anus  must  be  made,  or  else  "short-circuiting" 
must  be  performed. 

As  the  last  can  very  rarely  help  us  in  acute  intestinal  obstruction,  I 
will  first  dispose  of  this  subject.  It  will  be  remembered  that  I  am 
speaking  of  short-circuiting  as  one  of  the  courses  open  to  a  surgeon 
when  he  fails  to  find  the  cause  of  an  acute  intestinal  obstruction,  or 
rather,  of  an  acute  supervening  upon  a  chronic  obstruction.  It  is 
evident  that  it  is  only  to  a  few  cases  that  this  method  is  suitable — e.g., 
cases  of  matting  together  of  coils  of  small  intestine,  as  after  previous 
mischief  set  up  by  a  mesenteric  gland,  or  appendicitis.  In  such  cases 
if  there  is  inextricable  matting  but  no  recent  inflammatory  changes  and 
nothing  like  gangrene,  a  coil  of  the  distended  small  intestine  may  be 
short-circuited  to  the  most  conveniently  placed  piece  of  large  intestine. 
This  is  effected  by  the  use  of  a  Mayo-Robson's  bobbin,  Murphy's 
button,  according  to  the  surgeon's  familiarity  with  each,  and  the  time 
at  his  disposal.  In  the  majority  of  cases  where  the  surgeon  cannot 
find  the  cause,  some  part  of  the  small  intestine  will  be  suffering  not 
from  chronic  matting  as  above,  but  from  the  pressure  effects  of  some 
band,  orifice  in  the  omentum,  &c,  and  softening,  or  even  gangrene,  may 
be  impending  ;  then  a  safer  and  better  plan  to  relieve  the  distended 
intestine  will  be  by  performing  enterostomy  as  described  below,  by 
fixing  in  an  enterostomy  tube,*  or  puncturing  with  a  large  trocar  and 
cannula  (p.  349)  one  of  the  most  distended  coils,  this  being  first 
withdrawn  and  completely  isolated  with  sterilised  towels  or  iodoform 
gauze.  While  the  distension  is  being  relieved  the  parietal  wound  may 
be  sutured,  and  the  knuckle  of  projecting  bowel  attached  by  a  few  points 
to  the  edges  of  the  wound. 

The  peritonseal  sac  must  be  next  cleansed  of  any  fluids,  and  above  all 

*  I  have  recorded,  page  350,  a  case  in  which  this  treatment  saved  the  life  of  a 
patient  suffering  from  strangulation  of  the  small  intestine  (localised  gangrene  having  set 
in)  by  a  band. 


266  OPERATIONS  ON  THE   ABDOMEN. 

of  any  discharges,  either  by  sponges  introduced  on  large  Spencer  Wells's 
forceps  down  into  the  pelvis  and  along  the  costo-vertebral  furrows,  or  by 
flushing  with  a  hot  solution  of  boracic  acid  (2  per  cent.)  or  ^  per  cent, 
of  salicylic  acid,  in  boiled  water ;  pints  of  this  being  introduced  by  an 
irrigating  tube.  After  the  flushing,  sponges  are  again  used,  and  a 
drainage  tube*  inserted.  Drainage  is  always  to  be  employed  when 
the  peritoneal  sac  has  been  contaminated.  Further  details  are  given 
at  p.  303. 

The  opening  in  the  abdominal  Avails  is  then  rapidly  closed  with 
sutures  of  wire,  or  silk  or  fishing  gut,  material  of  sufficient  stoutness 
being  provided  if  any  tension  is  present.  Care  should  be  taken  to 
include  the  parietal  peritoneum,  and,  as  the  sutures  are  inserted,  to 
prevent  any  blood  entering  the  cavity  of  the  peritoneum.  In  early 
and  favourable  cases  the  wound  may  be  sewn  up  in  layers  in  the 
overlapping  manner  recommended  at  p.  103. 

B.  Late  Cases. — Here  the  condition  of  the  patient  will  not  allow  of 
airv  but  the  briefest  operation.  A  small  incision,  two  inches  long, 
is  made  in  the  median  line  below  the  umbilicus.  On  opening  the 
peritoneum,  two  fingers  are  introduced  and  carefully  feel  for  the  most 
distended  coil  within  reach,  and  bring  this  up  into  the  incision. 
This  must  now  be  opened  and  an  artificial  anus  formed  as  described 
below  at  p.  347. 

It  may  happen  that  this  plan  will  result  in  the  opening  of  a  coil  too 
high  above  the  obstruction,  or  that  the  obstructed  portion  of  intestine 
is  already  gangrenous,  and  in  either  of  these  cases  the  result  may  be 
fatal.  On  the  other  hand,  it  may  be  urged  that  in  these  extreme  cases, 
further  interference  would  be  almost  certainly  fatal,  even  though  the 
obstruction  were  relieved,  and,  moreover,  that  the  most  distended  coils 
of  intestine  usually  rise  to  the  surface  and  are  situated  close  to  the 
umbilicus  ;  and,  finally,  that  a  few  lives  have  certainly  been  saved  by 
this  means. 

Having  spoken  of  the  operation  generally,  I  shall  next  refer  to 
a  few  practical  points  connected  with  the  chief  causes  of  obstruction 
individually. 

I.  Strangulation  by  Bands  and  through  Apertures,  f 

A.  Bands.  1.  Adventitious  Peritoneal  Bands. — Perhaps  there  has 
been  a  histoiy  of  peritonitis,  starting  possibly  from  the  appendix,  the 
uterus  and  appendages,  or  a  mesenteric  gland.  These  bands  are  usually 
attached  by  one  end  to  the  mesentery.  2.  Omental  Bands. — Here  some 
part  of  the  lower  end  of  the  omentum  has  become  adherent  to  the  brim 
of  the  pelvis,  a  hernial  sac,  the  uterine  appendages,  the  cecum,  or  a 
tuberculous  mesenteric  gland.  3.  Meckel's  Diverticulum.\ — This  is 
usually  met  with  in  young  subjects.  Tubular  or  cord-like,  it  will  be 
found  attached  at  one  end  to  the  ileum,  within  three  feet  of  the  cecum, 
at  the  other  near  the  umbilicus,    or  to   the  mesentery  or  intestine. 

*  An  indiarubber  tube,  which  has  several  perforations  and  a  strand  of  gauze  in  its 
lumen,  is  wrapped  in  antiseptic  or  sterile  gauze. 

t  Sir  F.  Treves  (Infest.  Obstruct.,  p.  13  ;  Diet,  of  Surg.,  vol.  ii.  p.  S02)  groups  these 
together  from  the  similarity  of  their  obstruction  and  their  close  resemblance  to  stran- 
gulated hernia. 

J  For  an  account  of  other  surgical  conditions  due  to  Meckel's  diverticulum,  vide  infra, 
pp.  268  and  313. 


ACUTE   INTESTINAL   OBSTRUCTION.  267 

Under  this  arch  small  intestine  is  very  liable  to  slip.  In  other  cases 
one  end  is  free,  and  ensnares  or  knots  up  a  l<><>p  of  intestine.  4.  Some 
Nornidl  Structure  abnormally  attached,  e.g.,  the  Fallopian  Tube  or  the 
Appendix. ' 

In  most  cases  bands,  when  found,  are  not  difficult  to  deal  with.  If 
they  do  nol  give  way  to  the  finger  as  attempts  are  made  to  hook  them 
up,  they  should  be  divided  between  two  ligatures  of  silk.  Occasionally 
transfixion  is  required.  When  one  band  has  been  discovered,  the 
possibility  of  a  second,  attached  to  the  pelvic  brim,  must  always  be 
remembered.  In  Gibson's  list  of  cases  there  are  186  of  obstruction 
by  bands,  and  in  no  less  than  thirty-three  of  these  there  was  a  record  of 
more  than  one  band  being  present,  and  it  is  probable  that  the  proportion 
is  even  higher  than  this. 

Two  other  points  connected  with  bands  must  be  remembered :  one, 
that  if  they  are  vascular  both  ends  should  be  secured ;  the  other,  that 
on  the  division  of  the  band  the  piece  of  intestine  which  has  been  released 
maybe  found  to  be  gangrenous  or  even  perforated,  and  allowing  its  con- 
tents to  escape  into  the  peritonajal  sac.  The  intestine  must  then  be 
brought  outside  and  drained,  and  the  peritoneal  sac  cleansed  if  possible 

(P-  3I9)- 

Every  band  should  be  resected  as  closely  to  its  attached  points  as  is 
safe,  to  prevent  any  recurrence  of  the  trouble. 

About  three  years  ago  one  of  us  operated  upon  a  boy  of  six  years  of  age  at  the  East 
London  Hospital  for  acute  intestinal  obstruction.  The  symptoms  had  come  on  quite 
suddenly  four  days  earlier  with  severe  pain  to  the  right  of  the  middle  line  of  the  abdomen. 
Constipation  had  been  complete  and  vomiting  frequent,  biliary  but  not  foul  fluid  being 
brought  up.  The  abdomen  was  slightly  distended,  especially  in  the  middle  line,  where  three 
large  coils  could  be  observed,  after  flicking  the  abdomen  with  a  wet  towel  and  watching  for 
a  few  minutes.  The  appearance  of  the  coils  coincided  with  colicky  pain  and  vomiting.  It 
was  therefore  concluded  that  the  obstruction  was  probably  a  band  high  up  in  the  small 
intestine,  and  the  fact  that  hardly  any  urine  had  been  passed  for  twenty-four  hours  con- 
firmed this  diagnosis.  An  incision  was  made  through  the  middle  of  the  right  rectus 
muscle,  and  a  strand  of  great  omentum  was  discovered  stretched  over  a  piece  of  the 
jejunum  and  adherent  at  its  end  to  the  right  side  of  the  mesentery,  whence  it  tore  off, 
leading  to  the  rupture  a  caseous  mesenteric  gland.  The  piece  of  omentum  was  ligatured 
and  excised  and  the  abscess  scraped  out,  and  the  peritonaeum  sutured  over  its  site.  Multiple 
miliary  tubercles  were  seen  upon  the  coils  of  small  intestine,  and  the  great  omentum  was 
shrivelled  hard  and  diseased.  The  constriction  upon  the  jejunum  was  tight,  but  it  had 
not  produced  any  gangrene,  but  only  a  white  semi-circle,  which  was  inverted  by  suture. 
The  distended  coils  were  compressed  and  some  of  their  contents  were  seen  to  pass  into  and 
distend  the  collapsed  intestines  below.  The  child  recovered  without  interruption,  and  two 
years  later  he  had  no  sign  of  tuberculous  peritonitis,  but  only  attended  for  treatment  of 
paralytic  talipes  for  which  he  had  been  under  treatment  before  the  sudden  onset  of  his 
more  serious  illness. 

In  striking  contrast  with  this  case  was  a  more  recent  one,  under  the  care  of  Dr.  Frederick 
Taylor,  at  Guy's  Hospital.  The  patient  was  a  woman  of  37,  who  gave  a  history  of  a  severe 
attack  of  appendicitis  eleven  years  earlier.  Her  fatal  illness  came  on  very  suddenly.  As 
she  was  stooping  forwards  she  felt  "something  slip  inside  "  her  abdomen,  and  she  was 
immediately  seized  with  severe  abdominal  pain  and  vomiting,  followed  by  collapse  and  com- 
plete obstruction.  One  of  us  first  saw  her  on  the  fourth  day  of  her  disease,  and  soon  after  her 
admission.  Upon  opening  the  abdomen  through  the  left  rectus,  sanious  fluid  escaped,  and 
very  distended  congested  coils  of  small  intestine  presented,  but  the  site  and  nature  of  the 

*  One  classification  of  bands  useful  to  the  operator  is  into  those  easily  found  and  those 
which  are  inaccessible. 


268  OPERATIONS    ON   THE   ABDOMEN. 

obstruction  could  not  be  discovered  until  the  incision  was  freely  enlarged.  About  eight 
feet  of  small  intestine  were  seen  to  be  greatly  distended,  and  terminating  at  each  end  at 
an  opening  to  the  left  of  the  lumbar  spine.  The  left  margin  of  the  opening  contained 
larjre  blood  vessels,  which  were  afterwards  seen  to  be  the  superior  mesenteric,  and  coils  of 
small  intestine  were  felt  and  seen  to  move  behind  the  mesentery.  The  condition  was  in 
fact  very  suggestive  of  a  right  duodenal  hernia,  only  that  the  distension  was  in  the  wrong 
part  of  the  intestine.  The  real  state  of  affairs  was  soon  discovered  to  be  due  to  a  prolapse 
of  a  part  of  small  intestine  forwards  through  a  ring,  consisting  of  a  tough,  broad  band, 
stretching  from  the  right  side  of  the  pelvic  brim  to  the  left  side  of  the  root  of  the  mesentery, 
and  the  displaced  mesentery  itself,  which  had  been  pressed,  and  rotated  to  the  left  by  the 
enormously  distended  coils  in  front  and  to  the  right.  The  collapsed  small  intestines  had 
been  displaced  with  and  lay  behind  the  mesentery.  The  band,  which  was  clearly  due  to 
an  old  appendicitis,  was  ligatured  and  severed.  The  distended  intestine,  which  was  the 
upper  part  of  the  jejunum,  was  severely  damaged  at  the  lower  point  of  constriction, 
and  a  loop  containing  this  part  was  therefore  brought  out  and  drained.  The  patient's 
condition  was  too  grave  for  a  resection  to  be  contemplated,  and,  moreover,  it  was  hoped 
that  the  intestine  would  recover  with  drainage.  The  patient,  however,  died  a  week  later 
due  to  gangrene  of  a  small  loop  of  the  intestine  which  had  been  strangulated. 

Dr.  C.  L.  Gibson  (Ann.  of  Surg.,  1900,  vol.  xxxii.  p.  486),  in  his 
classical  study  of  1,000  cases  of  intestinal  obstruction,  found  the 
mortality  of  186  recorded  cases  of  bands  to  be  41  per  cent.,  but  the 
figures  are  in  a  sense  too  favourable  for  published  cases,  consist  of  too 
many  successes  and  too  few  failures ;  in  another  sense  they  are  too 
unfavourable,  for  the  figures  refer  to  the  ten  years  between  1888  and 
1898,  and  it  is  certain  that  more  recent  results  are  more  favourable  to 
some  extent,  although  the  results  of  operations  for  intestinal  obstruc- 
tion have  not  improved  to  the  extent  that  they  should,  because  of  the 
want  of  recognition  of  the  value  of  emptying  and  draining  the  distended 
intestines,  whenever  it  is  probable  that  nature  will  not  be  able  to  do 
this  quickly  without  aid. 

Meckel's  Diverticulum. — This  may  act  as  a  band  over  the  intestine, 
and  the  foetal  relic  may  become  twisted  at  its  base.  In  the  case 
of  a  diverticular  band  which  is  tubular,  the  contiguous  peritoneal 
contents  being  all  shut  off  with  sponges  or  tampons,  the  diverticulum 
and  the  intestine  into  which  it  opens  are  emptied  by  pressure.  Then 
the  diverticulum,  being  lightly  clamped,  is  divided,  at  its  origin  the 
mucous  coat  is  disinfected  and  tied  with  silk  or  closed  with  a  continuous 
catgut  suture,  and  inverted  by  means  of  a  continuous  Lembert's  stitch. 
When  the  diverticulum  is  narrow  the  simplest  and  most  rapid  way  is 
to  invert  and  bury  the  stump  by  means  of  one  or  two  purse-string  sutures 
passing  through  the  sero-muscular  coats  round  the  base. 

In  some  cases  gangrene  of  the  ileum  occurs  at  the  twisted  base  of 
the  diverticulum,  and  then  a  resection,  with  or  without  intestinal 
drainage,  will  have  to  be  undertaken,  unless  the  area  of  gangrene  is  so 
small  that  inversion  can  be  performed  without  risk  of  narrowing  the 
lumen  too  much. 

A  most  interesting  and  fully  reported  case  successfully  treated  by  laparotomy  was 
published  in  the  Lancet,  March  9,  1889,  by  my  old  friend  R.  J.  Pye-Smith,  of  Sheffield. 
Two  others  successfully  treated  in  the  same  way  by  Mr.  Clutton  {Clin.  Sue.  Trans., 
vol.  xvii.  p.  186)  and  Mr.  McGill  {Brit.  Med.  Journ.,  Jan.  14,  1888)  will  well  repay 
reference. 

Dr.  Roberts  {Ann.  of  Stirg.,  vol.  ii.  190C,  p.  87)  records  two  interesting  cases.  One 
patient  was  a  boy  of  four  and  a  half  years,  who  was  treated  by  operation  after  four  days' 


ACUTE   INTESTINAL   OBSTRUCTION.  269 

obstruction.  A  slender  diverticulum  was  discovered  abonl  three  feet  bom  the  ileo-crecal 
valve.  "  Its  diameh  v  was  less  than  that  of  t  lie  vermiform  appendix,  its  end  was  a  mere 
fibrous  ciMil  attached  to  the  abdominal  wall  near  the  umbilicus.  The  structure  was 
distended  a1  its  middle  into  a  sac  similar  to  thai  which  is  sometimes  Been  in  the  appendix 
when  it  is  inflamed,  lie!  ween  (he  sac  ami  the  ileum  there  was  a  patent  tube  lined  wilh 
mucous  membrane.  There  was  evidence  of  inflammation  <>t'  these  structures.  The  ileum, 
a  short  distance  Erom  the  point  of  origin  of  the  diverticulum,  was  tightly  strangulated  by 
the  passage  of  the  diverticulum  and  its  fibrous  continuation  across  it.  A  deep  groove  was 
thus  made  in  the  portion  of  the  bowel  opposite  the  mesentery,  similar  to  that  often  seen 
in  cases  of  tightly  strangulated  hernia  at  the  femoral  or  inguinal  ring."  The  diverticulum 
aud  its  fibrous  prolongation  were  removed,  and  the  groove  on  the  intest  ine  was  inverted  by 
means  of  Lembcrt  sutures,  because  it  was  so  dark  that  sloughing  and  perforation  were 
feared.     The  boy  recovered  after  a  severe  illness. 

I  operated  for  acute  obstruction  clue  to  this  cause  in  a  baby  of  three  weeks.  The  child 
died,  the  abdomen  being  greatly  distended  and  containing  a  large  amount  of  sanious  fluid 
at  the  time  of  the  operation.  In  this  case  the  diverticulum  originating  within  a  foot  of 
the  ileo-caecal  valve,  terminated  upon  the  mesentery  of  a  portion  of  the  ileum,  which  it 
passed  over  and  strangulated. 

Gibson  found  the  mortality  to  be  55  per  cent,  in  forty- two  operations 
for  intestinal  obstruction  due  to  this  structure. 

B.  Apertures  and  Slits. — These  may  be  congenital  or  traumatic, 
the  intestine  entering  and  enlarging  a  congenital  retro-peritonseal  fossa, 
or  slipping  through  a  rent  in  the  mesentery,  omentum  or  diaphragm. 

I.  Retro-peritonseal  Hernia. — For  most  of  the  information  upon 
this  subject  I  am  indebted  to  the  valuable,  scientific  and  exhaustive 
work  of  Moynihan  and  Dobson,  a  new  edition  of  which  has  just  appeared 
(Retro-Peritonceal  Hernia,  Moynihan  and  Dobson,  1906). 

The  chiej  varieties  are — 

(1)  The  left  duodenal,  of  which  over  60  cases  have  been  recorded. 

(2)  The  right  duodenal,  of  which  over  17  cases  have  been  recorded. 

(3)  The  meso-colic,  of  which  only  one  certain  case  has  been  recorded 
(Dobson),  and  possibly  that  described  by  Sir  Astley  Cooper  years  ago. 

(4)  The  infra-duodenal,  of  which  Molin  has  described  the  solitary 
recorded  instance. 

All  these  arise  in  the  neighbourhood  of  the  termination  of  the 
duodenum,  the  left  duodenal  hernia  occurring  into  the  para-duodenal 
fossa  of  Landzert,  which  has  the  inferior  mesenteric  vein  in  its  prominent 
left,  lower,  and  upper  borders.  The  right  duodenal  which  occurs  into 
the  mesenterico-parietal  fossa  of  Waldeyer,  which  lies  in  the  root  of  the 
mesentery  of  the  upper  part  of  the  jejunum,  and  has  the  superior 
mesenteric  artery  in  its  prominent  anterior  border.  The  meso-colic 
hernia  is  to  the  left  of  the  inferior  mesenteric  vein  ;  the  infra-duodenal 
lies  below  the  duodenum,  and  has  no  vessels  in  the  prominent  edge  of 
its  orifice. 

The  left  duodenal  hernia  enlarges  upwards  and  to  the  left  towards 
the  spleen,  its  orifice  being  placed  antero-internally  in  small  hernise, 
and  postero-internally  in  larger  ones. 

The  right  duodenal  enlarges  downwards  and  to  the  right  towards  the 
right  iliac  fossa,  its  orifice  being  directed  upwards  and  to  the  left. 
Duodenal  hernias  nearly  always  contain  only  small  intestine,  but 
Freeman  (Amer.  Joum.  Med.  Sci.,  Oct.  1903)  has  recorded  a  case 
in  which  the  entire  small  intestine,  the  caecum,  and  a  part  of  the  colon 
had  passed  into  a  left  duodenal  hernia. 


270         OPERATIONS  ON  THE  ABDOMEN. 

(5)  The  pericecal,  which  may  be  subdivided  into  the  ileo-appendicular, 
of  which  7  cases  are  recorded ;  the  retro-colic,  of  which  8  cases  are 
recorded;  the  hernia  into  the  fossa  of  Hartmann,  which  is  a  fossa 
placed  between  the  mesentery  of  the  appendix  and  a  continuation  of 
the  mesentery  of  the  small  intestines  to  the  iliac  fossa ;  one  possible 
case  is  recorded. 

Hernia  into  the  sub-facial  or  iliac  fossa,  which  is  pouch  of  peritonaeum 
pushed  downwards  through  a  wTeak  spot  in  the  iliac  fascia,  and  outside 
the  psoas  muscle  ;  two  cases  of  this  are  recorded,  and  Mr.  Dunn 
operated  upon  another  one  at  Guy's  Hospital  some  years  ago. 

(6)  The  intersigmoid. — Only  twro  genuine  cases  are  recorded,  those 
of  Eve,  and  Macadam  Eccles. 

(7)  The  hernia  into  the  lesser  sac  of  the  peritonaeum,  12  instances  of 
which  are  recorded. 

Diagnosis  will  generally  be  arrived  at  only  during  a  laparotonry  for 
the  relief  of  intestinal  obstruction,  but  in  some  cases  such  as  that  of 
Sherren,  a  diagnosis  has  been  made  before  the  operation. 

In  addition  to  the  classical  symptoms  and  signs  of  acute  intestinal 
obstruction,  other  points  may  suggest  or  even  strongly  indicate  a  retro- 
peritonaeal  hernia. 

The  existence  of  a  duodenal  hernia  may  be  indicated  by  the  presence 
of  a  "  palpable  definite  resonant  mass  "  at  the  upper  and  left  part  of 
the  abdomen  (left  duodenal  hernia),  or  at  the  lower  and  right  part 
(right  duodenal  hernia). 

This  mass  does  not  move  on  respiration,  and  coils  of  intestine  may 
be  evident  towards  the  middle  of  the  swelling,  the  size  of  which  may 
vary  with  the  severity  of  the  symptoms. 

Haemorrhoids  or  rectal  haemorrhage  may  develop  in  left  duodenal 
hernia  from  obstruction  of  the  inferior  mesenteric  vein. 

Only  one  case  of  pericaecal  hernia  has  been  diagnosed  before 
operation,  from  the  presence  of  a  mass  in  the  right  iliac  fossa,  which 
was  rendered  more  evident  by  means  of  rectal  injection  (Riese). 

Hernia  through  the  foramen  of  Winslow  may  be  indicated  by  agonising 
pain  in  the  epigastrium,  where  a  semi-resonant  tumour  may  soon  appear. 

Treatment. — "When  the  nature  of  the  obstruction  has  been  recognised, 
attempts  should  be  made  to  reduce  the  hernia  by  a  combination  of 
pressure  upon  the  sac  and  gentle  traction  upon  the  intestine.  In 
some  cases  it  may  be  possible  to  enlarge  the  orifice  by  stretching,  in 
others  the  prominent  margin  may  be  divided,  due  care  being  taken  to 
avoid  any  prominent  blood  vessels.  In  left  and  right  duodenal  hernia 
it  may  not  be  possible  to  enlarge  the  opening  without  injuring  the 
inferior  mesenteric  vein  in  the  one  case,  or  the  superior  mesenteric 
vessels  in  the  other.  Haberer  in  his  successful  case  divided  the 
inferior  mesenteric  vein,  which  he  then  found  to  be  already  thrombosed. 

The  foramen  of  Winslow  is  not  capable  of  enlargement,  surrounded 
as  it  is  by  the  liver  above  the  vena  cava  behind,  the  twist  of  the 
hepatic  artery  below  and  the  portal  vein,  bile  duct  and  hepatic  artery 
in  front.  The  difficulties  that  may  be  met  with  are  illustrated  b}'  Sir 
Frederick  Treves'  case  (Oper.  Surg.,  vol.  i.  p.  389). 

Here  the  surgeon  not  only  failed  to  reduce  the  gut  by  operation  during  life,  but  at  the 
necropsy  he  could  not  bring  about  reduction  until  the  hepatic  artery,  portal  vein,  and  bile 
duct  were  severed. 


ACUTE   INTESTINAL   OBSTRUCTION. 


271 


Incision  of  the  anterior  layer  of  the  gastro-hepatic  omentum  and 
retraction  of  the  first  part  of  the  duodenum  with  the  view  of  enlarging 
the  opening  is  considered  by  Moynihan  to  be  impracticable  incases  of 

obstruction,  and  I  do  not  believe  that  it  would  be  any  good,  for  the 
twist  of  the  hepatic  artery  would  still  form  the  lower  boundary  of  the 
ring. 

Mobilisation  of  the  duodenum  by  incising  the  posterior  parietal 
peritonaeum  to  the  right  of  it  and  detaching  it  forwards  and  downwards 
enlarges  the  orifice  according  to  Moynihan,  but  he  considers  this  measure 
to  be  almost  out  of  the  question  in  a  patient  suffering  from  acute 
intestinal  obstruction. 

When  the  rings  cannot  be  enlarged  by  stretching,  and  vessels  pre- 
vent an  incision  being  made,  it  is  best  to  open  the  sac  anteriorly  and  to 
try  to  reduce  the  bowel  from  within.  This  may  only  be  practicable  after 
pulling  out  a  loop  of  distended  bowel  and  emptying  it  through  an 
incision  made  along  its  convex  border  with  all  precautions  against 
contamination  of  the  peritonaeum.  The  incision  having  been  closed 
the  reduction  will  probably  be  easily  performed. 

An  attempt  should  be  made  to  close  the  neck  of  the  sac  to  prevent  a 
recurrence  of  the  hernia,  and  the  necessity  of  this  is  shown  by  the  recur- 
rence in  Mr.  Paton's  case. 

It  may  be  neither  wise  nor  necessary  to  prolong  the  operation  by 
attempting  to  close  the  foramen  of  Winslow,  for  a  recurrence  is  not 
likely  here. 

Results. — Successful  operations  for  left  duodenal  hernia  have  been 
recorded  by  Sonnenberg,  Tubby,  Priestley  Leech,  Narath,  Haberer, 
Lawford  Knaggs,  McArthur  and  Sherren,  and  one  successful  operation 
for  right  duodenal  hernia  by  Neumann.  Four  operations  for  pericecal 
hernia  have  been  successful,  one  of  these  being  the  case  recorded 
by  Sir  William  Macewen,  wrho  had  to  resect  8  inches  of  small  intestine 
for  gangrene. 

Two  successful  operations  for  hernia  at  the  foramen  of  Winslow 
have  been  recorded,  but  in  one  of  these  spontaneous  reduction  occurred 
after  the  surgeon  had  failed  to  reduce  the  hernia  during  the  operation. 

II.  Traumatic  apertures  may  be  formed  in  the  diaphragm,  omentum, 
mesentery  or  meso-colon,  and  may  result  from  crushing  violence,  gun- 
shot and  other  wounds,  or  careless  operations  during  which  certain 
openings  may  not  be  properly  closed.  For  instance,  after  gastro- 
jejunostomy, a  hernia  may  occur  through  the  rent  in  the  meso-colon, 
and  the  same  thing  may  follow  resection  of  intestine,  unless  the 
mesenteiy  is  property  sutured. 

The  following  is  an  instance  of  a  hernia  through  a  hole  in  the 
mesenteiy. 

In  Mr.  Howard  Marsh's  case  (Brit.  JJed.  Jbum.,  June  2,  1888)  a  loop,  probably  in  the 
middle  of  the  jejunum,  had  slipped  through  a  hole  in  the  mesentery.  The  edge  of  this 
opening  was  so  yielding  that  Mr.  Marsh  could  readily  stretch  it  with  his  finger-nail 
sufficiently  to  allow  the  loop  to  be  drawn  out.  The  patient  made  a  good  recovery,  though 
in  much  danger  for  a  while  from  the  paralysed  condition  of  the  intestine. 

Diaphragmatic  hernia  occurs  far  more  frequently  on  the  left  than 
on  the  right  of  the  middle  line ;  thus  in  133  instances  the  rupture  was 
on  the  left  in  100  (Boursier,  quoted  by  Gibson,  loc.  infra  cit.). 


272  OPERATIONS  ON  THE  ABDOMEN. 

The  hernia  may  be  traumatic  or  congenital  in  origin.  Dr.  Eustace 
Smith  (Lancet,  May  22,  1904)  has  lately  recorded  an  instance  of  the 
hitter.  Lickenstern  has  collected  250  cases  of  traumatic  ruptures, 
but  in  only  five  of  these  was  the  condition  recognised  before  death 
occurred. 

Mackenzie  and  Battle  (Lnncri,  vol.  ii.  1904,  p.  1582)  record  a  very  interesting  case  of 
hernia  which  followed  a  poniard  wound  in  the  lefi  anterior  axillary  line.  After  a  slow 
recovery  the  man  remained  well  for  about  three  years,  when  he  was  seized  with  pain  in 
the  left  side  of  the  upper  abdomen  and  Bevere  vomiting.  Several  similar  attacks  followed, 
and  "  seven  days  before  admission,  when  crossing  the  Channel,  he  suffered  much  from 
sea-sickness  and  had  vomited  almost  constantly  since." 

The  patient  was  greatly  collapsed  on  admission  into  St.  Thomas's  Hospital,  and  he  was 
infused.  Next  day  an  incision  was  made  parallel  to  the  left  costal  margin.  The  small  and 
large  intestines  were  found  to  be  "empty  "  ;  the  greater  part  of  the  stomach,  the  splenic 
flexure  of  the  colon  and  some  omentum  were  found  to  have  passed  through  an  aperture  in 
the  muscular  part  of  the  leftside  of  the  diaphragm  ;  the  omentum  was  adherent  and  could 
not  be  released.  The  stomach  was  reduced  with  i/vi-.d  difficulty,  but  the  colon  was  with- 
drawn with  case.  The  patient  died  after  three  days  from  peritonitis,  probably  arising 
from  the  site  of  the  constriction  in  the  stomach. 

Battle  and  Mackenzie  state  that  successful  operations  have  been 
undertaken  for  diaphragmatic  hernia  by  Llobet,  Humbert  Leisrink  and 
Mikulicz.  Lawford  Knaggs  (Lancet,  vol.  ii.  1904,  p.  358)  has  written 
an  elaborate  and  interesting  article  upon  the  subject  of  hernia  of  the 
stomach  through  the  diaphragm,  of  which  he  was  able  to  collect  63 
cases.  Only  two  operations  had  been  performed  in  these  cases  (by 
Knaggs  and  Berry),  and  both  these  failed  to  save  life.  In  23  cases  the 
hernia  was  congenital  in  origin,  in  21  traumatic,  and  in  12  acquired; 
in  the  acquired  cases  with  sac  formation  the  stomach  had  protruded 
through  or  near  the  oesophageal  opening  in  the  midriff. 

Gibson  (Ann.  of  Surg.,  1900,  vol.  xxxii.  p.  508)  collected  the  records 
of  six  operations  for  diaphragmatic  hernia  without  a  recovery;  in 
several  instances  the  condition  was  not  recognised  even  during  a 
laparotomy.  The  splenic  flexure,  stomach  and  omentum  were 
commonly  found  in  the  ruptures,  and  the  caecum  was  present  in 
one.  The  reduction  was  not  very  difficult  in  those  cases  in  which 
it  was  attempted. 

Diagnosis. — When  the  strangulation  chiefly  concerns  the  stomach, 
the  symptoms  may  be  very  characteristic,  but  when  the  obstruction  is 
in  the  colon,  the  nature  of  the  lesion  may  not  be  discovered  until  a 
laparotomy  is  performed,  and  it  may  not  be  suspected  even  then. 

Sir  Samuel  Wilks  (Lancet,  1858,  vol.  ii.  p.  434)  drew  attention  to 
the  existence  and  importance  of  excessive  thirst  in  cases  of  strangula- 
tion of  the  stomach;  other  suggestive  symptoms  are  urgent  vomiting, 
scanty  secretion  of  urine,  carinated  abdomen  and  pain  in  the  epigastrium. 
In  some  cases  there  have  been  signs  of  displacement  of  the  heart  or  left 
lung,  and  in  others  indications  of  pleural  effusion  ;  or  hyperesonance  of 
the_chest  with  gurgling  noises  have  been  noticed. 

When  the  obstruction  concerns  the  colon,  some  of  these  symptoms 
may  be  absent,  and  the  abdomen  may  be  markedly  distended. 

The  possibility  of  the  existence  of  this  rare  form  of  hernia  should 
be  borne  in  mind,  especially  when  the  cause  of  the  obstruction  can  not 
be  made  out  during  an  exploration. 


A<!  Ti:    INTKSTINAL    OUSTI!  I(TI<  >.\. 


273 


Treatment. — If  the  diagnosis  of  diaphragmatic  hernia  has  heen 
arrived  at,  a  long  incision  should  be  made  parallel  with  and  one  inch 
below  the  left  costal  margin,  which  should  be  well  retracted.  An 
attempt  should  be  made  to  withdraw  the  contents  of  the  hernia  with- 
out enlarging  the  aperture,  owing  to  the  dangers  of  haemorrhage  and 
the  difficulties  of  arresting  it  at  the  depth  of  the  wound.  The  margins 
of  the  ring  should  be  closed  by  sutures  of  catgut  if  possible.  It  is 
better  to  approach  the  hernia  from  the  abdomen  than  through  the 
chest  wall,  for  sudden  death  has  followed  incision  of  the  pleura,  and 
sudden  pneumothorax.  Llobet  has  operated  successfully  through  the 
pleura,  however,  and  after  closing  the  aperture  in  the  diaphragm  and 
the  parietal  wound  he  aspirated  the  air  from  the  pleural  cavity.  If  the 
abdominal  route  fail,  an  incision  may  be  made  through  the  chest  wall, 
parallel  with  but  below  the  pleural  reflection.  Three  or  four  inches  of 
two  ribs  may  need  resection  to  give  enough  room. 

II.  Intussusception. — From  its  frequency,  especially  in  early  life,  its 
fatality  in  infants,  and  the  fact  that  its  treatment  is  less  unsatisfactory 
because  its  diagnosis  is  easier  than  other  forms  of  obstruction,  this 
deserves  careful  notice. 

Diagnosis. — Nowhere  is  early  diagnosis  more  imperative.  This 
should  be  based  upon  the  following  symptoms  : 

Sudden  abdominal  pain  followed  b}r  shock  and  spasmodic  attacks  of 
colic,  as  indicated  by  frequent  fits  of  crying ;  more  or  less  frequent 
evacuations  of  blood  and  slime  with  no  /cecal  matter,  except  quite  eai'ly 
in  the  case  ;  vomiting,  and  perhaps  a  sausage-shaped  tumour,  discovered 
by  abdominal  or  bimanual  palpation.  The  absence  of  a  palpable 
tumour  is  far  from  conclusive  negative  evidence,  even  when  the 
abdominal  wall  is  relaxed  under  the  influence  of  chloroform,  and 
failure  to  find  one  must  not  be  allowed  to  delay  an  exploration 
indicated  by  more  important  signs  and  symptoms.  Erdman  (New 
York  Med.  Journ.,  Ma}r  14,  1904)  found  that  no  tumour  was  palpable 
in  60  per  cent,  of  his  cases,  either  by  the  rectum  or  through  the 
abdominal  wall.  I  think  that  this  experience  is  unusual,  however. 
Mr.  Wallace  found  a  tumour  in  all  of  his  20  cases.  A  dependent  lobe 
of  the  liver,  a  mass  of  mesenteric  glands,  and  a  prolapsed  spleen 
have  each  been  mistaken  for  an  intussusception. 

Two  more  points  must  always  be  remembered  in  the  diagnosis  of  intussusception  : 

(1)  that  in  cases  which  are  not  acute  there  may  be  very  few  symptoms  for  some  time  ; 

(2)  the  rectum  must  always  be  examined,  and  any  intussusception  which  may  be  met 
with  not  mistaken  for  a  prolapsus. 

The  disease  should  be  diagnosed  long  before  the  stage  of  distension 
and  collapse.  Careful  consideration  of  all  the  points  mentioned  above 
will  usually  prevent  delay  and  enable  the  surgeon  to  avoid  a  mistaken 
diagnosis  of  enteritis.  In  cases  of  grave  doubt  chloroform  should  be 
given. 

Treatment. — If  a  capable  surgeon  is  available,  laparotomy  should  be 
performed  without  dela}r  when  the  diagnosis  has  been  made,  for  an 
early  operation  quickly  performed  is  the  only  reliable  and  hopeful 
treatment.  In  very  early  cases  reduction  may  be  possible  with  com- 
paratively little  force,  and  may  be  brought  about  satisfactorily  by 
injection    or    inflation,    but    the    results    of    this    treatment    are    so 

s. — vol.  11.  18 


274  OPERATIONS  ON  THE  ABDOMEN. 

unsatisfactory  and  deceptive  that  no  reliance  must  be  placed  on  it, 
unless  suitable  surgical  aid  cannot  be  obtained  without  delay.  Very 
soon,  however,  the  engorgement  of  the  intussusceptum  and  the  included 
mesentery,  or  the  adhesion  of  the  entering  and  returning  layers  as 
the  result  of  peritonitis,  renders  reduction  much  more  difficult  or 
impossible.  In  such  cases  distension  of  the  colon  will  either  fail 
altogether,  or  will  produce  only  partial  reduction,  with  subsequent 
speedy  relapse.  The  following  figures  from  Gibson's  list  (loc.  supra  cit.) 
will  serve  to  emphasise  this  important  point :  94  per  cent,  of  the  cases 
treated  within  the  first  twenty-four  hours  were  reducible  on  abdominal 
section,  whereas  only  61  per  cent,  of  those  treated  on  the  third  dajr  were 
reducible.  The  proportion  reducible  by  distension  would  necessarily 
have  been  less  than  the  above  in  each  case. 

The  following  results  of  distension  will  also  serve  to  emphasise  the 
importance  of  not  wasting  time  in  attempting  to  reduce  an  intussuscep- 
tion by  injection  or  inflation.  Mr.  Eve  collected  24  cases  from 
the  records  of  the  London  Hospital  in  which  distension  was  tried. 
Of  these  six  died  without  further  treatment,  and  the  remaining  18 
required  operation.  Mr.  Barker  (Clin.  Soc.  Trans.,  vol.  xxxi.)  tried 
distension  in  eight  cases,  in  all  of  which  it  failed  ;  and  in  a  collection 
of  cases  by  Wiggins  distension  failed  in  75  per  cent,  of  72  cases  in 
which  it  was  tried. 

Moreover,  the  following  objections  to  distension  must  not  be  lost  sight 
of : — (1)  The  danger  of  sudden  collapse  or  rupture  of  the  bowel ;  (2)  the 
loss  of  valuable  time,  rendering  the  result  of  a  laparotomy  less  likely  to 
be  successful ;  (3)  it  will  be  of  no  use  in  enteric  intussusceptions  (which 
form  22  per  cent,  of  all  cases),  and  probably  of  no  use  in  ileo-colic 
intussusceptions  (which  form  12  per  cent.),  so  that  in  34  per  cent.,  or 
in  one  case  in  ever}'  three,  it  is  2U'actically  certain  to  fail ;  (4)  there  is 
no  certain  means  of  telling  at  once  that  the  injection  has  been  successful ; 
the  disappearance  of  the  tumour,  if  any,  is  not  reliable,  for  the  proximal 
first  few  inches  may  not  be  palpable ;  the  bowels  may  not  be  opened 
for  a  day  or  more  after  a  satisfactory  reduction. 

At  St.  Thomas's  Hospital  between  1892  and  1901  the  mortality  in 
62  patients  under  one  year  of  age  was  38,  or  62*29  per  cent.,  but  in  the 
last  three  of  those  years,  when  cceliotomy  became  primary  as  a  routine 
measure,  the  mortality  was  only  47*5  per  cent. 

In  cases  of  less  than  twenty-four  hours'  duration,  distension  of  the 
bowel  is  still  used  by  some  surgeons  as  an  auxiliary,  but  not  as  a 
substitute  for  laparotomy.  Mr.  Kellock  has  recommended  this  method 
as  a  means  of  reducing  the  greater  part  of  the  invagination  just  before 
the  abdomen  is  opened.  The  manipulations  and  exposure  of  the  intes- 
tine and  the  duration  of  tbe  operation  may  be  thus  lessened.  I  consider 
these  advantages  to  be  uncertain,  and  to  be  more  than  balanced 
by  the  increased  abdominal  distension  and  the  prolongation  of  the 
anaesthetic — a  grave  thing  in  these  cases.  Moreover,  the  finger  of  an 
assistant  or  a  bougie  in  the  rectum  give  all  the  aid  that  may  be 
required  to  displace  the  invagination  out  of  the  pelvis.* 

Personally,   I   never   attempt   to    distend   the  intestine,  even  as  a 


C,  H.  Fagge,  Clin.  Soc.  Tram.,  vol.  xxxviii. 


ACUTE   INTESTINAL   OBSTRUCTION. 


275 


preliminary,  but  proceed  to  operate  as  soon  as  the  necessary  prepara- 
tions can  be  made. 

Either  water  or  air  may  be  used  for  injection;  of  these  the  latter  is  to  be  preferri  ], 
as  being  less  dangerous, 

The  child's  limbs  arc  wrapped  in  cotton  wool  or  gamgee  tissue,  and  his  body  is 
exposed  as  little  as  possible. 

A  little  chloroform  or  A.C.E.  mixture  being  given,  the  lower  limbs  being  somewhat 
raised,  the  nozzle  of  a  Lund's  inflator,  or  a  full-sized  catheter,  or  a  rectal  tube,  attached 
by  tubing  to  a  bellows  and  well  coated  with  vaseline,  is  carefully  passed  into  the  bowel. 
The  nates  being  securely  pressed  round  the  tube,  air  is  steadily  pumped  into  the  colon, 

Fig.  82. 


<  £ 


Diagram  of  an  intussusception  in  vertical  section. 
M,  Mesentery.  A,  Artery,  v,  Vein.  D.v.  Dilated  vein.  I.M.  inflamed  mesen- 
tery, or,  Orifice  of  bowel  at  apex  of  intussusceptum  with  thickened  mucous 
membrane  around.  A.  Line  drawn  through  usual  seat  of  adhesions.  B,  Line  for 
resection  of  intussusceptum.  X  X,  To  mark  the  vertical  incision  through  which 
resection  is  performed.     (Greig  Smith.) 

while  the  surgeon  keeps  one  hand  on  the  abdomen,  not  only  to  prevent  over-distension, 
but  also  to  watch  for  any  receding  of  the  tumour  towards  the  cascal  region.  Great  care 
must  be  taken  not  to  use  too  much  force,  especially  towards  the  end  of  the  process. 

Dr.  Taylor's  advice  here  will  minimise  the  risk  of  rupture  of  the  bowel  :  "  The  risk 
can  be  reduced  to  a  minimum  by  injecting,  carefully  and  slowly,  successive  small 
quantities,  and  by  gently  kneading  the  abdomen  so  as  to  facilitate  the  passage  of  air 
upwards,  and  thus  prevent  the  sudden  over-distension  of  short  lengths  of  the  colon." 

Operation. — This  should  be  conducted  with  as  much  speed  as  is 
consistent  with  safety,  and  the  child  should  be  exposed  as  little  as 
possible ;  therefore  all  preparations  should  be  completed  before  the 
chloroform  is  administered.  Plenty  of  sutures  should  be  threaded 
ready  for  immediate  use,  for  every  moment  of  time  saved  is  of  value, 

18—2 


276  OPERATIONS  OX  THE  ABDOMEN. 

and  the  prognosis  varies  inversely  with  the  length  of  time  that  the 
patient  is  upon  the  operating  table.  All  aseptic  towels  used  should  he 
dry  and  warm,  so  that  the  child  may  not  be  chilled  by  evaporation;  the 
table  should,  of  course,  be  warm.  During  the  preparations  the 
abdomen  should  be  cleansed  and  covered  with  a  warm  antiseptic 
compress. 

The  urine  having  been  drawn  off,  an  incision  about  three  inches 
long  is  made  over  the  right  rectus  muscle  ;  the  centre  of  the  wound 
should  be  about  three-quarters  of  an  inch  below  and  to  the  right  of 
the  umbilicus  (Wallace,  loc.  infra  cit.). 

This  incision  gives  better  access  to  the  seat  of  origin  of  the  great 
majority  of  intussusceptions  in  children,  for  they  nearly  all  start  near 
the  caecum,  to  whatever  variety  ingenious  classification  may  refer 
them.* 

The  reduction  of  the  most  difficult  part  can  thus  be  performed 
within  sight — a  very  important  thing. 

The  anterio-rectus  sheath  is  incised,  and  one  edge  of  it  is  rapidly 
raised  from  the  muscle  to  facilitate  overlapping  later  on.  The  muscle 
fibres  are  separated  by  blunt  dissection  to  avoid  delay  from  haemorrhage, 
if  possible. 

The  posterior  layer  of  the  rectus  sheath  and  the  attached  peritonaeum 
are  incised  to  the  extent  of  two  inches,  and  an  attempt  then  made  to 
discover  the  intussusception  and  to  hook  it  into  the  wound  by  means 
of  one  or  two  fingers.  In  most  cases  this  is  not  possible,  for  the  mass 
is  usually  tethered  back  to  the  spine  by  the  invaginated  mesentery.  In 
these  cases  the  peritonaeal  incision  must  be  enlarged,  and  then  most  of 
the  reduction  can  be  easily  and  safely  j>erformed  within  the  abdomen 
by  manual  compression  of  the  distal  part  of  the  tumour,  which  also  may 
be  pushed  towards  the  proximal  end. 

In  some  cases  I  have  been  able  to  reduce  the  greater  part  of  the 
invagination  by  bimanual  compression,  the  intussusception  being 
squeezed  between  the  fingers  of  the  right  hand  within  and  the  left 
hand  outside  the  abdomen.  Care  must  be  taken  to  prevent  the  escape 
of  coils  of  small  intestine. + 

Early  and  small  invaginations  may  be  brought  into  the  wound 
at  once,  and  towards  the  end  all  reductions  can  and  should 
be  performed  with  the  aid  of  sight  ;  otherwise  serious  damage 
may    be    done    to    the    bowel.      This    part    of    the    reduction    must 

*  E.  M.  Comer  (Ann.  »f  Surg..  November.  1903)  concludes  that  double  intussusceptions 
are  more  common  than  single,  but  the  experience  of  other  observers  does  not  confirm 
this  view.  I  agree  with  him  that  the  ileo-colic  is  the  commonest  primary  variety,  the 
last  part  of  the  ileum  becoming  gripped  in  the  ileo-cagcal  valve.  He  considers  that  the 
primary  ileo-caecal  variety  is  decidedly  rare,  and  almost  limited  to  chronic  cases,  the 
recorded  cases  probably  starting  in  the  last  few  inches  of  the  colon  or  the  caecum. 

t  Mr.  Wallace  (Clin.  Sue.  Tram..  voL  xxxviii.  p.  59)  makes  no  attempt  to  retain  the 
intestines  in  the  abdomen,  and  if  they  escape  he  simply  covers  them  with  warm  sponges. 
Mr.  Wallace's  results  are  very  good,  but  all  the  surgeons  who  have  to  do  this  operation  are 
not  so  skilful  and  expeditious  as  he  is,  and  I  have  no  doubt  whatever  that  to  allow 
the  intestines  to  protrude  is  a  mistake,  for  it  may  be  very  difficult  to  replace  them, 
and  much  valuable  time  may  be  thus  wasted.  Moreover,  shock  is  greatly  increased  by 
the  exposure,  traction  on  the  mesenteric  plexuses,  and  the  manipulations  necessary 
for  reduction 


ACUTE    I.VIT.sTINAL    OBSTRUCTION.  777 

be  conducted  with  cure,  and  traction  on  the  entering  intestine  must 
not  be  made,  except  with  the  utmost  gentleness  ;  the  ensheathing  layer 
should  be  fixed  below  the  presenting  point,  and  then  it  will  usually  be 
found  that  pushing  or  backing  out  the  contained  bowel  by  gentle 
squeezing  movements  between  the  finger  and  thumb,  these  being 
gradually  shitted  along  the  gut,  will  prove  successful,  when  by  no 
force  that  is  justifiable  could  any  part  be  drawn  out. 

Whichever  method  is  found  to  answer  best  must  be  per- 
severed with  until  every  atom  of  the  mass  is  reduced,  this  being  often 
known  by  the  appearance  of  the  vermiform  appendix. 

If,  when  the  reduction  is  complete,  any  tears  are  noticed  in  the 
peritoneal  coat,  these  must  be  sewn  up  with  a  fine  continuous  silk 
suture,  and  any  thin  or  grey  lines  should  be  inverted  by  Lembert 
sutures  to  prevent  perforation  or  infection,  and  to  avoid  the  need  of 
enterectomy  in  some  cases. 

The  wound  should  be  rapidly  closed  by  means  of  fishing-gut  sutures, 
which  pierce  the  whole  thickness  of  the  abdominal  wall,  and  before 
these  are  tied  the  anterior  wall  of  the  rectus  sheath  may  be  closed  in 
an  overlapping  manner  by  means  of  a  continuous  catgut  suture  to 
lessen  the  risk  of  ventral  hernia.  "When  the  wound  is  sewn  up  in 
layers  without  the  aid  of  sutures,  which  pierce  the  whole  thickness  of 
the  parietes  to  relieve  tension,  there  is  some  risk  that  the  wound  may 
reopen,  allowing  the  intestines  to  escape.  This  happened  to  two  of 
three  cases  in  which  Mr.  Wallace  relied  upon  three  layers  of  sutures 
(loc.  cit.).  The  sutures  may  tear  out  the  delicate  and  thin  layers  of 
an  infant  during  the  stage  of  inflammatory  softening  that  precedes  firm 
union,  which  is  slow  to  occur  in  these  cases. 

A  warm  saline  enema  may  be  given  immediately  after  the  patient  has 
returned  to  bed,  and  every  effort  must  be  made  to  prevent  and  combat 
shock  both  during  and  after  the  operation  ;  saline  infusions  into  the 
cellular  tissues  of  the  axilla  and  the  subcutaneous  injection  of 
strychnine  should  be  given  in  bad  cases.  Liquor  strychnine  hydro- 
chloratis  n\  iii-  may  be  given,  and  repeated,  if  necessary,  every 
two  hours,  as  long  as  twitching  does  not  occur.  Adrenalin  chloride 
and  aseptic  ergot  are  preferable  to  strychnine. 

Feeding  with  peptonised  milk  and  albumen  water  should  be  com- 
menced as  soon  as  possible  after  the  operation,  as  long  as  vomiting 
does  not  occur,  for  starvation  is  one  of  the  serious  factors  in  the  cases. 

"When  the  intussusception  cannot  be  reduced,  all  attempts  at 
traction  and  kneading  only  causing  tears  in  the  peritoneal  coat,  the 
following  courses  are  open  according  to  the  condition  of  the  paiient, 
&c.  : — (1)  If  the  intussusception  is  gangrenous  but  small  in  amount,  it 
should  be  resected.  For  the  union  of  the  divided  ends  Murphy's 
button  has  the  great  advantage  of  saving  time,  and  it  is  thus  well 
adapted  to  acute  and  subacute  cases  in  children,  which  form  the 
majority  of  the  cases ;  but  most  surgeons  now  prefer  to  use  sutures 
only.  Whatever  method  is  used,  some  difficulty  must  be  expected  in 
effecting  exact  union  in  the  common  variety,  the  ileo-csecal,  owing  to 
the  difference  of  the  lumen  in  the  two  parts  of  the  bowel ;  where  this 
difficulty  is  very  marked,  the  best  plan  will  be  to  close  both  ends  by 
a  double  row  of  sutures,  continuous  and  Lembert's,  and  then  to  make 
a  lateral  anastomosis  (q.v.)  by  means  of  direct  suture   or  Murphy's 


278 


OPERATIONS  ON  THE  ABDOMEN. 


button,  &c.  (2)  If  the  invagination  is  irreducible  but  not  gangrenous, 
it  may  be  left,  and  the  continuity  of  the  canal  restored  by  short- 
circuiting  the  small  and  large  intestine  above  and  below  the  invagina- 
tion by  Murphy's  button  or  some  other  means.  (3)  Where  the 
patient's  condition  is  good,  as  in  chronic  cases,  an  irreducible 
intussusception  is  best  treated  by  an  operation  based  by  Mr.  Jessett 
(Surf/.  Dis.  of  Stomach  and  Intestines,  p.  140)  on  what  is  known  as 
spontaneous  cure.  It  was  three  times  performed  successfully  on  dogs. 
An  invagination  having  been  made  artificially,  and  found  a  week  later 
firmly  adherent,  it  was  thus  removed.  A  longitudinal  opening  was 
made  into  the  intestine  over  the  root  of  the  intussusception  on  the  side 


Fig.  83. 


Fig.  84. 


Diagram  showing  removal  of  apex  of  intussusceptum 
through  an  incision  in  the  intussuscipiens. 
1,  Entering  bowel.     2.  Xeck  of  intussuscipiens. 
3.  Incision  in  intussuscipiens.     4.  Cut  edges  united 
by  sutures.     5,  Apex  of  intussusceptum  excised. 
(Greig  Smith.) 


Operation  of  resec- 
tion of  mtussuscep- 
tum  completed. 
(Greig  Smith.) 


farthest  from  the  mesentery,  about  an  inch  and  a  half  long,  of  sufficient 
length  to  allow  the  invaginated  part  to  be  drawn  out  with  vulsellum 
forceps.  The  root  of  the  invaginated  part  having  been  pulled  out 
through  the  above  opening,  was  cut  through  close  to  its  origin,  any 
vessel  which  required  it  being  tied.  Then  the  divided  coats  where  the 
intussusception  had  been  cut  away  were  united  with  a  few  points  of 
suture,  the  lumen  of  the  bowel  being  left  open.  The  stump  was  then 
returned  into  the  intestine,  and  the  incision  in  this  closed  by  quilt 
sutures.  Greig  Smith  (Abdom.  Surg.,  p.  676)  recommended  this  method 
of  treatment,  but  modified  the  operation  in  cases  of  extensive  invagina- 
tion in  that,  as  will  be  seen  by  reference  to  Figs.  83  and  84,  he 
removed  only  the  apex  of  the  intussusceptum,  this  being  the  most 
swollen  part,  and  therefore  the  chief  obstacle  to  reduction.  The  rest 
was  then  gently  reduced.    Although  reduction  will  be  rendered  possible 


ACUTE   INTESTINAL   OBSTRUCTION.  279 

in  sonic  cases  by  removal  of  the  apex  of  tin-  intussusception,  in  others 
the  adhesion  of  the  layers  at  the  neck  of  the  intussusception  to  one 
another  will  make  reduction  impossible.  In  such  cases,  a  more  com- 
plete resection  of  the  intussusceptum  will  be  necessary.  Israel  (Mel. 
Record,  May  20,  1905)  advocates  a  modification  of  the  method  just 
described:  be  fust  fixes  the  intussusception  to  the  parietal  peritonaeum, 
and  then  resects  the  invagination  through  a  longitudinal  incision, 
which  is  now  extra-peritomeal ;  the  incision  in  the  bowel  is  left  open 
for  a  few  days  for  drainage.  Israel  has  had  two  successful  cases  with 
this  operation.  Other  and  less  desirable  methods  which  may  be  thrust 
on  the  surgeon,  owing  to  the  circumstances  under  which  he  operates, 
are:  (4)  Resection  and  formation  of  an  artificial  anus.*  (5)  Formation 
of  an  artificial  anus  without  resection,  which  is  not  recommended  under 
any  circumstances,  for  the  primary  mortality  is  as  great  as  that  of 
resection,  and  the  mortality  of  secondary  resections  is  high  (about  50 
per  cent,  Gibson)  in  these  cases.  Finally,  in  those  rare  cases  of 
invagination  of  the  colon  into  the  rectum,  the  intussusception  may  be 
drawn  down  and  removed  by  the  operations  of  Mikulicz  or  Mr.  Barker 
in  this  country.  The  latter  surgeon's  cases  will  be  found  in  the  Med.- 
Chir.  Trans.,  1887,  vol.  lxx.  p.  335,  and  Brit.  Med.  Journ.,  vol.  ii.  1892, 
p.  1226.  In  both  cases  a  malignant  growth  was  at  the  root  of  the 
invagination,  and  in  each  operation  steps  were  facilitated  by  the  ease 
with  which  the  growth,  after  dilatation  of  the  anus,  could  be  pulled  out- 
side. Two  rows  of  sutures  were  made  to  encircle  the  bowel,  and  to 
unite  the  two  layers  of  the  intussusception  firmly  together  well  above 
the  new  growth.  As  the  sutures  were  passed,  care  was  taken  that  no 
small  intestines  protruded.  Both  cases  recovered,  and  the  first  was 
alive  four  or  five  years  after  the  operation. 

Mortality. — In  considering  this,  it  must  be  remembered  that  every 
recovery  means  a  life  saved  from  almost  certain  death.  Earlier 
diagnosis  and  above  all  earlier  resort  to  primary  operation  have 
greatly  improved  the  prognosis.  Wallace  (Clin.  Soc.  Trans.,  vol.  xxxviii.) 
records  20  consecutive  cases  with  only  four  deaths,  a  mortality  of 
only  20  per  cent.,  or  excluding  the  cases  severe  and  late  enough  to 
require  resection,  ii'ii  per  cent.  The  average  duration  of  the  operation 
in  11  cases  was  fourteen  minutes,  and  this  list  included  one  of  resection, 
and  also  one  of  excision  of  a  gangrenous  appendix. 

Fagge  reports  18  cases  with  six  deaths,  a  mortality  of  39  per  cent.,  but 
he  was  unfortunate  in  meeting  an  unusual  number  of  gangrenous  cases, 
and  if  these  late  cases  be  excluded  the  mortality  is  only  15*4  per  cent. 

Clubbe  (British  Med.  Journ.,  Jan.  17,  1905)  gives  an  account  of  100 
consecutive  laparotomies  for  intussusception.  Of  the  first  fifty,  twenty- 
five  died,  whereas  of  the  last  fifty  only  twelve  died,  owing  to  the 
children  being  sent  into  the  hospital  earlier,  and  to  improvements  in 
treatment. 

F.  C.  Wallis  (Lancet,  vol.  i.  1904,  p.  1648)  relates  four  cases  without 
a  death.     The  average  duration  of  the  operation  was  eleven  minutes. 

Rigby  records  seven  cases  (Lancet,  Jan.  14,  1902),  one  of  which  was 

*  Prof.  Senn  quotes  a  case  of  Wassiljew's  (Cent):  f.  Chir.,  1888,  No.  I2j,  in  which  an 
operation  was  performed  to  close  the  artificial  anus  six  months  later.  It  was  ultimately 
successful. 


280  OPERATIONS  ON  THE  ABDOMEN. 

too  late  for  operation,  and  one  needed  resection  ;  the  other  five  recovered. 
In  none  of  the  cases  did  the  operation  last  more  than  fifteen  minutes. 

G-.  Owen  (Intercolonial  Med.  Journ.  of  Australasia,  Oct.  20,  1902) 
records  a  case  in  which  a  recurrence  occurred  within  twenty-four  hours 
of  the  operation  ;  the  second  operation  did  not  save  the  child. 

Cole  (idem,  August,  November,  and  December,  1904)  mentions  a 
case  in  which  a  second  operation  proved  successful. 

Erdman  (New  York  Med.  Journ.,  May  14, 1904)  removed  the  appendix 
in  all  his  11  cases,  because  it  formed  apart  of  the  intussusception. 

This  is  not  to  be  recommended  unless  the  appendix  is  dangerously 
damaged,  for  the  delay  may  be  serious.  Keetley  recommends  an 
appendicostomy  as  a  means  of  drainage,  feeding,  and  prevention  of 
recurrence.     In  some  cases  of  great  distension  this  may  be  wisely  done. 

Recovery  after  resection  of  a  gangrenous  intussusception  is  a  very 
rare  event.  Thus  Gibson*  in  his  collection  of  1,000  cases  of  intestinal 
obstruction  found  only  one  case  of  recovery  after  resection  for  this  con- 
dition. In  an  earlier  collection  in  1897  there  were  239  cases  of  intus- 
susception, with  no  recovery  from  irreducible  intussusception  in  a 
patient  under  seven  years  of  age,  and  only  nine  in  older  people. 

W.  H.  Brown  (Lancet,  Sept.  16, 1905)  records  a  remarkable  case  of  an 
enteric  irreducible  intussusception  caused  by  a  worm.  Resection  was 
resorted  to,  and  Paul's  tubes  tied  in.  After  four  attempts  the  artificial 
anus  was  closed,  and  the  patient  recovered. 

Dowd  (Ann.  oj  Surg.,  vol.  xxxvi.  1902,  p.  48)  records  a  recovery 
after  resection  in  a  gangrenous  subacute  invagination  in  a  boy  of 
4!  years,  and  Skevington  (Lancet,  1905,  vol.  xi.  p.  890)  relates  a 
successful  resection  for  gangrene  in  a  boy  of  12. 

The  hope  of  the  future  lies  not  in  successful  resection,  but  in  less 
frequent  need  of  that  operation,  which  must  always  cany  a  veiy  high 
mortality  with  it  in  these  cases.  In  chronic  or  subacute  cases  in  older 
patients  recovery  is  not  so  rare. 

Mr.  F.  C.  Wallis  (Lancet,  Dec.  5,  1903)  records  an  interesting  case 
of  irreducible  chronic  intussusception  of  the  small  intestine,  occurring 
in  a  woman.  Mr.  Wallis  resected  forty-two  inches  of  the  bowel,  and 
joined  the  ends  by  means  of  a  Murphy's  button,  which  he  had  to 
remove  from  the  ileum  about  three  and  a  half  weeks  later.  The 
button  used  was  too  large,  and  therefore  gave  rise  to  symptoms  of 
obstruction,  but  the  patient  recovered. 

Mr.  Watson  Cheyne  records  a  successful  case  of  resection  of  a  chronic 
intussusception  which  was  due  to  invagination  of  Meekel's  diverticulum, 
and  he  refers  to  another  case  (Ann.  of  Surg.,  vol.  xl.   1904,  p.  796). 

Zum  Busch  (Clin.  Soc.  Trans.,  vol.  xxxvi.  p.  213)  records  a  success- 
ful resection  in  a  similar  case  in  a  young  man,  and  he  mentions  a  case 
of  Hirschsprung  in  which  spontaneous  recovery  occurred. 

III.  Volvulus. — The  intestine  here  is  usually  either  twisted  on  its 
mesenteric  axis,  or  bent  at  an  angle.  The  first  is  the  acuter  condition, 
owing  to  the  strangulation  of  vessels.  It  is  usually  met  with  in  the 
sigmoid  flexure,  when  this  has  a  long  mesocolon,  especially  in  adults 
who  have  been  subject  to  constipation  (Treves).  The  distension  may 
be  enormous,  the  sigmoid  appearing  to  occupy  the  whole  abdomen. 

*  Ann.  of  Surg.,  October,  1900,  p.  497. 


ACUTE   INTESTINAL   OBSTRUCTION.  281 

Ulceration  loading  to  fatal  peritonitis  may  set  in  either  in  the  sigmoid, 
the  colon,  or  the  caecum. 

Mr.  Makins  (Lancet,  vol.  i.  1904,  p.  156)  believes  that  volvulus  of 
the  caecum  is  far  commoner  than  is  generally  considered,  and  he  records 

a  typical  and  interesting  case  : — 

The  patient  was  a  woman,  67  years  of  age.  During  the  last 
eighteen  months  she  had  heen  the  suhject  of  four  or  five  distinct  attacks 
of  abdominal  pain,  accompanied  by  vomiting  sufficiently  severe  to  con- 
fine her  to  bed.  Ten  days  prior  to  her  admission  to  hospital  she  was 
seized  with  severe  pain  in  the  lower  abdomen,  most  acute  in  the  region 
of  the  umbilicus.  Obstruction  of  the  bowels  had  been  complete  for 
six  days,  vomiting  had  been  frequent,  and  neither  flatus  nor  fasces  had 
been  passed  per  rectum.  On  admission  the  woman  looked  anxious 
and  ill ;  vomiting  of  dark  fseculent  smelling  fluid  was  frequent.  Con- 
stipation was  absolute.  Her  tongue  was  furred  but  not  very  dry.  Her 
pulse-rate  was  108,  and  her  temperature  was  97°  F.  Her  abdomen 
was  considerably  distended ;  the  prominence  was  median,  and  on 
inspection  gave  the  impression  of  a  tumour  rising  from  the  pelvis.  It 
was  resonant  throughout  except  in  the  right  flank. 

An  operation  having  been  decided  upon,  the  abdomen  was  opened 
through  the  right  rectus  from  just  above  the  level  of  the  umbilicus 
downwards.  A  hugely  ballooned  piece  of  bowel  was  at  once  disclosed, 
occupying  the  whole  field  of  operation.  The  incision  was  enlarged, 
but  the  distended  gut  could  not  be  delivered,  as  it  was  tightly  wedged 
into  the  pelvis.  A  trocar  and  cannula  were  therefore  introduced,  and 
a  large  quantity  of  gas  and  liquid  fasces  was  evacuated.  The  slacken- 
ing of  the  tumour  thus  produced  allowed  of  the  hand  being  inserted 
into  the  pelvis  beneath  the  sac,  and  the  piece  of  bowel  was  brought  out. 
The  intestine  affected  proved  to  be  the  caecum  and  lower  part  of  the 
ascending  colon,  which  was  provided  with  an  unusually  long  mesentery. 
The  twist  was  through  half  a  circle,  and  involved  the  ascending  colon 
about  the  centre  of  its  length.  The  ileum  remained  viable.  It  was 
considered  advisable  completely  to  empty  the  loaded  bowel,  which  was 
then  readity  replaced,  the  two  punctures  having  been  securely  sutured. 
The  patient  made  an  uneventful  recovery,  the  bowels  acted  spontane- 
ously the  day  after  the  operation,  and  the  stitches  were  removed  from 
the  abdominal  wound  on  the  eighth  day.  On  the  fourteenth  day  a 
localised  collection  of  pus  was  evacuated  from  the  lower  part  of  the 
wound  in  the  abdominal  wall,  and  at  the  end  of  a  month  the  patient  left 
the  hospital  recovered. 

Corner  and  Sargent  (Ann.  of  Surg.,  1905,  vol.  xli.  p.  63)  have  since 
collected  and  analysed  57  cases,  including  their  own.  They  lay  stress 
on  the  fact  that  all  the  cases  are  not  acute,  but  that  chronic  and  sub- 
acute varieties  exist.  Before  the  final  complete  obstruction,  many  of 
the  patients  suffer  from  constipation,  paroxysms  of  pain  in  the  right 
iliac  fossa,  which  may  be  mistaken  for  appendicular  colic,  because  fever 
is  absent.  In  some  cases  there  is  a  history  of  a  previous  and  milder 
attack  of  intestinal  obstruction.  The  caecum  and  the  ascending  colon 
may  be  unduly  loose,  and  the  mesentery  of  the  ileum  unduly  long,  with 
narrow  attachment.  Rotation  ma}r  occur  upon  the  root  of  the  mesentery 
and  the  superior  mesenteric  artery,  or  upon  the  lower  part  of  the  mesen- 
teric attachment,  or  upon  the  vertical  axis  of  the  caecum  and  colon. 


282  OPERATIONS  ON  THE  ABDOMEN. 

In  the  majority  of  cases  the  distended  caecum  travels  upwards  and 
to  the  left  behind  the  root  of  the  mesentery,  and  may  be  found  near 
the  spleen ;  in  others  it  ma}'  lie  in  the  lumbar  region,  or  fall  into  the 
true  pelvis. 

Hilton  Fagge  in  his  classical  paper  on  intestinal  obstruction 
described  two  interesting  subacute  or  chronic  cases  many  years  ago 
(Guy's  Hospital  Reports,  vol.  xiv.). 

In  recent  years,  many  surgeons  have  discovered  this  condition 
during  an  exploration  for  acute  or  subacute  obstruction.  It  is  curious 
that  Mr.  A.  E.  Barker  states  that  he  has  not  seen  a  case  (Lancet, 
vol.  i.  1906,  p.  599).  Sherren,  Jonathan  Hutchinson,  Spencer,  and 
others  mentioned  cases  (loc.  supra  cit.).  It  is  three  times  more  common 
in  males  than  females. 

The  following  points  are  noteworthy  in  the  diagnosis  and  treatment 
of  volvulus.  It  is  not  uncommon  for  this  form  of  obstruction  to  follow 
an  injury,*  some  loop  of  bowel  distended  with  fseces,  and  with  a  long 
mesentery  probably  becoming  suddenly  displaced  and  unable  to  recover 
itself.  Again,  this  form  of  obstruction  has  been  noticed,  whether  as 
a  mere  coincidence  or  not,  in  many  cases  in  the  insane.  Finally,  at 
the  time  of  treatment,  Sir  F.  Treves's  warning  (Oper.  Surg  .,vol.  ii. 
p.  390)  must  always  be  remembered  :  "  The  reduction  of  a  volvulus 
does  not  usually  remove  the  anatomical  condition  that  led  to  it." 
The  truth  of  this  is  shown  by  their  tendency  to  recur. 

Thus  the  late  Mr.  Greig  Smith  (Abdom.  Surg.,  p.  450)  described  a  case  of  volvulus  of 
the  small  intestine  which  recurred  a  week  after  it  had  been  untwisted  by  abdominal 
section.  Enterotomy  was  then  performed,  and  the  patient  for  some  time  wore  a  catheter 
in  the  opening  to  allow  of  the  passage  of  flatus  into  a  bottle  which  he  carried  in  his 
pocket.  After  some  time  the  distended  bowel  had  so  contracted  that  the  use  of  the 
catheter  could  be  dispensed  with.  Dr.  Finney  reports  (Johns  Hopkins  IIosp.  Bull., 
March,  1893)  a  case  of  volvulus  which  involved  the  whole  colon  between  the  ileo-cascal 
valve  and  the  sigmoid  ;  it  was  rectified  by  operation,  and  recurred  nearly  three  years 
later.     A  second  recovery  followed. 

Whiting  (Ann.  of  Surg.,  vol.  xxxix.  p.  1036)  relates  two  cases  of  vol- 
vulus of  the  whole  of  the  jejunum  and  ileum.  One  of  the  patients,  a 
boy  of  five,  was  moribund  at  the  time  of  the  operation  ;  the  other,  a 
man  of  34,  recovered. 

Tully  Vaughan  (Journ.  Am.  Med.  Assoc.,  May,  1903)  has  collected 
21  cases  of  volvulus  of  the  small  intestines;  seven  of  these  were  submitted 
to  operation,  and  14  recovered.  In  several  cases,  the  difficulties  were 
so  great  and  the  appearances  so  puzzling,  that  the  operators  did  not 
recognise  the  condition  during  the  operation. 

J.  B.  Koberts  (Ami.  of  Surg.,  1906,  vol.  xi.  p.  242)  records  a  case 
of  volvulus  of  a  part  of  the  ileum  complicating  typhoid  fever;  the 
patient  recovered.  He  also  refers  to  two  other  cases,  in  which  the 
lesion  was  only  discovered  at  the  autopsy  (Eustis).  In  another  case, 
volvulus  followed  coeliotomy  for  a  perforated  typhoid  ulcer;  the  patient 
recovered  from  the  two  operations. 

*  See  cases  mentioned  by  Mr.  Turner,  Dr.  F.  Hawkins,  and  Mr.  Stavely  (Lancet, 
vol.  ii.  1892,  p.  995)  ;  a  case  successfully  operated  on  by  Mr.  Silcock  (Clin.  Soo.  Trans., 
vol.  xxviii.  p.  180).  References  are  made  in  the  latter  paper  to  eight  successful  cases 
operated  on  abroad. 


A<  !UTE    INTKSTINAL    OBSTRUCTION.  283 

1*'.  T.  Stewart  (Jowrn.  Amer.  Med.  Assoc,  March  19, 1904)  records  one 
case  and  presents  an  analysis  of  eight  other  cases  of  volvulus  of  the  great 
omentum,  but  in  none  of  these  was  intestinal  obstruction  diagnosed. 
In  five  of  them  the  omentum  was  connected  with  a  hernia,  and  a 
diagnosis  of  strangulated  hernia  was  arrived  at  in  two  of  these.  Four 
of  the  patients  were  thought  to  be  suffering  from  appendicitis. 

I  know  of  one  fatal  case  in  which  a  volvulus  of  the  sigmoid  followed 
and  was  probably  due  to  an  operation  for  the  relief  of  haemorrhage  from 
a  left  tubal  fostation. 

Treatment. — A  free  incision  will  be  required  here,  so  as  to  enable 
the  surgeon  to  get  at  the  root  of  the  volvulus.  The  volvulus  may 
present  at  once  as  a  hugely  distended  coil ;  it  may  be  felt  as  a  localised 
collection  of  intestine;  if  twisted,  the  twist  may  feel  like  a  band,  and  a 
band  may  actually  complicate  the  case,  as  when  a  vermiform  appendix 
is  coiled  round  the  root  of  the  twist  of  the  volvulus  (Brit.  Med.  Journ., 
vol.  ii.  1892,  p.  170).  If  attempts  at  reduction  fail,  the  volvulus  should 
be  emptied  by  carefully  inserting  a  temporary  enterostomy  tube  near 
the  summit  of  the  loop  brought  outside  the  abdomen  if  possible  and 
surrounded  with  gauze  packing.  If  a  proper  enterostom}*-  tube  be  not 
available,  a  long  and  curved  trocar  and  cannula  may  be  inserted  within 
an  area  which  is  surrounded  by  a  purse-string  suture,  which  can  be 
tied  as  the  cannula  is  withdrawn.  The  perforation  made  to  introduce 
an  enterostomy  tube  can  be  closed  in  the  same  way  or  by  the  introduc- 
tion of  several  Lembert  sutures.  When  the  loop  has  been  emptied  as 
far  as  possible,  further  attempts  at  reduction  should  be  made,  and  they 
will  generally  succeed.  The  coil  should  be  fixed  to  the  parietes  to 
prevent  recurrence  of  the  trouble.  This  is  best  done  by  suturing  the 
loop  and  its  mesentery  to  the  postero-lateral  wall  of  the  abdomen. 
Care  must  be  taken  not  to  insert  sutures  near  the  course  of  the  ureter 
or  the  iliac  vessels  or  other  structures  of  importance  on  the  posterior 
wall.  No  potential  hernial  cavity  or  orifice  must  be  made  by  leaving  a 
gap  or  fossa  between  the  loop  and  the  parietal  peritonaeum.  Shortening 
of  the  mesocolon,  as  advocated  by  Prof.  Senn,  is  not  to  be  recom- 
mended, for  gangrene  of  the  loop  may  follow  this  proceeding. 

Mr.  Maunsell's  method  of  fixing  the  reduced  caecum  by  performing 
appendicostomy  has  much  to  recommend  it,  for  not  only  is  the  caecum 
drained  of  its  poisonous  products  for  as  long  as  may  be  thought  desir- 
able, but  the  fistula  can  be  closed  practically  without  risk  at  any  time 
(vide  p.  146).  Plication  of  the  cascum  has  been  adopted  to  lessen  the 
size  of  the  viscus  and  prevent  recurrence  (Corner  and  Sargent,  loc.  cit.) ; 
but  judging  by  the  temporary  nature  of  the  results  of  gastroplication,  this 
does  not  seem  to  be  a  very  reliable  way  of  preventing  recurrence. 

In  some  cases,  small  gangrenous  areas  or  grey  thin  lines  may  be 
seen;  and  these  ma}fbe  inverted,  as  recommended  byMakins  (Clin.Soc. 
Trans.,  vol.  xxxvi.  p.  183).  If  the  condition  of  the  bowel  be  too  bad 
for  the  safe  adoption  of  this  treatment,  the  damaged  loop  should  be 
resected  as  rapidly  as  may  be,  and  after  the  contents  of  the  bowel 
above  the  obstruction  have  been  evacuated  end  to  end  anastomosis 
should  be  performed  by  direct  suture.  T}ring  in  Paul's  tubes  in  the 
ileum,  and  lower  end  of  the  ascending  colon,  in  cascal  cases,  is  not 
recommended,  for  anastomosis  does  not  take  much  more  time,  and  it 
is  far  more  satisfactory  both  immediately  and  remotehy. 


284  OPERATIONS  ON  THE  ABDOMEN. 

If  the  volvulus  be  merely  irreducible,  a  temporary  artificial  anus 
may  be  made  above  the  twisted  loop,  which  has  been  first  completely 
emptied  and  securely  closed.  Although  this  plan  ma}'  be  successful  in 
some  cases,  it  should  not  be  resorted  to  until  every  reasonable  effort 
has  been  made  to  untwist  the  coil,  and  in  patients  who  are  in 
extremis.  In  some  cases,  where  the  volvulus  is  persistent,  recurrent, 
or  irreducible,  or  where  a  faecal  fistula  persists,  excision  of  the  twisted 
loop  is  the  best  treatment. 

Lateral  anastomosis  of  the  extremities  of  the  loop,  as  advised  by 
Braun,  is  not  to  be  recommended,  for  the  base  of  attachment  of  the 
loop  of  bowel  becomes  too  small.  Anastomosis  between  the  ileum  and 
the  descending  loop  of  the  sigmoid  may  be  of  service  in  some  rare  and 
irreducible  cases. 

Mr.  Sherren  (Lancet,  vol.  i.  1906,  p.  599)  has  recorded  a  brilliantly 
successful  resection  of  a  gangrenous  volvulus  of  the  caecum,  followed 
by  immediate  and  direct  end  to  end  anastomosis  of  the  ileum  and 
ascending  colon.  Mr.  Arbuthnot  Lane  has  successfully  resected  an 
enormously  distended  gangrenous  volvulus  of  the  sigmoid  flexure. 

The  mortality  of  volvulus  is  very  high.  Thus  in  Corner  and  Sargent's 
collection  of  57  cases  19  recovered  and  21  died  after  operation ;  the 
remainder  died  without  operation.  This  gives  a  mortality  of  52*5  per 
cent,  for  the  operation,  but  it  should  be  pointed  out  that  these  statistics 
range  over  a  good  many  years,  and  that  future  results  may  be  expected 
to  be  better.  Earlier  recognition  and  earlier  exploration  in  all  cases  of 
reasonable  doubt  will  do  much  towards  attaining  this  end.  But  of  the 
six  cases  that  formed  the  basis  of  Corner  and  Sargent's  paper  only  one 
recovered,  although  five  at  least  of  the  operations  were  performed 
since  1902.  Evacuation  of  the  distended  loop  and  of  the  intestines 
above  the  obstruction  are  also  important  elements  in  the  success  of 
the  operation. 

IV.  Gallstones,  Intestinal  Calculi,  &c. — Gallstones,  the  most 
common  of  these,  present  cases  very  favourable  for  operation  if  taken 
in  time,  owing  to  the  simplicity  of  the  cause  of  obstruction,  and  the 
facility  with  which  it  may  be  usually  dealt  with.  Operation  has  been 
here  too  often  deferred,  owing  to  the  fact  that  these  patients,  usually 
advanced  in  life  and  stout,  are  not  well  suited  to  operation  from  a 
general  point  of  view,  and  because  it  has  been  strongly  insisted  upon 
by  some  that  if  pain  and  spasm  can  only  be  removed,  the  local  cause 
of  the  obstruction  will  pass  on.  This  I  believe  to  be  a  mistake.  Sir 
F.  Treves  (Intest.  Obstruct.,  p.  335)  states  that  of  20  cases  in 
which  gallstones  "produced  definite  and  severe  symptoms  of  obstruc- 
tion "  six  patients  recovered  by  the  spontaneous  passage  of  the  stone, 
and  14  died  unrelieved.  It  is  to  be  hoped  that  the  successful 
cases  which  have  been  published,  one  as  long  ago  as  1887  (Lancet, 
Dec.  3),  by  Mr.  T.  Smith,  Mr.  Clutton  (Clin.  Soc.  Trans.,  vol.  xxi. 
1888,  p.  99),  and  more  lately  by  Mr.  A.  Lane  (ibid.  ii.  1894,  P*  3^2) 
and  Mr.  Eve  (Clin.  Soc.  Trans.,  vol.  xxv.  1895,  p.  91),*  Mr.  Barnard 
(Ann.  of  Surg.,  vol.  xxxvi.  1902,  p.  160),  Mr.  Paul  (Liverpool  Med.-Chir. 
Trans.,  June,  1904),  may  bear  good  fruit.     In  some  cases,  in  addition 

*  In  this  paper  some  30  cases  which  have  been  treated  by  abdominal  section  are  given 
and  the  result  considered. 


ACUTE   INTESTINAL   OBSTRUCTION'.  285 

to  the  ago,  stoutness,  and  habits  of  the  patient,  the  history  of  previous 
inflammation  in  the  neighbourhood  of  the  gall-bladder  may  help  the 
diagnosis.  In  four  cases,  certainly,  the  calculus  has  been  felt — the 
abdomen  being  undistended — before  operation.  But  in  the  majority  it 
is  probable  that  here,  as  elsewhere,  operation  alone  will  demonstrate 
the  cause  of  the  obstruction. 

The  following  courses  may  be  adopted  :  (1)  To  try  and  pass  on  the 
stone  through  the  ileo-csecal  valve  into  the  large  intestine.  Mr.  Glutton 
(Clin.  Soc.  Trans.,  vol.  xxi.  p.  99)  succeeded  in  doing  this,  the  stone 
being  situated  eight  inches  above  the  valve.  But  usually  the  stone  is 
too  firmly  fixed. 

Mr.  Outturn's  case  is  a  very  instructive  one.  The  patient,  a  woman  aged  70,  was 
operated  upon  within  twenty-four  hours  of  the  beginning  of  the  attack.  Fifteen 
months  before  she  had  passed  a  large  facetted  biliary  calculus,  and  after  her  recovery 
from  this  had  had  a  swelling  in  the  region  of  the  gall-bladder.  This  disappeared  with 
the  onset  of  the  obstruction.  A  median  incision  four  inches  long  having  been  made,  the 
stone  was  readily  felt,  and  though  it  tightly  fitted  the  lumen  of  the  intestine,  it  could  be 
forced  along.  As.  owing  to  the  early  date  at  which  the  operation  was  performed,  there 
was  no  marked  difference  between  the  intestine  above  and  below  the  obstruction,  the 
site  of  the  ileo-crecal  valve  was  determined  by  making  out  the  cascum  and  the  appendix. 
There  was  not  much  difficulty  in  urging  the  calculus  in  the  right  direction,  but  as 
soon  as  the  valve  was  reached  some  considerable  force  was  required  to  make  it  pass 
through.  This  most  successful  case  strongly  supports  Mr.  Clutton's  advocacy  of  an  early 
operation,  before  the  stone  has  become  so  immovable  as  to  require  opening  of  the 
intestine. 

If  the  stone  cannot  be  pushed  onwards,  and  if  it  is  too  hard  to  be 
broken  up  by  gentle  pressure  with  the  finger,  it  must  be  removed. 
The  loop  of  bowel  containing  the  calculus  is  drawn  well  outside  the 
abdominal  cavity,  and  the  stone  is  displaced  upwards  into  more  healthy 
intestine  if  possible.  An  assistant  fixes  the  stone  by  compressing  the 
bowel  above  and  below  it,  while  the  surgeon  removes  the  stone  through 
a  longitudinal  incision  made  along  the  free  border  of  the  intestine. 
Care  is  taken  not  to  lacerate  or  bruise  the  edges  of  the  wound  by 
trying  to  extract  the  stone  through  an  incision  which  is  too  small.  If 
the  intestine  above  the  obstruction  is  distended,  its  toxic  contents 
must  be  evacuated  through  the  incision,  care  being  taken  to  hold  the 
latter  over  a  basin  well  away  from  abdomen.  The  intestine  is  then 
thoroughly  cleansed,  and  the  incision  closed  carefully  with  Lembert's 
or  Halstead's  sutures. 

If  the  bowel  at  or  just  above  the  stone  be  gangrenous,  it  should  be 
resected,  and  end  to  end  anastomosis  performed  immediately  after 
emptying  the  distended  intestine  above.  If  the  condition  be  doubtful, 
any  small  grey  area  may  be  inverted,  and  the  intestine  returned  just 
within  the  abdomen,  or,  better,  the  loop  may  be  resected.  In  some 
grave  cases  an  enterostomy  tube  of  comparatively  small  calibre  may  be 
temporarily  tied  in,  the  opening  being  inverted  after  two  or  three  days. 

Immediate  resection  is  far  preferable  to  the  formation  of  an  artificial 
anus  if  the  condition  of  the  patient  is  good  enough  to  allow  this. 

Mr.  S.  M.  Smith  (Lancet,  vol.  ii.  1905,  p.  1174)  relates  a  fatal  case 
of  obstruction  of  the  sigmoid  flexure  by  a  gallstone  which  had  entered 
the  transverse  colon  from  the  gall-bladder;  the  stone  was  not  discovered 
at  the  operation. 


286  OPERATIONS  ON  THE  ABDOMEN. 

Mr.  Milward  records  a  similar  case,  in  which  he  successfully  removed 
a  large  stone  from  the  sigmoid  (he.  cit.,  p.  1327). 

Dr.  Le  Conte  (Ann.  of  Surg.,  1902,  vol.  xxxvi.p.  300)  had  to  resect  a 
piece  of  gangrenous  small  intestine  above  the  stone,  which  had  been 
forced  along  by  purgatives  after  it  had  caused  injury  and  infection  of 
the  bowel  and  its  mesentery  at  the  site  of  its  original  impaction.  End 
to  end  anastomosis  was  performed  at  once,  but  the  patient  died. 

Prognosis. — From  the  deceptive  nature  of  the  symptoms  and  often 
from  the  incompleteness  of  the  obstruction,  delay  in  exploring  is  far  too 
common,  and  the  septic  contents  of  the  obstructed  bowel  are  often  not 
removed.  It  is  not  surprising  therefore  that  the  operation  is  attended  by 
a  high  mortality.  In  Barnard's  eight  cases  (Ann.  of  Surg.,  vol.  xxxvi. 
1902,  p.  161)  the  mortality  was  57  per  cent.,  in  Courvoisier's  125 
cases  it  was  44  per  cent.,  and  of  Sclmeller's  82  cases  56  per  cent.  died. 
In  Eve's  20  collected  cases  the  mortality  was  40  per  cent. 

Embolism  ;  Thrombosis  of  the  Mesenteric  Vessels  or  of  the  Abdo- 
minal Aorta.— Mention  must  be  made  of  the  above  conditions,  as  it  is 
clear,  from  the  cases  published,  that,  though  rare,  they  may  simulate 
acute  intestinal  obstruction  very  closely.  The  explanation  appears  to 
be  that  a  loop  of  intestine,  deprived  of  its  blood  supply  by  an  embolus, 
will  functionally  be  as  completely  paralysed  as  if  it  had  been  strangled. 
Instructive  cases  of  this  kind  will  be  found  published  by  Mr.  M'Carthy 
(Lancet,  vol.  i.  1890,  p.  646)  and  Dr.  Munro,  of  Middlesborough  (ibid., 
vol.  i.  1894,  p.  147). 

Dr.  Munro  quotes  from  Gerhardt  and  Kussmaul  the  following  diagnostic  points  of 
these  cases  :  (1)  A  source  of  origin  for  the  embolus  ;  (2)  profuse  haemorrhage  from  the 
bowels  ;  (3)  severe  colic-like  pains  in  the  abdomen  ;  (4)  rapid  reduction  of  temperature  : 
(5)  demonstration  of  an  embolus  in  some  of  the  other  arteries  ;  (6)  palpation  of  infarct 
in  the  mesenteries.  In  Dr.  Munro' s  case,  one  of  these,  situated  in  the  mesosigmoid,  could 
be  felt,  before  operation,  in  the  left  iliac  fossa.  To  these  points  might  be  added  advanced 
age  and  no  evidence  of  malignant  disease.  The  mischief  is  usually  too  extensive  to 
admit  of  surgical  interference.  If  it  be  limited  to  the  small  intestine,  several  branches 
are  usually  plugged. 

The  recorded  cases  have  almost  always  ended  fatally.  In  several 
cases,  however,  the  portions  of  bowel  and  mesentery  involved  were 
removed  with  success. 

T3Tson  and  Linington  (Clin.  Soc.  Trans.,  vol.  xxxv.  p.  114)  report  a 
case  of  resection  of  about  a  foot  of  gangrenous  small  intestine,  the 
condition  being  due  to  atheromatous  embolism  of  a  branch  of  the 
superior  mesenteric  artery  in  a  woman  66  years  of  age.  Considerable 
difficulty  was  experienced  in  getting  the  stitches  to  hold  in  the  sodden 
and  friable  mesentery,  and  the  patient  died. 

Jackson,  Porter,  and  Quinby  (Journ.  Amcr.  Med.  Assoc.,  June  4, 
July,  1904),  have  collected  and  anahysed  214  cases  of  embolism  and 
thrombosis  of  the  mesenteric  vessels. 

They  found  that  blood  was  passed  per  anum  in  only  41  per  cent,  of 
the  cases.  In  47  cases  operations  had  been  performed,  with  four 
recoveries,  or  a  mortality  of  92  per  cent. 

A  review  of  the  pathological  appearances  indicated  that  in  about  15 
of  the  cases  which  had  not  been  submitted  to  operation  short  resections 
might  have  been  performed  with  advantage. 

Elliot  (Ann.  of  Surg.,  1905,  vol.  xlii.  p.  674)  describes  an  interesting 


ACUTE    INTESTINAL    OBSTRUCTION.  287 

case  of  thrombosis  of  a  part  of  the  superior  mesenteric  vein  leading  to 
gangrene  of  a  loop  of  jejunum  fourteen  inches  long;  this  was  successfully 
resected.  The  thrombosis  came  on  eighteen  days  after  anterior  gastro- 
jejunostomy. 

APPENDICITIS.* 

Before  discussing  the  question  of  surgical  interference  here,  it  will  be 
well  to  make  plain  what  we  mean  when  speaking  later  of  the  varieties 
of  this  disease.     These  are — 

i.  Catarrhal  and  Early  Interstitial  Appendicitis. — Here  the  inflamma- 
tion is  limited  to  the  mucous  membrane  and  the  other  coats  of  the 
appendix,  but  goes  no  farther  (if  the  attacks  be  slight)  than  at  the  most 
a  little  plastic  peritonitis  and  a  few  slight  adhesions. 

ii.    Appendicitis  with  a  Localised  Abscess. 

iii.  Acute  Perforating  and  Gangrenous  Appendicitis. — Of  these  two, 
the  first  may  at  any  time  lead  to  a  general  peritonitis;  the  second,  if 
left,  often  does  so. 

iv.  Relapsing  or  Recurrent  Appendicitis. 

Question  of  Operative  Interference  in  Acute 
Appendicitis. 

When  to  Operate  and  wiiex  to  "Wait  :    Two    Camps  of  Opinion. 

One  of  us  has  already  said,  in  a  lecture  elsewhere  (\Y.  H.  A. 
Jacobson,  Polyclinic,  December,  1900),  much  of  what  follows  concerning 
the  present  state  of  opinion  on  this  subject ;  but  some  more  recent 
statistics  and  comments  have  been  added. 

"  (a)  Advocates  of  Waiting  and  Watching. 

"  Those  who  follow  on  these  lines  rely  on  the  fact  that  the  majority 
of  cases  of  appendicitis  recover  under  medical  treatment.  In  other 
words,  they  represent  that  the  dangerous  forms  in  which  sloughing 
or  gangrene  or  perforation  of  the  appendix  with  suppurative  peritonitis, 
pylephlebitis,  &c,  follow,  are  but  few.  Dr.  Hawkins,  quite  one  of  the 
highest  authorities  on  the  subject,  puts  the  death-rate  of  appendicitis 
at  14  per  cent.,  and  hopes  it  may  be  reduced  to   12  per  cent. 

"  With  all  respect  to  Dr.  Hawkins,  I  myself  look  upon  the  above 
estimate  of  14  per  cent,  as  too  low  when  hospital  cases  are  considered. 
It  is  interesting  to  note  that  Dr.  MacDougall  in  his  address  at  Carlisle 
in  1896,  quoting  from  returns  made  from  the  Edinburgh  Royal 
Infirmary  for  the  three  years  1893,  1894,  and  1S95,  found  that  the 
death-rate  of  acute  appendicitis  was  25  per  cent.,  and  that  the  returns 
of  two  London  hospitals — St.  Bartholomew's,  1893  to  1895,  and 
St.  Thomas's,  1892  to  1894 — &ave  a  death-rate  of  nearly  20  per  cent., 
and  it  is  doubtful  if  these  returns  included  all  the  cases  admitted  of 
purulent  peritonitis.  .   .   . 

*  I  use  this  term,  etymologically  unsatisfactory,  because  it  is  convenient  and  based  on 
correct  pathology. 


288  OPERATIONS  OX  THE  ABDOMEN. 

"  The  advocates  of  waiting  and  watching  further  maintain  that  in 
the  ^discriminating  removal  of  appendices  which  they  say  lias  heen 
going  on  in  America,  we  have  had  an  abuse  of  Burgery  similar  to  that 
which  characterised,  some  years  ago,  the  operation  of  oophorectomy." 

Ochsner  (Med.  News,  May  2,  1903)  advises  that  the  operation  be 
deferred  in  cases  which  are  very  grave  when  first  seen,  whether  early 
or  late  in  the  disease.  This  advice  only  refers  to  cases  which  experi- 
ence has  shown  to  do  badly  after  immediate  operation. 

Delay  is  recommended  until  the  general  condition  has  improved  and 
localisation  has  occurred;  and  an  operation  can  then  be  performed  with 
comparatively  little  risk.  In  these  cases  and  also  in  all  cases  of 
appendicitis,  Ochsner  strongly  advocates  absolute  cessation  of  adminis- 
tration of  any  food  or  fluid  by  the  month,  and  especially  condemns  the 
exhibition  of  cathartics,  because  peristaltic  movements  of  the  intestines 
spread  the  infection. 

The  mouth  may  be  moistened  and  washed  out,  but  all  food  and 
fluid  must  be  given  by  the  rectum.  Gastric  lavage  is  recommended 
for  nausea  and  vomiting.  In  all  acute  cases  seen  before  there  is 
evidence  of  spread  of  the  disease  beyond  the  appendix,  an  immediate 
operation  by  a  capable  surgeon  is  advised  to  prevent  complication  as 
well  as  to  save  life. 

These  views  are  based  on  a  study  of  337  cases  admitted  into 
Augustana  Hospital  in  1902  ;  192  were  acute  cases,  145  chronic  ;  the 
mortality  of  the  acute  cases  was  3  per  cent.,  or  six  deaths,  three  of  which 
occurred  without  operation.  Only  one  of  145  chronic  or  internal 
cases  died. 

"  (b)   The  Advocates  of  Operation  at  Once  or  at  the  End  of  Thirty-six 
or  Forty -riyld  Hours. 

"  Let  us  consider  how  this  school,  to  which,  I  confess,  I  have  felt 
myself  drawn  increasingly  during  the  last  few  years,  would  answer  the 
objections  to  early  operation  which  I  have  just  mentioned.  And  I 
will  take  the  last  first,  viz.,  the  criticism  that  this  operation  of  early 
removal  of  the  appendix  has  been  abused,  and  the  comparison  between 
it  and  the  similar  abuse  with  which  most  of  us  are  familiar  as  to 
oophorectomy. 

"  There  is  an  old  saying  that  '  Abusus  mm  toUit  mum.1  A  pendulum 
of  opinion  which  sways  strongly  first  in  one  direction,  then  in  another, 
needs  watching.  And  in  my  opinion  there  is  a  danger  that  in  being 
influenced  by  the  needless  operations  which  have  no  doubt  been  done 
in  America  and  elsewhere,  we  shall  lose  sight  of  the  very  sound  and 
splendid  work  done  by  the  best  surgeons  of  that  country.  I  shall  allude 
to  this  more  in  detail  shortly.  I  will  only  add  that  in  this  country 
hasty  and  needless  operating  will  certainly  not  be  the  rule  of  treat- 
ment, but  there  is  a  risk  that  in  priding  ourselves  on  this  we  err  on  the 
other  side.  I  am  certain  that  the  results  of  the  best  American  surgeons 
are  far  superior  to  anything  in  this  country,  and  are  but  little  known 
amongst  us. 

"  With  regard  to  the  comparison  between  removal  of  the  appendix 
and  the  ovary,  I  scarcely  think  this  holds  good.  A  diseased  ovary  may 
cripple,  but  it  very  rarely  kills  ;  it  is  not  a  vestigial  structure  ;  though 


APPENDICITIS. 


289 


unsound,  it  is  not  necessarily  functionless.  An  appendix  has  not,  like 
the  ovary,  peculiar  importance  not  only  to  its  owner,  but  also  perhaps 
to  others,  an  importance  quite  sui  gejieris,     The  advocates  of  early 

operation  would  answer  to  the  conservative  school:  'Von  sanction, 
nay,  perhaps  you  urge,  operation  as  soon  as  evidence  of  gangrene, 
perforation,  suppurative  peritonitis,  or  local  ahscess  is  certain.  But 
by  the  time  the  evidence  is  sufficient  for  you  to  call  in  surgery  it  is 
often  too  late;  you  admit  that  it  is  usually  impossible  to  diagnose  such 
conditions  as  gangrene  and  perforation  till  the  disaster  is  announced 
by  evidence  which  is  unmistakable,  but  which  announces  a  condition  in 
which  surgical  interference  is  too  often  useless.' 

"  The  advocates  of  early  operation  claim  that  by  operating  early, 
and  thus  making  sure  that  infection  has  not  extended  beyond  the 
appendix,  the  surgical  death-rate  would  be  much  below  the  medical 
one,  which  we  have  seen  to  be  put  by  one  of  the  best  authorities  at 
14  per  cent.  Thus  Dr.  Morriss  holds  that  the  death-rate  should  not 
exceed  4  or  5  per  cent,  when  cases  of  gangrene,  perforation,  and  sup- 
purative peritonitis  are  operated  on,  and  goes  so  far  as  to  say  that  a 
surgical  death-rate  of  2  per  cent,  in  cases  operated  on  early  '  would 
be  illegitimate.' 

"Let  us  examine  this  claim  that  the  medical  death-rate  will  he  much 
lowered  by  early  surgical  interference.  It  will  he  seen  to  stand  or  fall 
very  largely  upon  the  meaning  of  the  word  '  early.'  The  question  at 
once  arises,  '  How  many  cases  are  really  seen  within  the  first  twenty- 
four  or  thirty-six  hours  ?  '  Certainly,  I  think  but  few  in  hospital 
practice.  Here  the  patient  very  often  goes  on  working  for  days  after 
he  has  had  warnings  of  pain,  and  even  sometimes  with  a  lump  in  his 
right  iliac  fossa.  AVe  must  face  the  fact  that  it  will  be  difficult  to 
determine  whether,  with  this  word  '  early  '  before  us,  we  really  are 
dealing  with  the  first  twenty-four  or  thirty-six  hours.  A  patient  from 
carelessness  or  inaccuracy,  or  a  desire  to  make  the  best  of  his  case, 
from  a  dread  of  operation,  may  misrepresent  his  symptoms  as  just 
beginning.  In  reality  this  man  has  had,  for  a  day  or  two,  pain  or 
other  evidence  that  a  catarrhal  condition  has  been  established,  and 
thus  the  appendix  epithelium  has  had  time  to  become  shed,  and  an 
infection-atrium  has  had  the  opportunity  of  forming  before  a  medical 
man  is  asked  to  see  the  patient.  Then,  when  the  latter  is  called  in, 
the  pulse,  temperature,  pain,  tenderness,  and  so  forth  betoken  not 
the  commencement  of  an  attack,  as  the  patient  represents,  but  a  stage  in 
which  an  actual  abrasion  is  present,  perhaps  even  that  the  peritonaeum 
is  becoming  infected. 

"  Having  mentioned  this  caution,  we  will  suppose,  for  the  sake  of 
argument,  that  all  cases  are  seen  within  a  really  early  stage,  viz., 
twenty-four  hours.  Is  it  certain  that  early  operation  at  this  stage  will 
be  largely  successful?  Let  us  examine  the  ground  on  which  we  stand. 
If  we  accept  Dr.  Hawkins's  mortality  of  appendicitis  treated  medically 
as  one  of  14  per  cent,  from  gangrene,  perforation  of  the  appendix,  and 
suppurative  peritonitis,  in  order  to  ensure  a  surgical  mortality  of  4  or  2 
per  cent. — though  Dr.  Morriss  is  inclined  to  look  upon  even  the  latter 
as  '  illegitimate  ' — it  is  clear  that  we  must  operate  successfully  on 
96  or  98  cases  of  acute  appendicitis  in  the  early  stage.  This 
is   a    statement  which    there   is   no   gainsaying,   and   it  is  one  which 

s. — vol.  11.  19 


290 


OPERATIONS  ON  THE  ABDOMEN. 


at  once  makes  a  mind  capable  of  weighing  evidence  very  thoughtful. 
"When  one  considers  the  conditions  under  which  this  earl}-  operation 
may  have  to  be  done  in  a  febrile  patient  with  an  infected,  septic  organ 
to  be  removed,  with  intestines  very  likely  distended,  and  many  other 
conditions  present  the  very  reverse  of  those  which  make  an  operation 
during  the  quiescent  stage  so  successful,  it  is  difficult  to  say  how  far 
the  medical  mortality  of  14  per  cent.,  or,  perhaps  more  correctly,  of 
20  per  cent.,  will  be  reduced,  even  if  the  surgery  be  always  that  of 
skilled  hands.  That  it  will  be  reduced  by  habitual  earlier  operation, 
and  in  the  lifetime  of  some  of  us,  I  am  certain  ;  but  I  doubt  if  it  will 
be  brought  below  8  per  cent,  when  all  the  conditions  and  the  different 
personal  equations  of  the  operators  are  weighed. 

"But  here  it  will  be  only  just  to  examine  some  of  the  results 
gained  by  the  best  of  those  American  surgeons  who  advocate  early 
operation  in  every  case.  These  results  are  not  sufficiently  known  in 
this  country. 

"I  will  take  only  two  of  the  more  recent  ones,  viz.,  those  of 
Dr.  Mynter,  of  Niagara,  and  Dr.  Morriss,  of  New  York.  Dr.  Mynter 
{Appendicitis,  p.  172),  whose  book  emphatically  bears  the  stamp  of  a 
candid  and  judicious  worker,  writing  in  1897,  had  had  13  cases,  all 
of  which  had  more  or  less  total  gangrene  but  yet  without  perforation. 
They  all  recovered  by  prompt  operation  and  extirpation  of  the  appendix. 
Two  cases  were  operated  on  during  the  first  day,  five  on  the  second  day, 
two  on  the  third  day,  three  on  the  fourth  day,  and  one  on  the  seventh 
day.  '  These  cases,'  he  goes  on  to  say, '  are  most  interesting,  as  giving 
conclusive  evidence  of  the  importance  of  operating  before  perforation 
has  occurred.  Xo  one  can  doubt  that  perforation  with  profuse  perito- 
nitis would  shortly  have  occurred,  and  that  they  all  would  have  died 
under  any  other  than  surgical  treatment.' 

"  Dr.  Mynter  operated  on  another  group  of  20  cases,  all  of  which 
had  gangrene  with  perforation  of  the  appendix,  and  commencing  or 
diffuse  peritonitis.  Five  of  these  recovered,  while  15  died — 13  of 
diffuse  peritonitis,  one  of  gangrene  of  the  caecum,  and  one  of  suppu- 
rating pylephlebitis  after  the  peritonitis  had  disappeared.  The  five 
who  recovered  were  operated  on,  in  two  cases  on  the  first  day,  in  two 
cases  on  the  second  day,  and  in  one  case  on  the  third  day.  Of  the 
15  who  died,  one  was  operated  on  during  the  second  day,  two  on 
the  third  day,  five  on  the  fourth  day,  two  on  the  fifth  day,  four  on  the 
sixth  day,  and  one  on  the  seventh  day. 

"Dr.  Mynter  adds:  'Comment  seems  unnecessary;  all  died  if 
operated  on  later  than  the  third  day.' 

"Dr.  Morriss's  cases  (Lectures  on  Appendicitis,  New  York,  1895)  are 
somewhat  less  carefully  tabulated,  but  are  most  instructive. 

"  Of  91  cases  of  acute  appendicitis  operated  on  early,  in  59  in  which 
only  the  immediate  vicinity  of  the  appendix  was  infected,  although  many 
of  these  cases  involved  extensive  operative  work,  there  was  no  death  in 
this  series  0/59  cases. 

"  In  six  cases  of  intense  general  septic  peritonitis,  with  the  whole 
abdominal  cavity  bathed  in  pus,  only  one  patient  died. 

"  In  three  cases  with  intense  general  septic  peritonitis,  not  marked 
by  the  presence  of  pus,  only  one  died. 

"  In    23  cases  of  the  walled- off  abscess  form  of   appendicitis,  the 


APPENDICITIS. 


291 


most  varied  complications  were  present.  Five  only  of  these  died,  but 
one  oi'  these  deaths  was  from  acute  suppurative  nephritis,  a  second  from 
'intestinal  obstruction  due  to  adhesions  which  could  not  be  separated 
at  the  time  of  operation  on  account  of  the  patient's  condition,9  and  a 
third,  already  weak  from  several  months'  septicaemia  due  to  an  absc 
overlooked  before  Dr.  Morriss  saw  the  case,  died  of  a  continuance  of 
the  sentica'inia. 

"This  death-rate  of  seven  in  91  cases  testifies  in  no  uncertain 
terms  to  the  admirable  care  and  skill  which  must  have  been  exercised 
to  attain  such  a  result. 

"  Dr.  Morriss  is  quite  justified,  after  such  success,  in  writing  :  '  I  feel 
that  the  death-rate  in  100  such  cases  as  the  list  contains  should  not  be 
more  than  4  or  5  per  cent.,  notwithstanding  the  fact  that  many  of  the 
cases  were  in  a  condition  which  seemed  to  prohibit  interference.' 

"  It  seems  to  me  that  even  if  this  surgical  death-rate  of  4  or  5  per 
cent,  were  doubled,  viz.,  8  or  10  per  cent.,  it  would  give  a  better  result 
than  the  medical  one  of  14  or  20  per  cent.,  and  our  duty  would  be 
clear." 

More  recent  results  are  even  better.  Thus  Dr.  Murphy  (Amer. 
Journ.  Med.  Sci.,  August,  1904),  in  his  very  valuable  paper  based  on 
2,000  operations  performed  by  him  since  1889,  states  that  the  mortality 
of  his  first  ioo  cases  was  11  per  cent.,  but  that  has  been  reduced 
to  2  per  cent,  in  his  last  100  cases.  About  two-thirds  of  these  patients 
were  operated  upon  in  the  intermediate  stage,  but  the  statistics  include 
all  cases  of  suppuration,  gangrene,  and  peritonitis. 

Dr.  Deaver  (Amer.  Med.,  Oct.  17,  1903)  reports  566  cases  operated 
upon  in  1902-3,  with  a  total  mortality  of  5*3  per  cent. 

In  the  following  interesting  tables,  all  cases  with  no  pus  outside 
the  appendix  are  labelled  "  appendicitis  "  (Deaver) : — 

Table  I. 


Peritonitis,  general 
Abscess  cases ... 
Appendicitis  ... 


16 
183 
367 


566 


5    deaths 

22  deaths 

3  deaths 


30   deaths 


31-0  % 

12-0  % 

o-8  % 


5S  % 


Table  II. 


Adults,  acute  ... 
Adults,  chronic 
Children,  acute 
Children,  chronic 


344 
164 

49 
9 


566 


26   deaths 
4   deaths 


30  deaths 


756  °/o 
8-i6  o/0 


5'3  % 


Dennis  (Med.  News,  Jan.  9,  1904)  records  119  consecutive 
operations  with  only  two  deaths,  one  due  to  empyema  in  an  alcoholic 
tramp  and  the  other  due  to  subdiaphragmatic  abscess  and  pulmonary 
abscess,  and  28  of  the  patients  had  abscesses,  and  these  include  the 
two  deaths.     In  11,  perforations  and  peritonitis  had  occurred,  but  all 

19 — 2 


292  OPERATIONS  ON  THE  ABDOMEN. 

of  these  recovered.  Dennis  strongly  advocates  early  operation,  free 
incision,  and  thorough  drainage. 

Mr.  Paul  {Lancet,  vol.  i.  1906,  p.  674)  reports  252  operations 
performed  since  1901  :  there  were  43  cases  of  abscess  and  17  of 
peritonitis  ;  the  total  mortality  was  6*3  per  cent.  In  the  last  year, 
however,  the  results  had  improved  :  72  cases,  including  16  abscess 
cases  and  4  of  peritonitis,  were  operated  upon,  with  a  mortality  of  only 
2'7  per  cent.  Mr.  Paul  aims  at  interval  operations,  and  only  operates 
on  acute  cases  when  he  has  reason  to  suspect  suppuration  or  peritonitis. 
It  would  be  interesting  to  know  how  many  cases  seen  in  an  acute 
attack  and  treated  conservatively  die  of  a  subsequent  attack  which  may 
come  on  before  an  "interval"  operation. 

Mr.  G.  R.  Turner  (Lancet,  vol.  i.  1905,  p.  643)  records  125 
operations  which  were  performed  for  acute  appendicitis  as  soon  as 
possible  after  the  surgeon  saw  the  patients.  The  mortality  was  8  per 
cent.  ;  and  Mr.  Waterhouse  {loc.  cit.)  mentions  19  operations  per- 
formed within  the  first  twenty-four  hours  of  the  disease  with  no  death, 
although  perforation  of  the  appendix  was  noticed  in  three  cases. 

Prof.  Koerte  reported  137  recent  operations  before  the  German 
Surgical  Association  [Lancet,  vol.  i.  1905,  p.  1455).  In  57  of  these 
symptoms  of  peritonitis  existed  before  operation  ;  of  the  patients 
operated  on  before  forty-eight  hours  18  per  cent,  died,  and  of  those 
operated  on  on  the  third  day  36  per  cent.  died.  All  the  cases  without 
peritonitis  recovered. 

Prof.  Kiimmell  (loc.  cit.),  who  used  to  advocate  conservative 
treatment,  now  prefers  early  operation,  because  he  believes  that  the 
disease  has  become  more  grave.  Only  three  patients  died  out  of  nine 
operated  upon  by  him  in  the  early  stage. 

"But  the  following  cautions  must  be  borne  in  mind  : 

"  First,  that  we  have  here  the  results  of  especial  experience  of  those 
who  have  had  opportunities  of  acquiring  especial  skill.  Dr.  Mynter 
strikes  a  very  important  note  when  he  emphasises  the  point  that 
wherever  the  home  surroundings  are  unfavourable  the  well-regulated 
operating-room  of  a  home  or  hospital  is  a  sine  qua  non. 

"  Secondly,  it  is  never  to  be  forgotten  that  these  operations  are 
always  serious,  often  very  difficult,  and  that  they  require  good  experi- 
ence, efficient  assistance,  and  efficient  antiseptic  precautions. 

"  Thirdly,  in  estimating  the  surgical  death-rate,  which  I  do  not 
myself  expect  to  be  less  than  6  or  8  per  cent.,  when  all  the  conditions 
under  which  this  operation  will  be  performed  are  taken  into  account, 
we  must  remember  that  in  certain  cases  of  appendicitis  beginning  very 
acutely  the  operation,  however  early,  will  not  save  life.  I  refer  to 
cases  where  a  general  peritonitis  sets  in  early,  possibly  within  the  first 
few  hours  of  the  case  coming  under  notice.  The  explanation  of  these 
cases  probably  is  that  in  some  it  is  not  really  a  first  attack.  The 
history  given  is  unreliable,  the  appendix  is  already  a  damaged  one, 
and  either  gangrene  or  a  perforation  of  its  unhealthy  structures  sets  in 
quickly,  with  the  result  of  a  rapid  general  peritonitis.  In  others,  the 
explanation  is  that  the  bacillary  activity  is,  from  the  first,  acute,  the 
resisting  power  of  the  patient's  tissues  very  poor,  or  that  some  minute 
point  in  the  anatomy  of  the  appendix,  as  the  gaps  between  the  fibres 
of  the  muscular  roots  (vide  supra),  facilitates  rapid  transit  of  the  septic 


AI'I'KNMCITIS. 

process.     No  one  can  tell  how  often  the  lives  of  our  patients  hang  on 
such  minute  points. 

"  There  is  another  of  the  points  of  dispute  between  the  two  camps  to 
which  I  would  ask  your  attention.  The  advocates  of  early  operation 
maintain  that  many  of  the  cures  which  arc  secured  by  medical  treat- 
ment— we  will  call  them  80  or  85  per  cent. — are  not  permanent  and 
complete  cures  when  followed  up;  but  that  permanent  mischief  is  left 
behind,  sometimes  slight,  sometimes  severe  and  dangerous;  and  that 
patients  would  he  saved  from  the  great  annoyance  and  suffering  of 
recurrent  attacks  and  much  waste  of  time  if  the  appendix  were  removed 
in  the  first  attack.  The  following  is  an  interesting  instance  of  how 
incomplete  may  he  the  cure  of  a  case  treated  on  medical  lines,  and  of 
the  thread  on  which  such  a  patient's  life  may  he  hanging : 

"  A  gentleman,  aged  23,  was  sent  to  me  in  July,  1896,  by  Dr.  Goodhart  with  the  following 
history  : — In  1895  he  had  had  a  severe  attack  of  appendicitis,  in  which  the  temperature 
was  for  some  days  between  1020  and  1030.  Under  medical  treatment  lie  made  an  apparently 
perfect  recovery.  In  June,  1896,  while  bowling  for  an  eleven  of  the  Zingari  at  Manchester, 
as  he  shot  up  to  the  crease  he  suddenly  felt  an  acute  pain  and  dropped  to  the  ground.  He 
was  carried  to  an  hotel  in  a  state  of  collapse,  and  when  the  mischief  had  abated  came  into 
my  hands,  as  I  have  said.  There  was  the  characteristic  thickened  knotty  lump  and 
tenderness  at  one  small  spot  in  the  right  iliac  fossa.  The  appendix,  when  removed, 
showed  a  good  deal  of  thickening  in  its  distal  half,  but,  save  for  the  adhesion  of  one 
single  tag  of  omentum  at  one  spot,  it  struck  me  as  being  strangely  free  from  adhesionst 
considering  the  severity  of  the  two  attacks.  The  patient  made  a  good  recovery,  and  is 
now  growing  and  exporting  that  excellent  dry  sherry,  '  Pando,'  at  Xeres.  I  happened, 
after  the  operation,  to  pass  a  probe  down  the  lumen  of  the  appendix,  when,  to  my  surprise, 
the  blunt  end  passed,  without  the  slightest  force,  through  the  walls  at  a  spot  exactly 
where  the  tag  of  omentum  was  adherent.  Here  the  end  of  the  probe  could  be  seen  just 
covered  by  a  filmy  layer  of  peritonaeum  only.  The  chief  events  of  the  illness  and  the 
very  narrow  escape  of  the  patient  stood  out  very  clearly.  In  the  first  severe  attack,  with 
a  temperature  of  103°  the  appendix  had  suffered  very  severely  ;  no  walling-off  life-saving 
adhesions  had  formed,  save  the  one,  single  and  omental.  As  the  patient  was  bowling  his 
very  best,  the  uplifted  arm  and  rotation  of  the  whole  trunk  upon  one  leg  brought,  by 
means  of  the  latissimus  dorsi,  pectoralis  major,  and  external  oblique — all  continuous  with 
each  other  and  with  the  muscles  of  the  lower  limb  at  Poupart's  ligament — a  violent  strain 
upon  the  abdominal  wall,  and  so  upon  the  omental  tag,  causing  a  stretching  here,  and 
perhaps  a  minute  tear,  and  thus  the  agonising  pain  and  collapse  which  heralded  the  onset 
of  the  second  attack. 

"  There  is  one  other  of  the  points  of  dispute  hetvveen  the  two  schools 
to  which,  as  a  surgeon,  I  must  allude.  By  the  opponents  of  routine 
early  operation  it  has  heen  ohjected  that  such  a  course  would  he  followed 
by  a  large  number  of  ventral  hernias.  There  is,  no  doubt,  truth  in  this, 
for  the  incision  will,  in  many  cases,  have  to  be  free  in  order  to  find  the 
appendix  and  to  enable  the  surgeon  to  get  his  field  of  operation 
thoroughly  isolated  with  gauze  tampons ;  secondly,  drainage  will  often 
be  required,  but  modern  methods  of  operating  in  the  abscess  cases  will 
do  much  to  reduce  the  number  of  post-operative  hernias. 

"  But  a  ventral  hernia  must  weigh  lightly  against  a  saved  life.  To 
put  this  matter  succinctly,  it  will  be  better  for  such  a  patient  to  be  fitted 
with  an  abdominal  belt  than  to  be  measured  for  his  coffin." 

Such  is,  I  think,  a  fair  expression  of  the  two  camps  of  opinion  on 
this  subject. 


294  OPERATIONS    OX    THE   ABDOMEN. 

For  my  own  part,  then,  I  consider  that  any  physician  is  justified  in 
asking  a  surgeon  who  is  skilled  in  abdominal  surgery  and  who  has  the 
necessary  aids,  &c,  to  remove  the  appendix  as  soon  as  the  diagnosis 
is  made.  Again,  I  hold  very  strongly  that  every  physician  is  not 
only  justified  in  asking,  but  bound  to  ask,  a  surgeon  skilled  in  this 
branch  of  surgery  to  interfere  at  the  earliest  possible  moment  in  certain 
cases — viz.,  where  the  evidence  of  appendicitis  is  from  the  first  severe 
and  progressive.  Of  the  evidence,  the  most  valuable  points  are  marked 
pain,  tenderness,  and  vomiting.  Next  in  value  to  these  I  should  place 
the  temperature  and  pulse.  These  may  be  fallacious,*  the  temperature 
often  falling,  due  to  septic  absorption  following  perforation.  Another 
guide  to  which  I  attach  much  importance  is  the  early  look  of  grave 
illness  or  anything  approaching  to  the  pinching  of  the  "  facies  Hippo- 
cratica."  Two  other  points  of  evidence  which  are  of  great  importance, 
but  which,  it  is  to  be  hoped,  the  surgeon  will  be  allowed  to  try  and 
forestall,  are  a  tendency  for  the  abdominal  wall  to  become  fixed  and  a 
tympanites  spreading  from  the  right  iliac  fossa.  Leucocytosis,  and 
especially  a  disproportionate  increase  in  the  polynuclear  cells,  nnvy  be 
of  value  when  taken  with  other  symptoms  (Gibson,  loc.  infra  cit.). 

I  should  like  to  call  attention  to  one  other  point  to  which  I  attach 
great  importance,  and  that  is,  the  position  of  the  most  marked 
tenderness,  resistance,  and  swelling,  if  present.  The  more  internal 
to  McBurney's  point  this  evidence  is  found,  the  greater  the  risk  that 
perforation  will  light  up  a  general  peritonitis  instead  of  one  limited 
to  the  iliac  fossa.  We  have  learnt  much  of  late  years,  from  American 
writers  (e.g.,  Bryant  and  Fowler),  of  the  importance  of  remembering  the 
position  of  the  appendix  (Ann.  of  Surg.,  vol.  i.  1893,  p.  164;  vol.  i. 
1894,  p.  12).  It  is  clear  that  when  the  appendix  is  directed  internally 
not  only  is  the  risk  of  general  suppurative  peritonitis  greater  if  the 
appendix  perforate,  but  if  a  localised  abscess  form  it  is  more  likely 
to  communicate  with  the  pelvis,  and  perhaps  open  into  the  rectum  or 
vagina  ;  if  adhesions  form  about  it  there  is  a  greater  risk  of  much 
more  important  structures  being  involved — viz.,  the  iliac  vessels,  ureter, 
bladder,  &c. — than  if  the  appendix  be  directed  downwards,  when  it 
may  be  only  adherent  to  Poupart's  ligament.  Many  other  instances  of 
the  practical  bearing  of  anatomy  upon  the  different  positions  of  the 
appendix  will  suggest  themselves. 

I  will  now  allude  more  particularly  to  one  sign  which  I  have  only 
mentioned  above,  viz.,  swelling.  Although  some  degree  of  swelling  is 
usually  present  in  the  right  iliac  region,  it  cannot  be  too  strongly 
insisted  upon  that  in  cases  of  "fulminating"  appendicitis  there  may  be 
no  swelling  from  first  to  last.f     In  a  very  few  cases  swelling  is  absent 

*  In  Mr.  G.  Barling's  words  {Brit.  Med.  Jburn.,  vol.  i.  1895,  p.  1135),  "the  tempera- 
ture is  an  uncertain  guide,  and  one  only  to  be  relied  upon  when  confirmed  by  other 
phenomena.  If  it  present  the  paradox  of  a  falling  temperature  with  a  quickening  pulse 
the  improvement  in  the  former  would  be  a  fallacious  guide.  .  .  .  The  great  point  in 
recognising  these  cases  is  not  to  regard  any  one  point  as  essential  to  diagnosis.  It  is 
desirable  to  dwell  not  so  much  on  the  absence  of  one  particular  feature,  as  upon  the 
intensity  of  those  which  are  present.'' 

t  Some  casss  mentioned  by  Dr.  Tyson,  of  Folkestone,  at  one  of  the  discussions  on  this 
subject  at  the  Clinical  Society  {Lancet,  vol.  i.  1892,  p.  424),  form  good  instances  of  the 
truth  of  this.     In  three  cases  in  which,  after  mild  symptoms  had  lasted  for  three  days 


APPENDICITIS. 


295 


from  the  right  iliac  fossa,  but  present  elsewhere  owing  to  the  appendix 
being  misplaced.     Tims,  a  very  few  cases  of  left-sided  appendicitis  b 
been  recorded.      Dr.   Fowler  (Ann.  of  Sun/.,    1894,  vol.   i.   p.   160) 
publishes  a  case  in  which  there  was  marked  tenderness  in  the  direction 

of  the  gall-bladder.  No  appendix  could  be  found  in  the  usual  place, 
as  it  lay  behind  the  liver.  Again,  rectal  examination  may  reveal  a 
pelvic  swelling. 

It  will  be  seen  that  the  above  opinion  of  mine,  that  any  physician  is 
justified  in  asking  a  surgeon  skilled  in  this  branch  of  surgery  to  operate 
in  cases  of  appendicitis  in  the  earliest  stages,  and  that  he  is  bound 
to  do  so  where  certain  evidence  just  given  points  to  probable  rapid 
perforation,  is  not  the  same  thing  as  sanctioning  the  removal  of  the 
appendix  as  a  routine  practice  by  anyone  who  thinks  himself  competent 
to  do  so.  Considering  the  increasing  tendency  at  the  present  day  for 
surgery  to  be  taken  out  of  the  hands  of  properly  qualified  surgeons,  men 
with  a  bond  fide  and  lifelong  hospital  training,  and  for  it  to  pass  into 
the  hands  of  those  who  have  no  such  ripe  experience,  no  such  operative 
training,  and  who  are  occupied  with  other  work  and  other  claims  not 
always  running  on  smooth  lines  with  aseptic  surgery — considering  this 
and  its  effects,  any  such  wholesale  and  routine  removal  of  the  appendix 
would  be  attended  with  disastrous  consequences. 

Since  Mr.  Jacobson  expressed  his  views  more  recent  results  have 
amply  confirmed  them.  The  results  have  improved,  partly  because 
the  surgeon  is  called  earlier  and  partly  because  surgical  methods  have 
improved  with  wider  knowledge  and  experience,  and  especially  because 
early  operation  has  become  more  and  more  popular  with  both  surgeons 
and  physicians. 

At  the  present  time  it  is  practically  certain  that  the  ideal  treatment 
for  all  cases  of  acute  appendicitis  is  an  operation  performed  by  a  capable 
surgeon  within  twenty-four  hours  of  the  onset  of  the  attack,  for  no  one 
can  foretell  the  course  of  the  disease  in  any  individual  case  ;  it  may  be 
towards  recovery  in  the  great  majority  of  patients,  but  in  many  per- 
foration, suppuration,  or  suppurative  peritonitis  will  occur,  and  the 
patient's  life  may  be  sacrificed  by  delay. 

No  one  can  tell  a  patient  that  he  will  do  well,  but  only  that  a  certain 
percentage  of  about  85 — 90  will  recover  with  conservative  treatment. 
Nor  can  anyone  even  guess  with  moderate  accuracy  the  existing  con- 
dition of  the  appendix  in  any  given  case  at  any  time ;  patients  who 
have  been  able  to  walk  to  the  hospital  within  a  few  hours  of  the 
supposed  onset  of  their  disease  have  been  found  upon  immediate 
operation  to  possess  gangrenous  appendices.  Such  an  appendix 
need  not  necessarily  give  any  symptom  until  it  perforates  and  sets  up 
peritonitis. 

If  an  operation  could  be  performed  within  twenty-four  or  thirty-six 
hours  of  the  onset  of  symptoms,  most  of  the  deaths  which  now  occur 
from  abscesses,  suppurative  peritonitis,  and  complications  would  be  pre- 
vented. Troublesome  complications  like  faecal  fistula,  empyema,  pyle- 
phlebitis, thrombosis  of  veins,  pulmonary  embolism,  and  ventral  hernia, 
would  also  be  largely  avoided.     Unfortunately,  a  great  many  patients 

there  was  sudden  collapse  and  death,  there  had  been  sickness  and  tenderness,  but  no 
swelling.  Operation  was  performed  in  one  case  unsuccessfully.  In  all  three  suppurative 
peritonitis  following  perforation  of  the  appendix  was  found. 


296  OPERATIONS  OX  THE  ABDOMEN. 

are  not  seen  by  a  surgeon  or  physician  until  the  most  favourable  time 
for  operation  has  passed.  Too  absolute  reliance  must  not  be  placed 
on  time  as  an  indication  of  the  progress  or  stage  of  the  disease,  for  in 
some  cases  perforation,  gangrene,  or  even  peritonitis  may  be  discovered 
only  a  few  hours  after  the  onset  of  symptoms. 

The  writer's*  conclusions  on  the  important  question  of  operation  for 
appendicitis  are  briefly  as  follows  : — 

(i)  An  operation  by  a  capable  surgeon  should  be  advised  in  all  acute 
cases,  as  soon  as  possible  after  the  diagnosis  is  made,  and,  if  possible, 
within  twenty-four  or  thirty-six  hours  of  the  onset  of  symptoms. 

(2)  In  cases  seen  for  the  first  time  two  or  three  days  after  the  onset 
of  symptoms,  if  the  signs  as  well  as  the  symptoms  are  subsiding,  con- 
servative treatment  may  be  recommended.  A  radical  operation  is 
advised  after  the  first  attack,  for  no  one  can  sa}r  that  another  may  not 
occur;  and  it  is  not  possible  to  foretell  the  nature  of  the  second  or 
subsequent  attack.  One  attack  predisposes  to  another,  and,  as  a  rule, 
the  attacks  increase  in  severity. 

(3)  In  cases  first  seen  later  than  thirty-six  to  forty-eight  hours  from 
the  onset,  if  the  symptoms  and  signs  are  severe  and  not  abating,  and  are 
such  as  to  indicate  the  probability  of  existing  or  impending  suppuration, 
an  operation  should  be  performed  without  delay,  for  these  abscesses  often 
increase  in  size  very  rapidly  and  may  burst  in  any  direction,  frequently 
with  disastrous  consequences.  Early  operation  may  prevent  general 
peritonitis,  faecal  fistula,  pylephlebitis,  pulmonary  complications, 
septicaemia,  &c. 

(4)  An  immediate  operation  is  indicated  when  there  is  even  a  reason- 
able suspicion  of  the  existence  ofjieritonitis.  Recent  results  show  that 
a  very  large  proportion  of  these  very  serious  cases  can  be  saved  by  a 
timely  and  rapidly  performed  operation  by  a  surgeon  experienced  in 
abdominal  surgery  (vide  infra). 

Operative  Interference  in  Acute  Appendicitis  with  Abscess. — 
Directly  suppuration  is  diagnosed  or  reasonably  suspected  at  any  stage 
of  the  disease  an  operation  must  be  undertaken  without  delay. 

A  few  j'ears  ago  there  was  a  tendency  to  wait  until  the  abscess  was 
thought  to  be  safe — i.e.,  till  it  was  walled  in  by  adhesions,  and  gene- 
rally till  it  showed  signs  of  being  adherent  to  the  abdominal  wall — the 
reason  given  being  that,  if  opened  before,  the  risk  was  great  that  the 
peritomeal  sac  would  become  infected.  On  the  other  hand,  it  is  clear 
that  in  waiting  we  run  serious  risks,  for  (a)  the  abscess  may  rupture 
and  burst  into  the  peritonseal  sac,  especially  if  the  patient  is  restless  ; 
{b)  the  pus  will  burrow,  e.g.,  into  the  pelvis,  opening  into  the  rectum 
or  bladder,  downwards  under  Poupart's  ligament  or  backwards  and 
upwards  to  the  loin,  all  these  directions  being  influenced  by  the  position 
in  which  the  appendix  was  lying  before  the  attack. 

Delay  greatly  increases  the  mortality  and  the  risks  of  all  the  com- 
plications of  the  disease.  These  risks  being  increasingly  recognised, 
there  is  a  general  tendency  to  try  and  find  the  pus  early.  The  following 
is  the  best  evidence  as  to  the  early  existence  of  pus  : — Persistence  and 
increase  of  the  symptoms,  both  local  and  general,  after  thirty-six  to  forty- 
eight  hours  ;  marked  local  resistance  and  tenderness  f  ;  a  persistent  and 


R.  P.  R.  f  This  may  be  masked  by  unwisely  given  opium. 


AlPPENDICITIS. 


297 


usually  progressive  swelling*;  impaired  resonance  in  the  flank,  loin,  or 
groin;  bulging  into  the  pelvis,  especially  if  unilateral  or  uneven. 

Leucocytosis,  if  increasing,  is  Bomel  inns  of  value  as  confirmatory  evidence,  bul  it  is  not 
to  be  relied  upon  for  negative  evidence.  In  no  case  with  a  counl  of  35,000  was  pus 
absent,  but  in  many  with  only  15.000  pus  was  found  (  French,  Praet.,  June,  1904). 

A  disproportionate  increase  of  the  polynuclear  cells  is  of  nun.'  value. 

Dr.  Gibson  (.1////.  of  Sun/..  1906,  vol.  i.  p.  483)  concludes  from  a  differential  counl  in 
20  cases  of  acute  appendicitis  that  it  is  of  real  value  "all  the  severer  lesions,  those 
with  gangrene  of  the  appendix  or  progressive  peritonitis,  and  all  the  fata]  cases,  Bhowing 
a  rising  line  on  the  standard  chart." 

It  is  in  these  Bevere  cases  thai  aid  is  needed,  for  the  early  symptoms  may  be  obscure 
and  perplexing.  No  reliance  must  be  placed  on  negative  evidence  obtained  from  this 
source,  if  the  symptoms  and  signs  indicate  the  probability  of  suppuration  or  peritonitis. 

The  diagnosis  of  suppuration  should  of  course  he  made  after  a 
careful  study  of  all  the  available  information,  and  a  conclusion  should 
be  arrived  at  long  before  the  appearance  of  the  time-honoured  symptoms 
of  hectic  fever,  oedema,  fluctuation,  and  redness.  An  attempt  should  be 
always  made  to  determine  the  position  of  the  abscess  and  appendix. 

Dulness  and  tenderness  in  the  loin  and  pain  along  the  outer  side  of 
the  thigh  indicate  a  high  and  generally  a  retrocecal  position. 

Rectal  or  vaginal  examination,  bladder  and  rectum  troubles,  and  the 
absence  of  a  swelling  in  the  iliac  fossa  may  strongly  suggest  that  the 
appendix  is  in  the  pelvis. 

Operation. — The  skin  having  been  shaved  and  cleansed,  an  incision 
three  to  four  inches  long  is  made  parallel  to  the  fibres  of  the  external 
oblique,  and  with  its  centre  over  the  middle  of  any  swelling  or  indura- 
tion that  may  be  discovered  and  located,  perhaps  for  the  first  time,  when 
the  patient  is  under  the  anaesthetic.  As  a  rule  the  centre  of  the  incision 
and  swelling  will  be  a  little  below  the  lower  point  of  trisection  of  the 
line  drawn  from  the  umbilicus  to  the  anterior  superior  spine  of  the 
ilium, f  but  when  the  swelling  and  dulness  are  unusually  high  and  far 
back,  so  must  the  incision  also  be  ;  and  when  there  is  reason  to  believe 
that  the  abscess  or  appendix  is  unusually  low,  the  incision  must  be 
made  as  low  as  possible  without  endangering  the  deep  epigastric 
vessels. 

The  fibres  of  tbe  external  oblique  are  separated  and  well  retracted 
by  means  of  tissue  forceps  or  hooked  retractors  ;  and  the  fibres  of  the 
internal  oblique  and  transversalis  muscles  are  then  separated  by  blunt 
dissection,  as  recommended  by  McBurney  years  ago  (Ann.  of  Surg., 
1894,  vol.  xx.  p.  38).  Should  more  room  be  required,  the  rectus 
sheath  may  be  opened  and  the  muscle  drawn  inwards,  as  suggested 
by  Harrington  (Boston  Med.  and  Surg.  Joiirn.,  August,  1899)  and  Weir 
(Med.  News,  Feb.  17,  1900,  p.  241). 

*  The  swelling  may  be  very  slight  or  difficult  to  detect  from  the  rigidity  of  the  abdo- 
minal walls  and  the  flinching  of  the  patient  unless  an  anaesthetic  be  given. 

t  This  incision  is  very  greatly  to  be  preferred  to  one  in  the  linea  semilunaris,  and 
a  fortiori  to  one  in  the  linea  alba,  because  it  gives  very  much  more  direct  access  to  the 
parts  concerned.  If  one  in  the  linea  semilunaris  be  made  it  will  be  found  that  the  outer 
edge  of  the  wound  often  requires  to  be  strenuously  drawn  aside  to  enable  the  surgeon  to 
get  at  the  appendix.  This  use  of  the  retractor  may  lead  to  bruising  of  the  wound.  Again, 
if  a  surgeon  working  in  the  linea  semilunaris  needs,  as  is  often  the  case,  to  come  low 
down,  the  deep  epigastric  vessels  must  be  divided. 


298  OPERATIONS  ON  THE  ABDOMEN. 

The  muscles  are  thoroughly  retracted,  and  the  tranversalis  fascia  and 
peritonaeum  are  carefully  incised  in  the  same  direction  as  the  skin  wound. 

In  those  cases — and  they  form  a  large  number — where  the  abscess 
is  made  additionally  safe  by  becoming  adherent  to  the  abdominal  wall, 
the  surgeon  will  have  a  hint  given  him  of  the  presence  of  this  condition 
by  the  oozing  and  inflammatory  matting  of  the  deeper  layers  as  he 
divides  them. 

We  will  suppose  a  more  difficult  case  with  no  such  tendency  of  the 
abscess  to  come  forward  through  the  abdominal  wall.  When  the 
peritonaeum  is  carefully  divided  the  structure  which  most  probably 
first  presents  itself  is  the  omentum,  matted  down  into  the  iliac  fossa, 
perhaps  adherent  to  the  ileum,  crecum,  or  the  neighbourhood  of 
Poupart's  ligament.  This  being  separated  off,  or  secured  and  divided 
in  several  pieces,  a  mass  is  found  which  consists  of  small  intestine, 
ceecum,  and  appendix.  Before  this  is  dealt  with  it  must  be  shut  off 
from  the  rest  of  the  peritonseal  cavity  by  tampons  of  sterile  gauze. 
The  operator  then  endeavours  to  find  any  evidence  of  a  longitudinal 
band  which  will  denote  the  caecum  and  may  lead  to  the  appendix  itself. 
This  help  is  rarely  forthcoming,  because  inflammatory  changes  obscure 
localising  structures.  Careful  blunt  dissection  in  the  direction  of 
greatest  oedema  and  matting,  and  towards  the  centre  of  the  swelling,  is 
more  reliable. 

If  the  surgeon  find  one  or  more  coils  of  intestine  he  gently  separates 
one  from  the  other,  or  turns  the  wThole  mass  upwards  carefully  from  the 
fossa,  and,  while  doing  so,  probably  gives  rise  to  an  escape  of  pus. 
Perhaps  the  site  of  this  may  be  recognised  by  a  yellowish  sloughing 
spot.  The  pus  is  carefully  mopped  away  as  fast  as  it  escapes.  If 
large  in  amount  the  patient  must  be  turned  on  to  his  right  side  to 
expedite  the  flow  and  preserve  the  peritoneal  cavity  from  contamination. 

In  a  patient  sent  to  me  by  Dr.  Dakin,  after  tying  off  a  sheet  of  omentum,  a  large  mass 
appeared  in  which  I  could  not  differentiate  large  or  small  intestine.  No  appendix  could 
be  seen  or  felt.  On  gently  turning  up  the  whole  mass  a  sloughing  spot  was  seen  below, 
from  which  a  blunt-pointed  director  gave  vent  to  two  drachms  of  pus.  Pressure  on  the 
mass  was  now  made,  but  no  more  pus  escaped,  and  as  no  stercolith  could  be  detected,  a 
gauze  drain  being  inserted  down  to  the  spot,  I  closed  the  rest  of  the  wound  by  three  layers 
of  buried  sutures  (ride  infra).  A  good  recovery  followed,  and  the  patient  has  been  able 
again  to  take  briefs  at  assizes. 

"When  the  pus  has  been  let  out,  the  surgeon  has  to  decide  the  impor- 
tant question  whether  the  appendix  should  be  removed  or  not.  The 
majority  of  surgeons  consider  that  this  should  be  done  only  when  the 
condition  of  the  patient  is  good,  and  the  abscess  is  of  small  size,  and 
the  appendix  can  be  found  without  much  delay.  (A.)  Thorough 
drainage  only  is  suitable  for  very  large  and  late  abscesses,  for  in  them 
the  appendix  is  so  greatly  disorganised  in  most  cases,  that  recurrence 
is  unlikely. 

Sir  Frederick  Treves  (Lancet,  vol.  i.  1905,  p.  569)  in  his  introduction 
of  the  interesting  discussion  which  took  place  before  the  Medico- 
Chirurgical  Society  in  1905  stated  that  recurrence  of  symptoms 
occurred  in  less  than  17  per  cent,  of  the  cases  in  which  the  abscess 
was  merely  drained.  Mr.  Pearce  Gould  gave  a  lower  estimate  of 
10  per  cent. 


AIM'KMUCITIS.  299 

Moreover,  the  condition  of  patients  with  large  abscesses  is  often 
too  serious  to  allow  a  prolonged  and  perhaps  fruitless  search,  during 
which  thin  Limiting  adhesions  may  be  unknowingly  torn  deep  in  the 
wound,  setting  up  general  peritonitis.  The  sodden  and  inflamed 
intestines  may  also  be  damaged,  and  a  faecal  fistula  produced,  by  a  too 
zealous  pursuit  oi'  the  appendix  in  some  of  these  cases.  Treves,* 
Pearce  Gould,  Bennett,  Murphy,!  and  other  recent  authorities  agree 
that  it  is  not  wise  to  attempt  to  remove  the  appendix  in  all  cases. 
If,  owing  to  the  persistence  of  a  sinus  or  to  later  attacks  of  inflamma- 
tion, its  subsequent  removal  should  become  necessary,  this  can  be  done 
under  much  more  favourable  conditions.  Some  surgeons,  on  the  other 
hand,  make  a  great  point  of  removing  the  appendix  in  every  case. 
Dr.  O'Conor,  of  Buenos  Ay  res,  for  instance,  says  (Glasgow  Med.  Journ., 
September,  1899) :  "  I  made  it  a  rule,  some  years  ago,  never  to  quit  the 
abdomen,  when  operating  for  appendicitis,  without  taking  the  appendix 
with  me."  Mr.  Lockwood  also  (Appendicitis,  1901)  considers  "that 
it  is  better  for  the  patient  to  take  the  immediate  risk  of  a  determined 
attempt  to  excise  the  appendix,  but  how  far  the  attempt  should  be 
carried  must  depend  upon  the  peculiarities  of  each  case " ;  and  he 
quotes  several  cases  where  subsequent  trouble  arose  from  leaving  an 
infected  appendix. 

Although  recurrence  and  other  troubles  do  undoubtedly  sometimes 
arise  when  the  appendix  is  left,  the  proportion  of  cases  in  which  they 
occur  is  certainly  comparatively  small — Mr.  Lockwood  puts  it  at  15  per 
cent. — and  therefore  hardly  justifies  the  greatly  increased  risk  of  the 
primary  operation  if  the  appendix  is  removed  in  every  case.  The 
appendix,  therefore,  should  be  removed,  if  this  is  possible  without 
greatly  increasing  the  risk  of  the  operation  ;  but  where  it  forms  part  of 
the  abscess  wall,  or  where  it  cannot  be  found  after  a  reasonable  search, 
the  wiser  and  safer  plan  will  be  to  leave  it.  When  found  free  in  the 
abscess  cavity,  a  transfixion  of  the  base  of  the  mesentery  with  an 
aneurysm-needle  carrying  a  loop  of  silk,  one-half  of  which  is  thrown 
round  the  appendix  and  the  other  round  the  mesentery,  the  ends  cut 
short,  and  the  appendix  and  its  mesentery  amputated  just  beyond  the 
ligature,  will  probably  be  found  sufficient.  Any  projection  of  the 
mucous  coat  should  be  disinfected.  Whether  it  be  removed  or  no, 
if  a  perforation  be  present,  search  should  be  made  for  a  possible 
stercolith,  as  a  fistula  may  follow  for  some  time  if  one  of  these  be  left 
behind.  Free  drainage  must  be  adopted,  and  the  wound  should  be 
only  partly  closed. 

(B.)  When  the  amount  of  pus  is  small  and  the  condition  of  the  patient 
is  good,  the  pus  may  be  carefully  mopped  away,  and  the  appendix 
sought.  The  wound  being  well  opened  out  and  the  adjacent  peritoneal 
contents  shut  off  with  tampons  of  iodoform  gauze,  the  appendix  is 
separated,  if  possible,  from  any  adhesions  present,  and  dealt  with 
according  to  one  of  the  following  methods.  If  gangrenous,  it  should  be 
cut  away  as  near  to  the  caecum  as  is  safe,  and  if  its  coats  here  will 
not  bear  ligature  and  sutures,  the  stump  must  be  disinfected  with  pure 
carbolic  or  nitric  acid,  and  a  cigarette  drain  should  be  inserted  near  it. 

*   Med.- Chi  r.  Trans.,  1905. 

t  Amer.  Journ.  Med.  Sri.,  August,  1904. 


300  OPERATIONS  OX  THE  ABDOMEN. 

Little  fear  need  be  entertained  that  a  faecal  fistula  may  result  from 
failure  to  ligature  or  invert  the  stump  in  suppurative  cases,  although  a 
slight  leak  may  occur  in  some  cases  for  a  day  or  two,  but  it  is  probable 
that  the  temporary  fistula  is  from  the  extension  of  necrosis  to  a 
contiguous  coil  of  the  ileum.* 

When  the  appendix  is  inflamed  and  soft,  but  not  actually  gan- 
grenous, it  will  be  quite  sufficient  to  trust  to  ligature  with  medium- 
sized  sterilised  silk  close  to  the  caecum.  If  the  state  of  the  patient  or 
the  softened  condition  of  the  appendix  prevent  anything  more  being 
done,  these  measures  will  be  found  quite  sufficient,  if  pure  carbolic 
acid  be  applied  to  the  mucous  membrane  on  the  stump  so  as  to 
disinfect  this.  If  the  appendix,  where  cut  through,  be  healthy 
or  only  thickened,  one  or  other  of  the  following  methods  may  be 
adopted. 

Mr.  Barker  (Brit.  Med.  Journ.,  vol.  i.  1895,  p.  863)  recommends  the 
following  method  of  double  ligature  as  being  simple  and  rapid.  It  is 
based  on  the  fact  that  when  the  appendix  is  much  thickened  the 
mucous  and  sub-mucous  coats  can,  after  circular  division  of  the  other 
coats,  be  drawn  out  in  an  unbroken  tube.  The  mesentery  having 
been  first  transfixed,  tied,  and  severed  near  the  caecum,  the  serous  and 
muscular  coats  are  divided  circularly  about  three-quarters  of  an  inch 
from  the  caecum.  The  mucous  and  sub-mucous  tube  is  now  drawn 
out,  and  the  outer  coats  having  been  stripped  back,  as  in  a  circular 
amputation,  towards  the  caecum,  the  above-mentioned  tube  is  tied 
close  to  its  juncture  with  the  caecum  with  fine  silk  and  cut  off.  It  at 
once  retracts.  The  outer  tube  is  drawn  down  over  it  and  tied  with  fine 
silk  or  gut.  Another  plan,  which  is  equally  rapid  and  satisfactory,  is 
to  ligature  and  remove  the  appendix  close  to  the  caecum,  then  to  invert 
the  stump  of  the  appendix  into  the  caecum  by  means  of  a  circular 
purse-string  suture,  situated  about  a  quarter  of  an  inch  from  the 
stump,  all  round.  This,  when  drawn  tight  and  tied,  inverts  the 
stum])  of  the  appendix.  However  the  appendix  is  removed,  when  it  is 
severed,  any  escaping  contents  must  be  received  on  gauze,  ixc.  The 
meso-appendix  must  always  be  looked  to,  its  artery  properly  secured, 
and  if  its  stump  can  be  drawn  over  that  of  the  appendix,  this  will 
suffice  in  place  of  any  more  elaborate  methods.  Where  the  surgeon  is 
in  doubt  about  dispensing  with  drainage  and  closing  his  wound 
entirely,  the  extent  and  severity  of  any  infective  process,  and  the 
completeness  with  which  he  has  been  able  to  disinfect  the  deeper  parts 
of  the  wound,  must  aid  in  the  decision.  The  safest  course  in  doubtful 
cases  will  be  to  leave  the  wound  partly  open,  leaving  enough  room  for 
a  cigarette  drain  between  the  catgut  sutures,  which  are  used  to 
approximate  the  muscles.  Provisional  sutures  of  fishing  gut  are 
inserted  at  the  site  of  drainage,  which  can  be  tied  on  removing  the  tube 
and  gauze  packing  after  thirty-six  hours  or  more.  The  risk  of  ventral 
hernia  is  now  reduced  to  a  minimum  by  the  adoption  of  this  and 
other  valvular  incisions  in  cases  of  localised  abscess  as  well  as  in  the 


*  Corner  (Clinical  and  Pathological  Observations  on  Acute  Abdominal  Diseases, 
1904)  examined  seven  cases  of  faecal  fistula  arising  after  operations  for  acute  appendicitis  ; 
in  five  the  leak  was  in  the  ileum,  and  in  two  thecascum  had  perforated  ;  but  not  one  fistula 
had  arisen  as  a  result  of  imperfect  closure  of  the  appendix  stump. 


APPENDICITIS.  301 

"  interval "  cases.  When  the  tuhe  is  removed  the  natural  tension  of 
the  separated  muscles  serves  to  close  the  deep  part  of  the  wound. 

Should  the  gridiron  incision  not  give  enough  room  even  when  the 
exposed  rectus  is  well  retracted  inwards,  then  in  rare  eases  of  retro- 
cecal or  pelvic  abscess  the  fibres  of  the  deep  muscles  may  have  to  be 
cut  across  either  upwards  or  downwards,  and  afterwards  most  carefully 
sutured.  In  most  cases,  the  surgeon  will  avoid  this  necessity  by 
taking  care  to  place  his  incision  to  suit  each  individual  case,  and  by 
not  following  too  slavishly  any  classical  operation. 

In  some  cases,  the  healthy  peritoneum  may  be  opened  in  this 
operation,  and  an  abscess  then  discovered  to  be  retro-caecal  and 
bulging  on  the  posterior  wall.  I  then  prefer  to  make  another  incision 
further  back  towards  the  loin,  and  to  drain  the  abscess  in  this  situation, 
without  risk  of  contamination  of  the  general  peritonaeum,  By  careful 
packing,  however,  the  surgeon  may  be  able  to  evacuate  a  small 
abscess  through  the  anterior  incision  without  much  risk. 

In  very  rare  cases  it  may  be  safe  to  open  a  pelvic  appendicular 
abscess  through  the  vagina  or  rectum  when  the  mucous  membrane  is 
felt  to  be  oedematons  and  bulging.  It  is,  however,  far  safer  to  make  an 
abdominal  incision  for  exploratoiy  purposes  in  all  cases,  whether  it  is 
decided  afterwards  to  drain  the  abscess  through  the  pelvis  or  not. 
Mr.  Barnard  mentions  10  successful  cases  in  which  this  treatment  was 
adopted  (Lancet,  vol.  i.  1904,  p.  510). 

I  believe  that  the  gridiron  incision  is  especially  valuable  in  abscess 
cases,  in  which  ventral  hernia  is  otherwise  very  apt  to  develop.  When 
the  muscle  fibres  are  cut  across  in  these  cases,  and  drainage  is 
needed,  a  ventral  hernia  is  the  natural  result,  and  there  is  a  con- 
siderable risk  of  this  even  after  the  adoption  of  separation  of  the 
fibres  of  the  rectus  muscle,  for  the  wound  is  a  direct  one  as  a  rule. 
There  is  little  doubt  that  the  liability  to  cellulitis  of  the  abdominal 
wall  is  increased  by  adopting  either  the  gridiron  incision  or  the 
operation  through  the  rectus  sheath ;  but  this  risk  has  been 
exaggerated. 

Operative  Interference  in  Suppurative  Peritonitis. — The 

perforation  here  is  due  either  to  the  acuteness  of  an  infective  process, 
to  the  pressure  of  a  stercolith,  to  both  combined,  or  to  the  rupture  of  a 
collection  of  pus.  It  is  important  to  bear  in  mind  these,  the  chief 
causes,  as  the  evidence,  both  before  and  later,  may  vary  somewhat. 
Thus,  suppurative  peritonitis  may  come  on  without  the  preliminary 
warning  of  a  swelling  (p.  296),  as  when  the  peritonitis  is  not  preceded 
by  an  abscess.  Again,  when  the  rupture  of  an  abscess  is  the  cause  of 
the  peritonitis  the  characteristic  symptoms  of  collapse  will  be  more 
marked. 

The  warning*  symptoms  will  be  chiefly  those  given  at  p.  296 — viz.,  a 
case  often  severe  at  first,  and  progressively  so,  severe  pain,  marked 
general  abdominal  tenderness,  rigidity,  perhaps  a  swelling,  tympanites 

*  Dr.  D.  B.  Lees's  cases  (67/ «.  Sue.  Trans.,  vol.  xx.  p.  135)  show  that  a  perforation 
communicating  with  the  peritonreal  sac,  as  long  as  this  is  shut  off,  does  not  give  rise  to 
collapse,  and  that  the  pain,  tenderness,  Sec.,  may  be  so  comparative]}-  slight  as  to  make  it 
appear  that  operative  interference  is  hardly  justifiable.  Yet  under  these  circumstances 
the  delay  of  a  few  hours  may  be  fatal. 


302 


OPERATIONS  ON  THE  ABDOMEN. 


spreading  from  the  iliac  fossa,  early  immobility  of  the  diaphragm  and 
abdomen,  obstinate  vomiting,  early  and  persistently  rapid  pulse,  and  a 
temperature*  rising  after  a  preliminary  drop.  Later  on  marked  dis- 
tension, absence  of  any  peristaltic  movement,  constant  vomiting  of  the 
effortless  regurgitation  type,  a  pulse  increasing  in  quickness  and  failing 
in  strength,  the  drawn-up  knees,  and  the  facies  Hippocratica — all  these 
are  time-honoured  evidence  which  will  show  that  while  surgical  inter- 
ference may  be  right,  it  will  probably  be  futile  in  most  of  these  late 
cases. 

The  results  of  operations  for  this  grave  condition  depend  very  much 
upon  four  things  : — (a)  The  nature  of  the  bacterial  infection,  strepto- 
coccal cases   and   those  due  to  the   bacillus   pyocyanus  being  almost 


Fig.  85. 


Umi>ilicu3 


AS.  Spine 


The  incision  through  the  rectus  muscle,  the  fibres  having  been  separated 
from  below  upwards. 

hopeless  whatever  is  done,  but  fortunately  these  cases  form  but  a  small 
minority  (Dudgeon  and  Sargent,  Lancet,  vol.  i.  1905,  p.  792) :  those 
due  to  the  bacillus  coli  communis  alone  are  much  more  hopeful ; 
(b)  early  operation,  before  the  peritonaeum  is  irretrievably  damaged, 
and  the  patient  hopelessly  poisoned  ;  (c)  the  speed  and  judgment  with 
which  the  operation  is  conducted ;  and  (d)  perseverance  in  the  after- 
treatment. 

It  is  very  important  therefore  to  operate  without  delay,  and  also  to 
have  everything  that  may  be  needed  during  the  operation  quite  ready 
before  the  anaesthetic  is  given.     In  some  cases  it  is  necessary  to  infuse, 


*  Too  much  attention  is  not  to  be  paid  to  these.  In  Dr.  Fowler's  words  (Ann.  of 
Surg.,  vol.  i.  1894,  p.  153),  "  a  lowering  temperature  and  a  lessening  pulse-rate  are  not 
inconsistent  with  impending  ulceration,  perforation  of  the  appendix  into  an  unprotected 
peritonaeal  cavity,  complete  gangrene  of  the  organ,  or  rupture  of  an  appendicular  abscess 
into  the  cavity  of  the  peritonaeum." 


AITKNMCITIS. 


3°3 


and  bandage  the  limits  firmly  over  cotton  wool,  before  an  operation  can 
be  undertaken.  Meanwhile  everything  should  be  got  ready  for  the 
operation.     As  soon   as   the  patient  is  ansBSthetised  with  A.C.E.  or 

ether,  and  the  abdomen  has  been  rapidly  cleansed,  a  vertical  incision 
about  lour  inches  long  is  made  over  the  lower  part  of  the  right  rectus 
muscle,  and  towards  its  outer  border,  beginning  on  a  level  with  the 
navel.  The  muscular  fibres  are  either  drawn  inwards,  as  originally 
recommended  by  Battle  (Brit.  Med.  Journ.,  1895,  vol.  ii.  p.  1360),  or 
separated,  as  advocated  by  Lennander  (Centralblatt  fur  Chirurg.,  1898, 
vol.  xxv.  p.  90).  To  avoid  haemorrhage  it  is  best  to  separate  the  fibres 
from  below  upwards.  After  any  bleeding  has  been  stopped,  the 
posterior  wall  of  the  rectus  sheath  and  peritonaeum  are  opened  in  a 
vertical  direction,  care  being  taken  to  avoid  injuring  the  distended 
intestines.  Pus  generally  escapes  at  once,  and  should  be  mopped 
away.  The  wound  is  held  open  with  large  retractors,  but  the  intestines 
should  not  be  allowed  to  prolapse,  for  much  delay  will  ensue  if  this 
happen,  owing  to  the  difficulty  of  replacing  them,  and  shock  will  also 
be  greatly  increased  by  the  manipulations  and  exposure.  The  pus  is 
rapidly  but  gently  mopped  up  with  rolls  of  aseptic  gauze  until  a  clear 
view  can  be  obtained,  and  the  caecum  and  appendix  are  then  sought, 
and  if  diseased,*  the  latter  is  removed  as  quickly  as  possible,  no  time 
being  wasted  in  needless  details  of  treatment  of  the  stump.  It  is  quite 
enough  to  apply  two  ligatures,  one  in  the  meso-appendix  and  the 
other  round  the  stump  of  the  appendix  close  to  the  caecum.  If  the 
appendix  is  gangrenous  at  its  base  and  will  not  hold  a  ligature,  it  can 
be  cut  off  flush  with  the  caecum,  and  the  orifice  inverted  if  possible  by 
means  of  a  purse-string  suture.  Neither  a  ligature  nor  inversion  is 
imperative,  but  a  "cigarette"  drain  must  be  inserted  close  to  the 
stump. 

If  there  is  any  difficulty  in  finding  the  appendix,  it  is  best  to  look  for 
its  root,  about  an  inch  below  and  behind  and  a  little  to  the  right  of  the 
termination  of  the  ileum.  If  it  cannot  be  brought  into  the  wound, 
a  small  counter-incision  may  be  made  directly  over  it ;  or  the  appendix 
may  be  left,  for  it  must  not  be  forgotten  that  it  is  not  absolutely 
necessary  to  remove  the  appendix,  but  only  to  cleanse  the  peritonaeum 
and  drain  it.  The  peritonaeum  should  be  mopped  as  dry  as  possible, 
especially  the  pelvic  part  of  it ;  but  care  must  be  taken  not  to  rub  away 
protecting  lymph  and  expose  raw  and  absorptive  surfaces.  There  are 
still  differences  of  opinion  concerning  the  wisdom  or  folly  of  irrigation 
in  these  cases.  It  is  not  possible  to  thoroughly  cleanse  the  peritonaeum 
by  this  means  alone,  and  it  may  carry  the  infection  further  afield, 
between  the  liver  and  the  diaphragm  for  instance  ;  and  it  takes  time  to 
cany  out  properly.  I  have  given  up  using  it  in  appendicular  cases, 
believing  that  it  does  more  harm  than  good,  and  that  swabbing  is  far 
superior  to  it.  Clark  and  Norris  (quoted  by  Hotchkiss),  however,  state 
that  irrigation  does  not  increase,  but  decreases,  the  danger  of  pyogenic 
infections. 

Murphy    (Amer.    Journ.    of    Med.  Sci.,    August,    1904),    from    an 

*  If  the  appendix  is  healthy,  it  is  probable  that  a  perforated  duodenal  or  pyloric  ulcer 
has  given  rise  to  the  symptoms,  or  more  rarely  perforation  of  a  pyo-salpinx.  The  wound 
must  then  be  enlarged  upwards  or  downwards. 


304  OPERATIONS   ON    THE   ABDOMEN. 

experience  of  over  2,000  cases,  strongly  condemns  irrigation  ;  and  his 
results  prove  the  efficiency  of  his  treatment.  He  states  that  in  two 
and  a  half  years'  experience  he  only  had  one  death  from  general 
suppurative  peritonitis.  Later  Le  Conte  {Ann.  of  Surg.,  vol.  i.  1906, 
p.  231)  states  that  Murphy  only  lost  one  of  his  last  29  cases  of 
suppurative  peritonitis. 

Sargent  (Dudgeon  and  Sargent,  Lancet,  vol.  i.  1905,  p.  792)  states 
that  in  25  cases  he  used  free  irrigation,  with  more  or  less  evisceration 
in  19,  and  18  of  these  patients  died.  In  his  last  six  cases  he  only  used 
local  swabbing,  and  all  of  the  patients  recovered. 

At  St.  Thomas's  Hospital  between  1899  and  1903  there  were  119 
cases  of  general  suppurative  peritonitis  arising  from  appendicitis.  In 
100  of  these  free  irrigation  was  used,  and  80  of  the  patients  died; 
the  remaining  19  were  treated  by  local  sponging  or  washing,  and  nine 
recovered,  a  mortality  of  47  per  cent. 

It  must  not  be  forgotten,  however,  that  figures  are  not  to  be  relied  upon 
too  absolutely;  and  the  undoubted  and  general  improvement,  which  has 
been  noticed  recently,  in  the  results  of  operations  for  general  suppura- 
tive peritonitis,  is  partly  due  to  the  fact  that  the  surgeon  gets  his 
opportunity  earlier,  and  also  that  every  surgeon  realises  more  and  more 
the  great  importance  of  speedy  work  in  these  cases. 

Blake  {Ann.  of  Surg.,  August,  1903)  prefers  irrigation  to  sponging 
because  it  can  be  carried  out  through  a  comparatively  small  wound, 
and  the  damage  done  is  less,  and  the  toxins  more  diluted  and 
removed. 

Dr.  Hotchkiss,  writing  quite  recently  {Ann.  of  Surg.,  vol.  ii.  1906, 
p.  197),  still  advocates  irrigation  of  the  appendicular  and  pelvic 
regions,  and  he  states  that  his  mortality  was  only  11  per  cent,  in 
the  43  cases  of  diffuse  peritonitis  which  were  operated  upon  by  him 
since  1899.  These  results  are  certainly  very  good,  especially  as 
Dr.  Hotchkiss  states  that  he  took  care  to  determine  the  extent  of 
the  peritonitis.  A  protest  may  be  made  here  against  the  too  common 
practice  of  publishing  cases  of  localised  and  large  collections  of  pus 
as  instances  of  general  peritonitis.  Before  1899  Dr.  Hotchkiss  used 
irrigation  and  evisceration,  and  between  1895  and  1899  he  treated 
12  cases  of  diffuse  peritonitis,  with  11  deaths.  Hotchkiss  now  finds 
the  appendix,  through  a  gridiron  incision,  often  more  by  touch  than 
by  sight,  and,  like  Blake,  frequently  does  not  drain  the  peritonaeum, 
but  only  the  abdominal  wound.  I  certainly  do  not  recommend  closing 
the  peritonaeum  in  any  case  of  general  suppurative  peritonitis,  however 
well  the  cavity  may  have  been  cleansed.  One  of  the  chief  objects  of  the 
operation  is  defeated  if  this  plan  is  adopted.  Drainage  is  essential. 
Evisceration  and  cleansing  the  individual  coils  of  intestine  has  been 
tried  and  found  to  be  accompanied  with  much  shock,  delay,  and  a  high 
mortality.  Moreover,  it  is  a  bad  thing  to  remove  the  protective  patches 
of  lymph  that  nature  has  provided,  "the  shingles  of  protection,"  as 
Murphy  calls  them.  The  pus  or  sero-pus  having  been  quickly  mopped 
away  as  far  as  possible,  especial  attention  being  paid  to  the  pelvis  and 
kidney  pouches,  perforated  large-sized  rubber  tubes,  with  gauze  wicks 
inside  them  and  a  thin  layer  of  gauze  outside,  are  passed  one  towards 
the  appendix,  one  into  the  pelvis,  and  one  to  the  right  kidney  pouch 
just  below  the  liver,  and  another  into  the  left  iliac  fossa  in  some  cases. 


AITKNhMTNS. 


305 


The  appendicular  region  and  the  right  kidney  pouch  can  be  must 
efficiently  drained  by  bringing  the  end  of  the  tube  out  through  a  Btab 
wound  in  the  loin.  In  women  the  pelvis  may  be  drained  through  a 
perforation  of  the  posterior  vaginal  wall  into  the  pouch  of  Douglas. 
The  wound  is  partly  closed  by  means  of  stout  fishing  gut  passed 
through  the  whole  thickness  of  the  abdominal  wall  by  means  of  large 
curved  needles,  or  a  similar  needle  on  a  handle;  and  the  drainage 
tubes  are  tixed  in  position  by  means  of  large  aseptic  safety  pins.  In 
some  very  late  and  grave  cases,  no  attempt  should  be  made  either  to 
remove  the  appendix  or  to  close  the  wound,  but  only  to  let  the  pus 
out  and  establish  drainage.  In  some  cases  with  obvious  distension 
and  probable  paralysis  of  the  small  intestines,  it  is  wise  to  let  out 
their  poisonous  contents  either  at  once  or  after  a  day  or  two  under 
cocaine  anaesthesia.  This  can  be  done  by  bringing  out  a  coil  of  the 
ileum  or  the  caecum*  and  packing  some  gauze  around  it,  and  then 
inserting  a  trocar  and  cannula  or  a  temporary  enterostomy  tube  of 
small  calibre  opposite  to  the  mesenteric  border  and  in  the  centre  of 
a  circle  formed  by  a  pursestring  suture,  which  can  be  used  either  to 
close  the  hole  in  withdrawing  the  cannula  or  to  fix  the  enterostomy 
tube  in  situ.  A  solution  of  magnesium  sulphate  may  be  injected  into 
the  bowel  through  the  cannula  or  enterostomy  tube.  Many  of  these 
patients  die  from  paralytic  distension  of  the  bowels,  from  which  a 
timely  and  temporary  enterostomy  might  save  some  of  them. 

In  niie  of  my  most  desperate  cases,  a  longitudinal  incision  was  made  into  a  coil  of  small 
intestine,  and  the  putrid  contents,  which  were  under  great  tension,  squirted  across  the 
room.  When  a  large  quantity  had  been  evacuated,  the  incision  was  rapidly  closed  by 
inversion.  Next  day,  however,  the  distension  again  became  great,  hampering  the  respira- 
tion, so  that  an  opening  had  to  be  made  again  into  the  coil  which  had  been  left  in  the 
wound,  surrounded  by  gauze  packing.  The  relief  was  immediate,  and  for  some  days  a  thin 
evil-smelling  mucous  and  sanious  discharge  escaped  from  the  puncture,  but  after  four  days 
the  bowels  began  to  act  naturally,  and  the  artificial  anus  which  had  been  so  valuable  was 
closed  by  inversion,  and  the  patient  made  a  rapid  recovery,  although  he  developed  diphtheria 
early  in  his  convalescence. 

After-treatment. — To  prevent  or  lessen  shock,  the  operation  should 
be  quickly  performed  under  ether  or  A.C.E.  and  not  chloroform; 
and  the  patient  should  be  kept  warm  during  and  after  the  operation. 
Care  is  taken  also  not  to  allow  too  much  exposure  of  the  intestines. 
During  or  soon  after  the  operation  infusion  may  become  necessary  ; 
continuous  or  repeated  infusions  into  the  subcutaneous  tissues  or 
into  a  vein  are  very  much  more  valuable  and  safer  than  large  and 
hurried  injections  into  a  vein.  These  should  be  resorted  to  when  the 
pulse  becomes  rapid  or  small,  or  when  the  sphygmometer  indicates  a  fall 
of  the  blood  pressure  (Lockhart  Mummery,  Hunterian  Lectures,  Lancet, 
vol.  i.  1905,  pp.  696,  777,  846). 

The  best  solution  to  use  is  physiological  normal  saline,  and  tabloids 
containing  the  proper  proportion  of  the  salts  of  the  serum  can  now  be 
bought.     Failing  this,  'g  per  cent,  solution  of  sodium  chloride  may  be 

*  Greenough  (Boston  Med.  and  Surg.  Jour/i.,  May  19,  1904)  prefers  to  make  an 
opening  in  the  caecum  if  the  latter  be  distended,  because  the  fistula  is  more  likely  to  close 
spontaneously.  He  gives  a  short  account  of  41  cases  in  which  drainage  of  the  intestine 
was  tried. 

S. — VOL.  II.  20 


3o6         OPERATIONS  OX  THE  ABDOMEN. 

used,  and  to  it  may  be  added  adrenalin  in  the  proportion  of  I  to  20,000,  as 
recommended  by  Mummery.  A  6  per  cent,  solution  of  dextrose  is  safer 
for  intravenous  injection ;  two  pints  may  be  given  in  a  little  over 
twenty  minutes  (Dr.  Beddard,  Guy's  Hasp.  Gazette,  1905,  vol.  xix. 
p.  308).  The  temperature  of  the  solution  should  be  about  103 — 
105°  F.  to  allow  of  some  loss  of  heat  in  transmission  to  the  body. 

Murphy  [loc.  supra  cit.)  administers  saline  solution  by  the  rectum. 
A  nozzle  with  several  perforations  in  it  is  introduced  into  the  anus,  and 
connected  by  means  of  a  rubber  tube  with  a  rubber  bag,  which  is  fixed 
only  a  i'ew  inches  above  the  level  of  the  rectum.  The  fluid  trickles  in 
about  as  fast  as  it  is  absorbed,  and  about  twelve  pints  may  be  absorbed 
in  this  way  in  twenty-four  hours  if  desired.  The  tube  may  be  discon- 
nected from  the  nozzle  when  required,  but  the  nozzle  should  be  left 
in  position  to  avoid  disturbance  and  pain  in  its  reintroduction. 

It  is  an  advantage  for  the  nozzle  to  have  several  apertures,  so  that 
flatus  may  pass  without  arresting  the  flow  of  fluid. 

In  my  experience  it  has  not  been  easy  to  administer  fluid  in  this  way 
when  the  patient  is  kept  in  the  semi-sitting  or  Fowler  position. 
Moreover,  in  the  very  worst  cases  absorption  by  the  rectum  is  poor,  so 
that  continuous  subcutaneous  or  venous  infusion  is  more  practicable 

Strychnine  is  strongly  condemned  by  Crile  from  his  experiments  on 
animals,  during  which  he  discovered  that  the  surest  and  quickest  way 
to  produce  shock  was  by  the  injection  of  strychnine,  although  it  did  not 
necessarily  cause  twitching. 

Mummery  (loc.  supra  cit.)  from  his  clinical  experience  with  the  aid 
of  the  sphygmometer  came  to  the  same  conclusion.  To  administer 
strychnine  or  stimulants  in  cases  of  shock  is  like  "  beating  a  dying 
horse":  it  may  induce  a  desperate  effort,  but  it  hastens  the  end. 
Subcutaneous  injection  of  aseptic  ergot  in  half-gramme  doses  is 
recommended  by  Mummery,  and  its  effects  last  longer  than  those 
of   adrenalin. 

As  soon  as  the  temporary  depression  that  follows  the  operation  is 
over,  the  patient  should  be  placed  in  the  semi-sitting  posture  so 
strongly  recommended  by  Fowler*  and  adopted  by  nearly  all 
American  surgeons.  Murphy,  Le  Conte,  and  Hotchkiss  speak 
very  highly  of  this  plan  ;  and  I  have  used  it  in  a  few  cases  with 
marked  benefit.  It  is  not  easy,  however,  to  keep  the  patient  in  this 
attitude,  and  a  special  but  simple  bed  rest  is  necessary  to  enable  the 
nurses  to  keep  him  up  properly.  The  advantages  of  this  attitude 
are  undoubtedly  very  great.  The  weight  and  pressure  are  taken 
off  the  lungs,  so  that  respiration  becomes  easier  and  pulmonary 
complications  less  likely.  Percolation  of  the  peritonseal  fluid  towards 
the  pelvis  is  encouraged  so  as  to  facilitate  drainage  and  also  to  divert 
the  poisonous  fluid  to  a  far  less  absorptive  part  of  the  peritonaeum,  for 


*  B.  S.  Fowler  (Med.  News,  May  28.  1904)  states  that  "  from  October  17,  1899,  to 
January  17,  1904.  Dr.  George  R.  Fowler  and  myself  have  operated  upon  100  well-marked 
cases  of  diffuse  septic  peritonitis  resulting  from  inflammation  of  the  vermiform  appendix. 
We  have  not  refused  operatiou  to  any  case,  however  desperate.  Of  these  cases  67  percent, 
have  resulted  in  recovery."  Before  the  adoption  of  elevation  of  the  head  and  shoulders  in 
the  after-treatment  only  25  per  cent,  of  the  cases  recovered.  Dr.  Fowler  irrigates  the 
peritoDffiurn  very  freely  during  the  operation. 


APPENDICITIS. 


307 


it  is  well  known  Unit  the  diaphragmatic  peritoneum  is  very  absorptive, 
whereas  the  pelvic  lining  absorbs  bul  little.  When  there  is  much 
adhesion  of  the  coils,  gravity  is  not  able  to  attract  the  fluid  to  the  pelvis 
to  any  great  extent,  but  it  may  at  least  prevent  fluid  from  ascending 
towards  the  diaphragm. 

Murphy  attempts  to  prevent  peristalsis  by  giving  nothing  by  the 
month  for  twenty-lour  to  forty-eight  hours,  and  by  administering  opium. 
Any  food  that  may  be  necessary  is  given  by  the  rectum. 

Hotchkiss  washes  the  stomach  out  before  the  patient  leaves  the 
table  and  introduces  5j.  to  5ij.  of  saturated  solution  of  Epsom  salts 
into  the  stomach,  giving  no  morphia,  as  he  believes  with  most  surgeons 
that  purgatives,  and  not  opium,  are  indicated  in  these  cases. 

Nux  vomica  and  belladonna  are  valuable  as  excellent  stimulants  of 
the  muscular  wall  of  the  intestine,  but  no  cathartic  will  act  in  late  cases 
with  paralytic  distension.     Enterostomy  is  indicated  in  them. 

I  should  certainly  not  give  any  opium  or  morphia  in  any  case  where 
I  had  reason  to  suspect  paralytic  distension  of  the  intestines.  A  turpen- 
tine enema  is  of  great  value  in  some  of  these  cases. 

Prognosis. — The  figures  already  given  serve  to  show  that  our  views 
of  the  prognosis  of  suppurative  peritonitis  must  be  considerably 
modified,  but,  even  with  all  the  recent  improvements  in  the  treatment, 
the  surgeon  cannot  hope  to  save  lives  which  have  already  been  too 
gravely  risked  by  delay,  so  that  the  mortality  will  probably  continue  as 
high  as  30 — 40  per  cent,  for  some  time  to  come.  Quite  recently,  however, 
one  of  us  (R.  P.  R.)  has  operated  upon  seven  consecutive  cases  of  general 
suppurative  peritonitis  with  only  one  death,  although  some  of  the  patients 
seemed  to  be  in  a  hopeless  condition  upon  their  admission.  The  patient 
who  died  was  suffering  from  a  perforated  duodenal  ulcer,  which  had 
unfortunately  been  mistaken  for  lead  colic,  and  treated  with  purgatives. 
The  peritonaeum  contained  a  curious  mixture  of  sero-pus  and  castor  oil 
in  large  quantities  at  the  time  of  the  operation,  from  which  the  patient 
rallied  only  to  die  after  three  days  from  profuse  haemorrhage  from  the 
ulcer. 

Operative     Interference    in    Relapsing    Appendicitis.— 

On  this  subject  the  profession  owes  its  lead  and  the  most  instructive 
of  its  information  to  Sir  F.  Treves,  who  first  proposed  the  removal  of 
the  appendix,  during  a  quiescent  period,  in  1877,  in  a  paper  read  before 
the  Medico-Chirurgical  Society.* 

One  or  more  of  the  following  conditions,  given  by  Sir  F.  Treves, 
will  be  accepted  by  all  as  justifying  operation: — (1)  The  attacks  have 
been  very  numerous.  (2)  They  are  increasing  in  frequency.  (3)  The 
last  has  been  so  severe  as  to  place  the  patient's  life  in  considerable 
danger.  (4)  The  constant  relapses  have  reduced  the  patient  to  the 
condition  of  a  chronic  invalid,  and  rendered  him  unfit  to  follow  any 
occupation.  (5)  Owing  to  the  persistence  of  certain  local  symptoms 
during  the  quiescent  period,  there  is  a  probability  that  a  collection  of 
pus  exists  in  or  about  the  appendix. 

*  The  most  valuable  contributions  of  this  surgeon  are  his  Treatment  of  Typhlitis,  1888 
and  18S9;  Brit.  Med.  Journ.,  vol.  i.  1893,  p.  835,  and  vol.  i.  1895,  P>  5J7-  ^n  America, 
Dr.  H.  Mynter,  following  on  the  lines  of  the  late  Dr.  G.  Buck,  was  one  of  the  earliest  to 
advocate  operative  steps  in  certain  cases  of  appendicitis,  especially  those  accompanied  by 
perforation  (Buffalo  Med.  Journ.,  1879,  p.  122). 

20 — 2 


308  OPERATIONS  ON  THE  ABDOMEN. 

I  would  go  further  and  advise  operation  after  the  first  genuine  attack 
of  appendicitis,  for  who  is  to  say  that  a  second  seizure  may  not  he 
fatal  ?  There  is  little  doubt  but  that  the  safest  course  for  the  individual 
is  to  have  his  appendix  removed  after  one  undoubted  attack,  for  one 
attack  predisposes  to  another,  and  the  mortality  of  the  interval  opera- 
tion by  capable  and  aseptic  surgeons  is  under  '5  per  cent. 

Some  surgeons  and  more  physicians  do  not  advise  operation  until 
after  the  second  attack. 

Operation. — This  is  performed  on  the  same  lines  as  those  given  at 
p.  297.     The  details  will  vary  with  each  case. 

"  Some  of  the  cases  have  been  most  trifling.  On  the  other  band,  in  two  instances  I 
failed  to  remove  the  appendix  after  very  persistent  attempts.  Tt  is  impossible  to  predict 
beforehand  the  features  of  the  operation.  The  attacks  may  have  been  violent  and  numer- 
ous, and  the  removal  of  the  diseased  process  nevertheless  prove  to  be  a  mere  trifle,  On  the 
contrary,  some  of  the  most  difficult  operations  I  have  met  with  have  been  cases  in  which  I 
had  hoped,  from  the  history  of  the  attacks,  to  have  encountered  no  complications  '» 
(Treves). 

The  skin  having  been  carefully  cleansed,  an  oblique  incision  is 
made  about  four  inches  long  and  crossing  McBurney's  line*  about  an 
inch  and  a  half  above  the  anterior  superior  spine.  The  aponeurosis  of 
the  external  oblique  is  divided  in  the  direction  of  its  fibres,  which  prac- 
tically corresponds  to  the  line  of  the  skin  incision,  the  small  piece  of 
external  oblique  muscle  being  split,  also  in  the  direction  of  its  fibres. 
The  internal  oblique  and  transversalis  muscles,  which  run  in  a  direction 
almost  at  right  angles  to  that  of  the  skin  incision,  are  now  likewise  split 
in  the  direction  of  their  fibres  and  well  retracted.  By  making  the 
abdominal  incision  in  this  way,  as  described  by  McBurney  {Ann-  of  Surg. , 
vol.  xx.  p.  38),  the  weakening  of  the  abdominal  wall  which  necessarily 
results  from  free  transverse  division  of  muscular  fibres  is  avoided,  and 
the  tendency  to  subsequent  ventral  hernia  thereby  greatly  diminished. 
Although  the  amount  of  room  obtained  to  work  in  by  this  method  is 
somewhat  lessened,  and  the  difficulty  of  the  operation  to  some  extent 
increased,  the  advantage  gained  is  so  distinct  that  it  should  be  adopted 
wherever  possible,  and  more  room  can  be  obtained  by  opening  the  rectus 
sheath  and  retracting  the  muscle,  as  advocated  by  Harrington  and 
Weir  {he.  cit.),  and  more  recently  by  Major  Holt  {Lancet,  vol.  i.  1905, 
p.  640).  Dr.  G.  G.  Davis  {Ann.  of  Surg.,  vol.  i.  1906,  p.  106)  has 
introduced  a  transverse  incision  one  and  a  halt  inches  long  with  its  centre 
over  the  semilunar  line  at  the  level  of  the  anterior  superior  spine.  The 
rectus  sheath  is  opened  and  the  muscle  retracted  inwards.  In  difficult  and 
in  suppurative  cases,  the  incision  can  be  prolonged  outwards  as  far  as 
the  anterior  spine  and  inwards  nearly  to  the  linea  alba.  The  centre  of 
the  incision  is  over  the  usual  position  of  the  base  of  the  appendix.  In 
suppurative  cases  drainage  can  be  used  near  the  ileum,  the  rest  of  the 
wound  being  closed.  This  incision  is  said  to  give  a  better  access  than 
the  gridiron  one,  and  also  not  to  increase  the  risk  of  hernia,  because  only 
the  external  oblique  fibres  are  cut  across,  the  fibres  of  the  deep  muscles 
being  separated.  It  certainly  gives  a  better  approach  to  the  retro-csecal 
appendix  than  that    given    by    the    rectus     incision.       The    greatest 

*  This  may  have  to  be  modified  according  to  the  position  of  any  swelling. 


APPENDICITIS. 


log 


care  must  now  be  exercised,  as  the  caecum  may  be  adherent  t<>  the 
peritonaeum.  If  any  difficulty  is  experienced  the  incision  should  be 
prolonged  until  it  is  certain  that  the  peritoneal  sue  is  opened.  Any 
omentum  that  is  present,  adherent  or  thickened,  should  be  removed. 
The  appendix  is  now  identified.  This  may  be  easy  or  difficult,  from 
the  structure  being  embedded  in  adhesions,  lying  under  a  caecum  itseh 
fixed  by  adhesions,  or  tied  down  in  one  of  the  loculi  which  Mr.  Lock- 
wood  has  described.  When  it  is  found,  its  removal  may  be  rendered 
difficult  or  impossible  by  the  density  of  its  adhesions,  or  by  the  im- 
portant structures  which  these  have  implicated.  Tims,  Sir  F.  Treves, 
in  the  32  cases  which  he  published,  found  it  adherent  to  the  ureter, 
internal  iliac  artery,  bladder,  and  ileum.  I  found  one  appendix 
closely  attached  low  down  to  the  anterior  wall  of  the  rectum  into  which 

Fig.  86. 


Skin 

Ir\t   obhq 
Ext  oblique 
A  S  Spine 


Aponeu-rosis  of 

Int.  oblique 
&  Transveraalia 


The  gridiron  incision  for  appendicectomy. 


an  abscess  had  discharged,  and  another  recently  operated  upon  was 
tucked  up  between  the  liver  and  the  diaphragm  just  in  front  of  and  to 
the  right  of  the  gall-hladder. 

The  following,  one  of  the  two  cases  in  which  Sir  F.  Treves  found  it 
impossible  to  remove  the  appendix,  gives  a  good  idea  of  the  difficulties 
which  may  be  present. 

"For  a  considerable  time  I  was  unable  to  demonstrate  the  abdominal  cavity,  owing 
to  the  adhesions.  The  caecum  was  completely  buried  in  a  dense  mass  of  adhesions,  and 
here  was  hidden,  no  doubt,  the  appendix.  I  was  not  disposed  to  undertake  the  serious 
risk  of  opening  up  this  area,  especially  as  the  adhesions  obliterated  both  the  ureter  and 
the  iliac  veins,  structures  in  no  little  risk  of  being  wounded  in  these  operations."  The 
patient  remained  free  from  attacks  up  to  the  date  of  the  case  being  published,  six 
months  after  the  operation. 

When  the  area  in  which  the  surgeon  is  going  to  find  or  separate  the 
appendix  is  defined,  it  should  be  shut  off  with  aseptic  gauze  tampons 


3.10 


OPERATIONS  ON  THE  ABDOMEN. 


or  flat  sponges.  Where  possible,  adhesions  should  be  cut  with  blunt- 
pointed  scissors ;  where  soft,  or  where  the  surgeon  is  in  doubt  as  to 
their  nature,  they  must  be  very  carefully  torn  through  with  a  fine- 
pointed  blunt  dissector.     Where  this  separation  of  adhesions  has  opened 


Fig.  87. 


Fundus 


Caecum 

turned  upwards 
U  to  the  right 


Purse - 
string 

Crushed  root 
of  appendix 

Artery  of 
appendix 


_,  Ligature  on 
ineso-  appendix 


Appendix 


The  removal  of  the  appendix. 
The  mesentery  is  transfixed  and  tied  close  to  the  root  of  the  appendix  ;  the 
latter  is  crushed,  tied,  and  then  inverted  by  the  pursestring  suture  previously 

inserted. 

the  caecum  or  ileum,  these  must  be  carefully  closed  with  Lembert's 
sutures  (p.  353).  Where  it  is  quite  impossible  to  separate  the  appendix 
from  such  structures  as  the  bladder,  iliac  vessels,  ileum,  &c,  Sir  F. 
Treves  recommends  division  of  the  appendix  as  near  to  the  csecum  as  is 

Fig.  88. 


Needle 


Puckered 
place 


Raw  surface 


Ligature  round 
mesentery 

The  stump  of  the  meso-appendix  is  made  to  cover  the  site  of  the  inversion. 


safe,  and  then  paring  down  the  part  adherent  to  the  dangerous  viscus 
until  it  is  reduced  to  a  mere  disc.  The  actual  removal  of  the  appendix 
is  carried  out  by  one  of  the  different  methods  given  at  p.  300.  I  transfix 
and  tie  the  mesentery  and  crush  the  appendix  close  to  the  caecum  so 


APPENDICITIS,  3tt 

ns  to  break  the  muscular  and  mucous  coats  and  arrest  hsBmorrlu 
(Doyen),      Tlie  roof  is   then    divided    and    inverted    by  means  of   a 
pursestring    suture    previously    inserted    m    the  outer  Layers    of  the 
caecum.     Jt  is  not  necessary  to  ligate  the  stump.     The  meso-appendix 
is  then  used  to  cover  the  site  of  inversion  (vide  Figs.  87,  88). 

Eastman  (Journ.  Amer.  Med.  Assoc,  Oct.  n,  1902)  prefers  to  remove  the  appendix  by 
means  of  t  lie  oautery,  ami  to  facilitate  this  In'  has  invented  a  pair  of  forceps  provided  with 
non-conducting  shields  to  protect  the  cascum.    The  sterilised  stump  is  inverted  by  m< 
of  Lemberl  or  pursestring  sutures. 

Kelly  (Amor.  Mnl.,  Dee.  31,  1904)  uses  a  pair  of  powerful  orushing  forceps,  which  he 
applies  to  the  base  of  the  appendix.  Be  divides  the  latter  with  the  cautery,  and  then 
inverts  the  stump.  A  pan  of  ordinary  pressure  forceps  is  applied  to  prevent  leakage  of 
the  contents  of  the  appondix.    Reidel  (Zeub.  f.  Chir.,  1903,  No.  51)  criticises  other  methods, 

especially  the  cull'  amputation.  He  advocates  division  between  two  catgut  ligatures, 
excision  of  the  mucous  membrane  of  the  stump,  suture  of  the  serous  and  muscular  coats, 
removal  of  the  basal  ligature,  and  inversion  of  the  stump  by  means  of  one  or  more  rows 
of  sutures. 

Zeller's  plan  (ibid,,  1903,  No.  45)  of  removing  a  part  of  the  caacal  wall  as  well  as  the 
appendix  is  not  to  be  recommended, 

Ries  (New  York  Med.  Jottm.,  July,  1903)  inverts  the  stump  within  the  cascum,  not 
being  content  with  merely  burying  it  in  the  caecal  wall,  lest  an  abscess  form  and  give  rise 
to  further  trouble.  The  invagination  is  accomplished  by  means  of  a  fine  needle  carrying 
a  thread  which  has  a  large  knot  at  one  end.  The  needle  first  pierces  the  appendix  from 
within  outwards,  then  back  again  at  a  distance  of  one-sixteenth  of  an  inch  from  the  base, 
and  into  the  eascum.  It  is  then  brought  out  through  the  csecal  wall  about  an  inch  from 
the  stump,  which  is  inverted  by  pulling  upon  the  string,  and  retained  in  this  position  by 
means  of  seromuscular  sutures  passed  through  the  orifice  of  the  funnel.  The  thread  is 
then  cut  short  and  allowed  to  retract  into  the  bowel,  and  the  mesenteric  stump  is  sewn 
over  the  site  of  the  former  stump.  The  crecal  suture  may  carry  infection  into  or  through 
the  wall  of  the  bowel. 

Most  of  these  methods  are  unnecessarily  elaborate,  and  some  of  them  require  special 
instruments,  which  may  not  be  available.  Whatever  method  is  used,  the  appendix  must 
be  removed  quite  close  to  the  ca3cum  to  prevent  the  possibility  of  recurrence  of  symptoms 
from  retention  within  a  stump  (Treves,  lor.  r/7.).  The  oautery  has  the  advantages  of 
thoroughly  sterilising  the  stump  and  preventing  primary  haamorrhage  from  it,  but  it  may 
lead  to  sloughing  unless  used  with  care.  Reidel's  method  is  a  good  one,  which  can  be 
simplified  and  improved  by  use  of  a  pursestring  suture  for  the  inversion. 

When  any  area  has  been  unavoidabby  denuded  of  its  peritonaea! 
covering,  the  edges  of  this  must  as  far  as  possible  be  drawn 
together,  or  an  omental  flap  applied.  If  the  part  is  intestine 
and  weakened,  gauze  strips  should  be  used  to  shut  it  off  and  drain 
it.  If  there  is  free  and  persistent  oozing  as  the  result  of  separation 
of  adhesions,  a  gauze  tampon  should  be  packed  down  on  to  the  bleeding 
surface  and  left  in  place  for  twenty-four  hours  ;  the  need  for  this 
should  be  rare. 

To  minimise,  as  far  as  possible,  the  risk  of  hernia,  especially  in  young 
subjects  with  an  active  life  before  them,  the  wound  in  the  abdominal 
wall  should  be  carefully  sutured.  The  peritonaeum,  internal  oblique  and 
transversalis,  the  aponeurosis  of  the  external  oblique,  each  of  these  three 
layers,  should  be  united  with  a  separate  row  of  buried  sutures  of  chromic 
gut,  and  then  tlie  skin  with  horsehair.  If  drainage  has  been  employed, 
provisional  sutures  should  be  placed. 

Mortality. — This  is  very  small  at  the  present  day.  Thus  Murphy 
(Amer,  Journ.  Med.  Sci.,  August,  1904)  states  that  about  two-thirds  of 


3i2  OPERATIONS  ON  THE  ABDOMEN. 

his  2,000  operations  were  performed  in  their  quiescent  stage,  and  that 
of  these  only  one  died.     The  cause  of  death  was  peritonitis. 

G.  R.  Turner  (Lancet,  vol.  i.  1905,  p.  643)  states  that  the  recent 
statistics  of  five  London  hospitals  show  a  mortality  of  *5  per  cent. 

Pearce  Gould  (loc.  tit.,  p.  569)  reported  214  interval  operations,  with 
three  deaths. 

Lynn  Thomas  (Lancet,  vol.  ii.  1905,  p.  753)  records  129  operations 
performed  in  the  "  interval,"  with  no  death. 

Complications  of  Appendicitis. — Owing  to  the  frequency  of  the 
disease  and  of  operations  for  it,  it  will  be  well  to  hear  in  mind  the  chief 
complications  which  may  accompany  the  severer  cases,  and  operations 
for  their  relief.  A  mere  enumeration  must  suffice.  (1)  Intestinal 
obstruction.  This  may  be  due  (a)  to  paralysis  of  the  intestines  from 
septic  peritonitis ;  (b)  to  adhesions  about  the  appendix ;  (c)  to  its 
becoming  adherent  to  some  piece  of  intestine,  mesentery,  &c,  and  so 
incarcerating  and  strangling  a  loop  of  bowel.  (2)  Fistula.*  This  may 
be  (a)  mucous,  or  (b)  faecal.  It  may  be  due  to  incomplete  closure  of  the 
appendix,  to  the  leaving  behind  of  a  stercolith,  or  especially  to  giving 
way  of  the  caecum  or  ileum.  (3)  Hepatic  abscess.  (4)  Empyema,  or 
(5)  purulent  pericarditis.  Dr.  Fowler  shows  (loc.  supra  cit.)  that  pus 
in  the  liver  will  tend  to  involve  the  diaphragm,  and  so  bring  about  the 
last  two  conditions.  I  should  have  thought  a  simpler  explanation  was  a 
collection  burrowing  upwards  along  the  psoas.  I  have  had  one  such 
case  of  right-sided  empyema.  The  patient,  aged  53,  made  a  good, 
though  very  slow,  recoveiw,  chiefly  due  to  the  devoted  attention  of  his 
dresser,  Mr.  Anderson.  (6)  Suppuration  in  the  loin  and  about  the 
kidney.  (7)  Suppuration  in  the  pelvis.  An  exceptionally  long 
appendix  may  dip  into  the  pelvis  and  bring  about  the  above.  A  case 
of  this  kind  is  given  by  Fowler.  It  was  successfully  treated  by  abdo- 
minal section.  (8)  Phlebitis  of  iliac  veins.  Fowler  gives  a  case  in 
which  the  appendicitis,  being  gangrenous,  brought  about  ulceration  and 
fatal  haemorrhage.  (9)  Appendicitis  in  a  hernial  sac.  Fowler  mentions 
a  case  reported  by  Dr.  Rand,  of  Brooklyn,  in  which  an  irreducible 
femoral  hernia  became  the  site  of  inflammation  due  to  an  inflamed 
appendix  which  it  contained.  Sir  F.  Treves  met  with  a  case  in  which 
the  appendix,  the  seat  of  recurrent  trouble,  occupied  an  inguinal  sac. 
(10)  Communication  with  the  rectum,  bladder,  or  vagina.  (11)  Septic- 
aemia. This  may  supervene,  as  on  one  of  the  last-mentioned  com- 
plications, quite  apart  from  suppurative  peritonitis.  (12)  Abscess 
in  the  abdominal  wall,  causing  most  extensive  burrowing.  (13)  Stitch 
sinus.  (14)  Ventral  hernia.  (15)  Thrombosis  of  the  femoral  vein, 
especially  the  left  one.  Dr.  Meyer  describes  two  cases  of  this  (Ann.  of 
Surg.,  May,  1901). 

Mr.  Lett  (Mcdico-Chir.  Trans.,  1905,  and  Lancet,  vol.  i.  1905,  p.  569) 
records  the  complications  of  1,000  operations  for  appendicitis  as 
follows  : — Faecal  fistula,  49  ;  thrombosis  of  the  femoral  vein,  12  ; 
intestinal    obstruction,    10 ;    broncho-pneumonia,    17 ;    pleurisy    with 


*  Treves'  Surgical  Treatment  of  Typhlitis,  p.  45.  Mr.  Southam  has  published  (Lancet, 
vol.  ii.  1892,  p.  835)  a  case  successfully  treated  by  short-circuiting  the  intestine.  Senn's 
plates  were  used. 


INFLAMMATION-    OF    MECKEL'S    DIVERTICULUM.  313 

effusion,  14;  pleurisy  withoul  effusion,  2j  empyema,  7;  acute 
bronchitis,  4 ;  pulmonary  embolism,  1;  parotitis,  4;  pylephlebitis,  4; 
residua]  abscess,  11  ;   secondary  abscess,  12. 

Failure  of  the  Operation  to  give  Relief.— Air.  Lett  (loc.  cit.)  found 
that  11  out  of  231  patients  complained  of  attacks  similar  to  those  which 
occurred  before  the  operation. 

Sir  Frederick  Treves  (loc.  supra  '-if.),  in  45  patients  imperfectly 
relieved,  found  that  the  appendix  had  not  been  completely  removed  in 
2,  ovarian  disease  in  9,  colitis  in  8,  local  pain  in  7,  neurasthenia  in  5, 
gallstones  in  3,  movable  kidney  in  2,  renal  calculus  in  1,  tender  mass 
in  the  iliac  fossa  in  5. 

INFLAMMATION    OF    MECKEL'S    DIVERTICULUM. 

This  may  closely  simulate  appendicitis  and  intestinal  obstruction, 
and  may  result  in  (a)  simple  catarrhal  inflammation  without  infection 
of  the  peritonaeum;  (b)  formation  of  a  localised  abscess;  or  (c)  perforation 
or  gangrene  leading  to  diffuse  suppurative  peritonitis,  which  is  relatively 
more  common  and  more  fatal  than  the  peritonitis  arising  from  the 
vermiform  appendix.  The  cause  of  the  trouble  is  not  diagnosed  before 
an  operation  is  undertaken  for  the  relief  of  intestinal  obstruction  or 
for  the  treatment  of  peritonitis,  generally  considered  to  be  of  appendicular 
origin.  This  condition  is  more  fatal  than  appendicitis  for  several 
reasons  :  the  greater  size  and  larger  lumen  of  the  diverticulum  favour 
faecal  extravasation  from  a  perforation ;  the  greater  freedom  and  more 
median  position  of  this  unusual  appendage  are  also  unfortunate  for 
localisation  of  inflammatory  products  and  extravasations  arising  from 
it ;  and,  lastly,  intestinal  obstruction  often  co-exists,  and  a  kink  or 
volvulus  at  the  base  of  the  diverticulum  may  cause  obstruction  of  both 
it  and  the  small  intestine  at  the  same  time.  A  gangrenous  or  per- 
forative inflammation  of  the  obstructed  diverticulum  is  likely  to  occur 
and  to  lead  to  peritonitis  in  a  few  hours. 

Gibbon  (Amer.  Journ.  Med.  Sci.,  November,  1903),  Clinton  (Buffalo 
Med.  Journ.,  June,  1904),  Dineur  (Journ.  Med.  de  Bruxelles,  Nov.  5, 
1903),  Oliver  Ashe  (Lancet,  Aug.  29,  1903),  Roberts  (Ann.  of  Surg., 
July,  1906),  Oliver  Smith  (Ann.  of  Surg.,  1904,  vol.  xl.  p.  744),  and 
others  record  interesting  cases  of  this  kind.  Smith  quotes  Blanc's 
thesis  to  the  effect  that  of  12  cases  of  acute  inflammatory  and  perforative 
diseases  of  the  diverticulum  eight  died  and  three  recovered  after 
operation,  the  result  being  uncertain  in  the  other  cases. 

Halstead  (Med.  Record,  Nov.  29,  1902)  has  related  two  fatal  cases  of 
perforation  occurring  during  the  second  and  fourth  weeks  of  typhoid 
fever ;  he  also  mentions  two  other  fatal  cases  reported  by  Galton  and 
Boinet,  and  he  points  out  that  perforation  is  very  likely  to  occur  at  the 
fundus,  because  the  muscular  wall  may  be  deficient  there.  Tuberculous 
ulceration  and  perforation  may  also  occur,  although  it  is  infinitely  rare 
as  compared  with  inflammation  following  sudden  or  chronic  obstruction 
and  the  formation  of  faecal  concretions. 

The  treatment  of  this  rare  disease  should  be  carried  out  along  the 
lines  laid  down  for  appendicitis  and  its  complications,  for  which  the 
operation  will  have  been  undertaken  as  a  rule.  The  diverticulum  may 
be  removed  and  its  base  inverted  by  pursestring  or  Lembert  s  sutures; 


3i4 


OPERATIONS  ON  THE  ABDOMEN, 


but  this  may  not  be  always  possible,  owing  to  the  constriction  or  twist 
or  gangrene  of  the  small  intestine,  which  may  have  to  be  resected  or 
primarily  drained  and  secondarily  resected  in  bad  cases  with  paralytic 
distension  existing  or  threatening. 


PERFORATION    OF    GASTRIC    ULCER.* 

The  perforation  may  either  be  acute,  associated  with  sudden  escape 
of  gastric  contents  into  the  general  peritoneal  cavity,  or  subacute, 
resulting  in  the  formation  of  a  localised  abscess.  It  may  also  be 
chronic,  leading  to  adhesion  of  the  base  of  the  ulcer  to  the  liver, 
pancreas,  or  abdominal  wall,  any  of  which  may  form  the  base  of  the 
ulcer  in  time. 

A.  Acute  Perforation. — The  successful  treatment  of  these  most  fatal 
lesions  depends  upon  early  operation. 

This  should  be  performed  as  soon  as  possible  after  the  accident, 
delay  only  leading  to  the  additional  escape  of  septic  material,  especially 
if  the  patient  is  moved  about.  Another  urgent  reason  for  early 
operation  is  the  fact  that  the  later  the  operation  is  deferred,  the  more 
difficult  it  is,  and  the  less  is  the  patient  able  to  bear  the  shock  of  the 
interference.  Again,  the  longer  the  delay,  the  greater  is  the  tendency 
to  the  formation  of  masses  of  lymph,  which  may  conceal  the  ulcer, 
mat  viscera  together,  and  so  form  culture-pools  for  bacteria,  and  hamper 
the  attempts  at  cleansing  the  peritonaeum. 

While  the  surgeon  will  be  unwilling  to  interfere  during  the  period  of 
early  collapse  which  follows  on  the  perforation,  he  should  utilise  this 
time  in  making  the  needful  preparations.!  The  serious  results  of  delay 
are  wrell  shown  in  the  following  table  from  Ilobson  and  Moynihan's 
Diseases  of  the  Stomach  : — 


Total  cases. 

Recovered. 

Died. 

Mortality, 

Operation  under  12  hours    ... 

49 

35 

x4 

28-5  °/a 

„         from  12 — 24  hours 

33 

12 

21 

63-6  °u 

„             „      24—36      „ 

16 

2 

14 

8y5  P/o 

„      36-48      „ 

2 

0 

2 

1000  70 

„          over  48  hours 

35 

16 

18 

51-5  °/o 

It  seems  clear  that  while  ulcers  occur  most  frequently  on  the  posterior 
surface  of  the  stomach,  those  on  the  anterior  surface  are  most  liable  to 
perforate.  Thus,  out  of  90  cases  operated  upon,  the  perforation  in 
86  was  on  the  anterior  surface,  posterior  perforations  occurring 
only  in  1 1  cases.  Perforations  are  more  frequently  nearer  the  lesser 
than  the  greater  curvature,  and  the  cardia  than  the  pylorus.  This  last 
fact  is  one  of  much  practical  importance,  as  the  cardia  is  a  relatively 
fixed  point,  and  the  nearer  an  ulcer  is  to  this  end,  the  greater  is  the 


*  This  is  placed  here  instead  of  under  the  "  Operations  on  the  Stomach,"  first  because, 
like  a  perforated  Termiform  appendix,  it  is  such  a  dangerous  source  of  peritonitis, 
secondly  because  it  calls  for  the  same  treatment  as  the  less  common  duodenal  ulcer. 

f  A  hot-water  table,  water-bed,  and  hot  bottles  should  be  provided,  the  patient's  limbs 
bandaged  in  cotton-wool,  the  head  kept  low,  ether  given,  and  an  enema  of  port  wine 
administered  ;  injections  of  strychnine  and  the  necessaries  for  saline  infusion  should  also 
be  at  hand. 


PKRFORATION    OF    (JASTKIC    ULCKK. 


315 


difficulty  in  Buturing  it.  Finally,  it  should  be  remembered  that  in 
Beveral  cases  there  have  heen  more  than  one  perforation.  Finney 
(Ann.  of  Surg. t  July,  1900)  says  that  in  20  per  cent,  of  the  cases  there 
is  a  second  perforation.  Gastric  and  duodenal  ulcers  sometimes 
perforate  simultaneously. 

A  warning  maybe  necessary  here  that  a  great  variety  of  conditions 
have  heen  mistaken  for  perforated  gastric  ulcer,  some  of  which  may  be 
mentioned: — Perforation  of  duodenal  ulcer,  ruptured  tubal  gestation, 
menstruation,  perforative  appendicitis,  acute  hemorrhagic  pancreatitis, 
thrombosis  of  superior  mesenteric  vein,  pneumonia,  acute  poisoning, 
acute  dilatation  of  the  stomach,  and  acute  inflammation  of  the  gall- 
bladder. It  will  be  noticed  that  most  of  these  conditions  require  operative 
treatment,  so  that  a  mistake  is  only  serious  as  regards  the  site  of  the 
incision  and  the  prognosis  that  can  be  given.  In  others,  an  operation 
can  do  no  harm,  but  may  do  good  ;  but  in  pneumonia,  pleurisy,  men- 
struation, &c,  the  confusion  of  these  with  perforated  gastric  ulcer  is 
as  serious  as  the  opposite  mistake  of  declining  to  advise  operation  for 
a  perforated  ulcer.  It  may  therefore  he  well  to  emphasise  the  leading 
and  really  important  diagnostic  features  of  perforation  of  a  gastric 
ulcer.  Too  much  stress  cannot  be  laid  on  the  history,  which  is  almost 
constant,  of  a  sudden  onset  of  dreadful  and  intolerable  pain ,  especially  in 
the  epigastrium,  and  later  becoming  general  and  even  pelvic  from  trickling 
down  of  the  escaping  fluids.  A  sensation  of  something  giving  way  is 
often  mentioned  by  the  patient.  Shock  of  a  severe  degree  soon  follows, 
and  is  very  characteristic  when  seen,  but  the  patient  is  often  better 
when  the  doctor  arrives.  A  contracted,  rigid,  tender  abdomen.  Later,  of 
course,  it  will  be  full  and  tympanitic.  The  respirations  are  shallow, 
catchy,  and  hurried,  hence  the  mistake  of  diagnosing  pneumonia  in 
some  cases.  Vomiting  occurs  in  about  half  the  cases,  and  about  80 
\>er  cent,  give  a  history  of  indigestion  or  more  serious  gastric  troubles 
(Robson  and  Moynihan). 

The  operation  itself  includes:  i.  Finding  the  perforation;  ii.  Success- 
fully closing  it ;  iii.  Efficiently  cleansing  and  draining  the  peritoneal 
sac — headings  which  will  be  taken  separately. 

Operation. — The  parts  having  been  fitly  cleansed,  and  every  pre- 
caution taken  against  shock,  an  incision  four  to  five  inches  long  is  made 
from  near  the  left  costo-xiphoid  angle  to  the  level  of  the  umbilicus  and 
through  the  rectus  sheath.  The  falciform  ligament  is  thus  avoided. 
When  the  peritoneum  is  opened  an  escape  of  gas  is  not  uncommon,* 
sometimes  of  fluid,  consisting  parti}'  of  the  last  meal  taken,!  and  partly 
of  serous  effusion  from  the  irritation  of  the  peritoneum. 

If  there  is  no  such  escape  the  outlook  is  so  far  more  favourable,  as  it 
ma}r  be  hoped  that  as  yet  the  effusion  is  slight,  and  limited  to  part  only 


*  If  it  is  a  late  case,  as  in  one  I  mention  (p.  321),  the  tympanites  and  distended 
intestines  may  be  most  embarrassing.  In  one  published  by  Dr.  Anson  (Ltincct,  vol.  i. 
1893,  p.  469),  the  distension  all  subsided  after  a  rush  of  odourless  gas  when  the  abdomen 
was  opened. 

f  The  interval  that  has  elapsed  is  most  important.  Thus  in  a  successf  id  case  published 
by  Dr.  Walter,  of  Heading  {Lancet,  vol.  i.  1895,  P-  484)>  five  hours  had  elapsed.  So,  too, 
in  a  case  of  Dr.  W.  Hall's  {Brit.  Med.  Joum.,  vol.  i.  1892,  p.  64)  which  recovered  without 
operation  after  very  severe  peritonitis,  the  interval  was  four  hours. 


316  OPERATIONS  ON  THE  ABDOMEN. 

of  the  peritonaeal  sac.  If  this  be  so,  though  it  is  uncommon,  the 
surgeon  should  shut  off  the  lower  part  of  this  sac  as  far  as  possible  with 
gauze  tampons  or  flat  sponges  before  he  disturbs  the  stomach  and  its 
surroundings. 

i.  rinding  the  Perforation. — This  varies  very  much  in  difficulty. 
Sometimes  the  eye  detects  it  at  once  when  the  stomach  is  drawn  down- 
wards and  to  the  right  and  the  edges  of  the  wound  well  retracted,  the 
left  costal  arch  being  pulled  upwards,  forwards,  and  outwards.  At 
other  times  the  exploring  finger  soon  feels  it  or  the  area  of  induration 
which  forms  the  base  of  the  ulcer.  In  other  cases  finding  the  ulcer  is 
beset  with  the  greatest  difficulty,  or,  owing  to  the  hurried  search  which 
alone  is  possible  from  the  state  of  the  patient,  is  quite  impossible.  In 
a  difficult  case  help  may  be  obtained  by  tracing  the  direction  in  which 
the  congestion  of  the  stomach  appears  to  be  increasing,  by  watching 
the  direction  from  which  any  flow  that  may  be  present  is  coming.  A 
suggestion  has  been  made  to  inject  air  through  an  oesophageal  tube 
so  that  the  escaping  bubbles  may  lead  to  the  ulcer.  The  liver  should 
be  raised  by  an  assistant,  and  the  stomach  drawn  downwards  and 
to  the  right,  while  the  whole  of  the  anterior  surface  and  the  lesser 
curvature  are  carefully  examined  with  a  good  light.  Adherent  lymph 
or  adhesions  between  the  stomach  and  liver  may  mark  the  site 
of  the  perforation,  and  require  gentle  separation  before  it  is 
revealed.  The  perforation  itself  may  be  extremely  small,  and  thus 
easily  hidden  by  any  fold  of  the  stomach,  still  more  readily  by  lymph 
and    adhesions. 

Mr.  Dunn's  case  {loc.  infra  cit.)  well  shows  how  difficulty  here  is  to 
be  met : 

On  separating  the  adhesions  which  fixed  the  liver  to  the  abdominal  wall,  a  quantity 
of  opalescent  fluid  escaped.  The  liver  was  then  pulled  upwards  and  the  anterior  wall 
of  the  stomach  pushed  backwards,  and  now  it  was  that  some  brownish  fluid  like  weak 
coffee,  containing  gas-bubbles  and  one  or  two  small  masses  of  coagulated  milk,  escaped. 
It  welled  up  from  a  considerable  depth,  at  the  left  of  the  incision,  and  was  found,  on 
subsequent  examination,  to  be  strongly  acid,  and  to  contain  a  little  albumen.  Several 
more  adhesions  were  broken  down,  but  still  no  perforation  could  be  seen,  and  it  was 
only  when  the  left  margin  of  the  wound  was  stretched  outwards  to  the  utmost,  whilst 
steady  traction  was  made  upon  the  stomach  towards  the  right,  that  the  hole  in  this  viscus 
became  visible. 

At  this  stage,  or  a  little  later,  to  facilitate  the  suturing,  it  may  be 
necessary  to  divide  the  left  rectus,  in  order  to  get  more  room.  Save 
for  weakening  the  abdominal  wall,  this  step  is  a  light  one,  as  long 
as  the  intestines  are  not  distended.  If  distension  is  present  it  is  a 
serious  complication,  as  it  facilitates  very  much  the  escape  of  the 
intestines. 

ii.  Closure  of  the  Perforation. — It  has  been  suggested  that,  before 
this  is  clone,  the  stomach  should  be  emptied  and  washed  out.  If  the 
perforation  has  been  quickly  found,  if  the  patient's  condition  is  good, 
and  if  the  stomach  can  be  got  well  outside  the  wound,  emptying  by 
gentle  squeezing  will  be  beneficial,  by  preventing  vomiting,  and  thus  a 
strain  on  the  sutures.  So,  too,  with  regard  to  washing  out  the  viscus, 
if  a  drainage-tube  can  be  readily  inserted  through  the  perforation. 
But  the  small  size  of  the  external  opening  will  often  prevent  this  ; 
and,  with  regard  both  to  emptying  and  washing  out  the  stomach,  it 


PERFORATION    OF   GASTRIC    ULCER.  317 

is  certain  that  in  neither  case  will  the  advantages  gained  counter- 
balance the  loss  of  time,  thai  would  have  been  better  spent  later  on, 
in  thoroughly  washing  out  the  peritonaea!  cavity. 

With  regard  to  excising  the  ulcer,  which  has  been  recommended,  the 
same  conditions  and  objections  apply.  Much  extra timewill  be  consumed, 
there  may  be  a  good  deal  of  additional  haemorrhage,  and  the  perfora- 
tion may  be  converted  into  a  large  gap  requiring  numerous  sutures  to 
close  it  (Swain,  Lancet,  vol.  ii.  1894,  p.  22).  In  this  case  much  difficulty 
was  met  in  inverting  the  pouting  mucous  coat.  Moreover,  the  success- 
fid  cases  treated  by  suture  without  excision  show  that  this  step  is  not 
needful.  St.  Clair  White  {Brit  Med.  Journ.,  Feb.  20,  1904)  reports 
five  consecutive  cases  in  which  the  ulcer  was  excised  and  the  aperture 
closed  with  two  layers  of  sutures,  fortified  by  an  omental  graft.  Two 
of  these  cases  died  some  time  later  as  a  result  of  ulceration  at  the  line 
of  suture.  One  died  a  fortnight  after  the  operation  from  profuse  and 
repeated  hsematemesis.  The  other  death,  which  occurred  after  six 
weeks,  was  due  to  a  small  abscess  in  the  stomach  and  secondary 
multiple  hepatic  abscesses. 

Mr.  Mothersole  (Lancet,  vol.  ii.  1905,  p.  223)  records  two  cases  in 
which  he  successful!}'  excised  the  ulcers  near  the  pylorus,  and  in  each 
case  he  sutured  the  wound  in  such  a  way  as  to  widen  the  pylorus.  About 
four  months  later  the  patients  were  quite  well.  Mr.  Mitchell  (Brit.  Med. 
Journ.,  1905,  vol.  ii.  p.  779)  and  Mr.  Anderson  {Lancet,  1905,  vol.  ii. 
p.  944)  found  that  excision  of  the  ulcer  did  not  give  permanent  relief, 
however.  In  Mr.  Anderson's  patient,  symptoms  of  ulceration  returned 
after  a  year,  and  gastrojejunostomy  had  to  be  performed  after  sixteen 
months  ;  this  gave  complete  relief.  If  the  perforation  is  spilling  its 
contents  when  seen,  a  finger  or  sponge  in  a  holder  should  be  placed 
upon  it,  or  a  silk  suture  passed  across  its  centre  so  as  to  prevent  further 
escape.  The  perforation  having  been  shut  off  with  iodoform  gauze 
tampons,  it  is  next  carefully  closed  with  Lembert's  sutures  of  sterilised 
silk.*  One  row  of  these  will  suffice  if  inserted  with  the  following 
precautions  :  They  should  begin  and  end  well  beyond  the  extremities 
of  the  perforation  (Fig.  353).  They  should  take  up  the  coats  of  the 
stomach  as  far  as,  but  not  beyond,  the  sub-mucous  layer.  When  the 
ulcer  is  near  the  pylorus  the  sutures  should  be  passed  from  side  to  side 
and  not  from  above  downwards,  to  avoid  narrowing  of  the  outlet  of  the 
stomach.  Fortunately,  it  is  also  easier  to  pass  the  sutures  in  this 
direction  than  from  above  downwards.  They  should  be  inserted  far 
enough  from  the  margins  of  the  perforation  to  ensure  sufficient  inver- 
sion of  the  serous  surfaces  when  the  sutures  are  tightened,  and  this 
inversion  may  be  aided  by  a  probe  or  director.  All  the  sutures  should 
be  inserted  before  any  are  tied.  If  any  cut  out  as  they  are  fastened,  fresh 
ones  must  be  reinserted  at  a  sufficient  distance  from  the  margins  of  the 
perforation  to  give  a  firm  hold,  and  a  second  set  must  be  employed 
where  the  union  is  certainly  weak.  For  small  perforations  a  continuous 
Lembert  suture  may  be  used,  and  this  is  a  very  rapid  way  of  closing  the 
hole ;  a  pursestring  suture  may  also  serve,  but  it  is  apt  to  tear  out. 

*  The  passage  of  these  may  be  facilitated  by  the  use  of  two  guide-stitches  of  medium- 
sized  silk,  passed  a  full  inch  from  the  edges  of  the  perforation,  as  used  by  Mr.  Gould  in 
his  case. 


318  OPERATIONS    ON    THE    ABDOMEN. 

Whenever  it  is  feasible  the  suturing  should  be  performed  with  the 
viscus  outside  the  wound,  this  part  of  the  stomach  resting  on  hot 
tampons  of  sterile  gauze.*  When  it  is  not  possible  to  bring  the 
stomach  outside,  the  difficulties  are  greatly  increased,  especially  if  the 
perforation  be  near  the  cardia,  a  more  fixed  part.  Here  drawing  up 
the  margin  of  the  ribs  and  liver,  pulling  down  the  stomach,  or  division 
of  the  left  rectus  may  be  of  service. 

Where  either  the  position  of  the  ulcer  or  the  amount  of  surrounding 
induration  makes  it  impossible  to  close  a  perforation  with  sutures,  one 
of  the  following  courses  should  be  followed  :  (i)  A  piece  of  omentum 
may  be  used  to  close  the  opening,  being  kept  in  position  by  means  of 
careful  suturing.  (2)  If  the  ulcer  lies  under  cover  of  the  liver  it  may 
be  possible  to  fix  this  down,  over  the  perforation,  by  means  of  sutures. 
(3)  A  cigarette  drain  may  be  inserted  near  the  perforation  and 
removed  after  thirty-six  hours.  (4)  A  posterior  gastrojejunostomy 
maybe  performed,  for  by  this  means  leakage  maybe  greatly  diminished, 
if  not  prevented.  Anterior  gastrojejunostomy  was  first  performed 
for  this  condition  by  Braun  {Centralblatt  fur  Chirurgie,  Leipsic, 
1897,  p.  739).  The  patient  recovered,  and  remained  well  for  several 
years. 

Mr.  Paterson  {he.  cit.)  considers  that  drainage  by  means  of  the 
anterior  operation  deserves  a  thorough  and  extended  trial  as  a 
routine  treatment  of  perforated  gastric  ulcer.  He  maintains  that  this 
may  prevent  subsequent  troubles  from  persistence  of  ulceration, 
haemorrhage,  secondary  perforation  of  the  same  or  of  another  ulcer. 
He  also  states  that  a  more  thorough  closure  of  pyloric  ulcers  will  be 
possible  without  risk  of  stenosis,  that  the  rest  given  to  the  stomach 
promotes  healing  of  the  perforation,  and  that  earlier  feeding  and 
administration  of  purgatives  can  be  allowed.  He  also  quotes  Finney 
that  in  20  per  cent,  of  the  cases  perforations  are  multiple,  and  that 
gastrojejunostomy  may  save  these  cases  even  if  a  perforation  be 
missed.  The  most  important  and  to  my  mind  sufficient  objection  is 
that  these  patients  are  rarely  in  a  condition  to  stand  a  prolongation  of 
the  operation  when  the}r  come  for  treatment.  If  a  gastrojejunostomy 
becomes  necessary  it  is  safer  in  the  great  majority  of  cases  to  do  it  at 
a  second  operation.  In  some  very  early,  and  especially  in  pyloric  or 
duodenal  cases,  a  gastrojejunostomy  may  be  primarily  performed.  Dr. 
Herbert  French  {Med.-Chir.  Trans.,  November,  1906)  was  able  to 
trace  and  examine  18  out  of  30  Guy's  Hospital  patients  who  had 
recovered  after  operations  for  perforated  gastric  ulcers.  Fifteen  of 
these  patients  were  wonderfully  well  in  every  way,  but  the  three  others 
had  abdominal  symptoms  of  various  degrees  of  severity.  When  such 
symptoms  arise  a  secondary  gastrojejunostomy  may  be  recommended, 
although  it  is  not  certain  that  the  operation  will  give  relief,  for  the 
symptoms  may  be  due  to  adhesions,  in  some  cases  at  least. 

Mr.  Crisp  Inglis  {Med.-Chir.  Trans.,  1903,  vol.  lxxxvii.)  found  that 
only  four  out   of   15   cases   had  any  gastric  symptoms    following  the 

*  Whenever  during  an  abdominal  section  it  is  necessary  to  keep  viscera  outside,  it 
should  be  the  duty  of  one  assistant  to  see  that  their  temperature  is  maintained  and  that 
their  surroundings  are  aseptic  only,  and  it  should  be  the  duty  of  a  separate  nurse  to  help 
in  this. 


PERFORATION    OF    <!ASTRI<'    I'LCKK.  319 

operation  of  closing  the  ulcer.  These  patients  had  symptoms  of 
dyspepsia,  for  which  two  were  readmitted  into  St.  George's  Hospital. 

.Mr.  Paterson  {U>c.  cit.)  traced  33  cases,  and  found  that  [6  were  quite 
well,  but  that  17  suffered  from  gastric  symptoms,  and  1  of  them  died 
of  a  secondary  perforation  ;  1  required  gastrojejunostomy  as  a  secon- 
dary operation,  and  9  had  symptoms  of  gastric  ulcer,  and  5 
Buffered  from  dyspepsia.  In  two  other  cases,  for  which  a  primary 
gastrojejunostomy  had  been  performed,  no  symptoms  were  complained 
of  within  fifteen  months  and  two  years. 

Paterson  states  that  in  112  cases  collected  from  the  statistics  of  two 
London  hospitals  there  were  13  deaths  which  might  possibly  have 
been  prevented  by  a  primary  gastrojejunostomy  :  3  died  from 
haemorrhage  ;  in  8  the  sutures  closing  the  ulcer  gave  way,  and  this 
led  to  secondary  extravasation  and  death  ;  and  2  died  because  a 
second  perforation  remained  undiscovered  in  each  of  them. 

Mr.  Moynihan  has  performed  gastrojejunostomy  in  6  of  these  cases 
of  perforated  gastric  ulcer,  with  5  recoveries  (Med.-Chir.  Trans., 
November,  1906). 

So  far  I  have  spoken  of  ulcers  on  the  anterior  surface  of  the  stomach. 
The  rarer  but  much  less  accessible  ones  on  the  posterior  surface  must 
now  be  referred  to.  As  is  well  known,  while  gastric  ulcers  are  much 
more  frequently  met  with  on  this  surface,  these  rarely  perforate,  owing 
to  the  tendency  for  adhesions  to  form  between  this  surface  of  the 
stomach  and  the  pancreas.  If  the  evidence  of  perforation  is  strong, 
and  nothing  can  be  found  on  the  anterior  surface  or  lesser  curvature 
the  surgeon  can  examine  the  posterior  wall  (a)  by  carefully  tearing 
through  the  lesser  omentum  and  inverting  the  anterior  wall  :  the 
posterior  one  comes  into  view  through  the  hole  made  in  the  lesser 
omentum  *  ;  (b)  by  tearing  through  the  great  omentum  ;  (c)  by  passing 
the  finger  through  the  foramen  of  Winslow.  In  five  out  of  42  cases 
reported  by  Crisp  Inglis  the  perforation  was  on  the  posterior  wall  close 
to  the  pylorus  (Medico-Cliir.  Trans.,  1903,  vol.  lxxxvii.).  In  10  per 
cent,  of  the  112  cases  collected  by  Paterson  the  ulcers  were  011  the 
posterior  surface  of  the  stomach. 

In  a  case,  under  the  care  of  Dr.  L.  E.  Shaw,  I  adopted  the  first  of  the  above  plans. 
The  operation  was  performed  seventeen  hours  after  the  perforation.  As  no  perforation 
could  be  found  on  the  anterior  surface  of  the  stomach,  the  lesser  omentum  was  carefully 
torn  through  and  the  posterior  surface  explored.  A  small,  recentdooking  ulcer  was  found 
near  the  lesser  curvature,  with  a  small  perforation  in  its  centre.  With  considerable  diffi- 
culty six  Lembert's  sutures  were  inserted  so  as  to  invert  the  ulcer.  Irrigation  was  not 
performed,  but  free  drainage  was  employed,  a  Keith's  tube  being  placed  in  the  pelvis, 
and  a  tube  and  gauze  strips  passed  down  to  the  lesser  curvature.  The  patient  made  a 
good  recovery. 

iii.  Cleansing  of  the  Peritonseal  Sac. — Though  most  stress  has  been 
laid  upon  the  point  of  efficient  suturing  of  the  perforation,  there  is  no 
doubt  that  this  one  is  quite  as  important.  Irrigation  is  indicated  in 
most  cases  of  perforated  gastric  ulcer,  because  of  the  extensive  degree 

*  Mr.  J.  R.  Morrison,  of  Newcastle,  adopted  this  plan  {Brit.  Med.Journ.,  vol.  ii.  1894, 
p.  864).  The  patient  survived  till  the  ninth  day.  and  at  the  necropsy  the  peritonitis  was 
limited  to  the  pelvis. 


320  OPERATIONS    ON    THE   ABDOMEN. 

of  the  extravasation  of  the  stomach  contents.  Irrigation  is  probably 
better  than  other  ways  of  removing  this  foreign  material,  and  creates 
less  disturbance  and  shock  than  extensive  mopping  would  require. 
The  fluid  used  should  be  boiled  water  or  saline  infusion,  e.g.,  sod. 
chlor.  3j. — Oj.  of  boiled  water  at  a  temperature  of  1050.  If  no  irrigator 
is  at  band  a  glass  tube  or  the  end  of  an  oesophagus-tube,  attached  to 
india-rubber  tubing  (all  having  been  sterilised)  and  arranged  as  a 
syphon  or  attached  to  a  funnel,  will  answer  very  well.  Failing  this, 
a  clean  Higginson's  syringe  will  suffice,  if  some  one  else  pumps  in  the 
fluid  so  as  to  set  free  both  the  surgeon's  hands  for  the  delivery  and 
distribution  of  the  fluid.  The  cleansing  must  be  systematic,  per- 
severing, and  thorough.  The  whole  cavity  must  be  gone  over  in  a 
regular  way,  and  there  is  no  better  method  than  that  given  by 
Dr.  Maclaren,  who  has  operated  in  three  cases,  in  one  with  success 
{Brit.  Med.  Journ.,  vol.  ii.  1894) : 

"The  plan  I  take  is  to  begin  with  the  neighbourhood  of  the  rupture,  wash  it  well, 
then  starting  from  this  as  a  centre,  to  make  the  nozzle  follow  the  course  of  the  colon, 
first  towards  the  csecum,  specially  cleaning  out  below  the  liver  ;  secondly,  starting 
again  from  the  stomach,  to  follow  the  great  bowel  to  the  rectum.  In  this  latter  course 
the  lumbar  and  pelvic  hollows  should  receive  special  care.  Finally,  the  douche  is 
directed  among  the  folds  of  the  mesenteric  attachments  of  the  small  intestines.  I  have 
repeatedly  noticed  here,  when  all  seemed  clear,  that  a  fresh  turn  of  the  instrument 
would  empty  some  unsuspected  pocket." 

It  is  an  advantage  to  make  a  small  wound  about  two  inches  above 
the  pubis,  care  being  first  taken  to  ascertain  that  the  bladder  is  empty. 
This  plan  facilitates  the  irrigation,  and  a  tube  can  be  passed  through 
the  puncture  and  the  irrigation  carried  on  throughout  the  greater  part 
of  the  operation. 

If  the  extravasation  is  limited,  as  it  may  be  in  very  earl}'  cases,  it  is 
wiser  not  to  irrigate,  as  this  may  do  more  harm  than  good.  The  soiled 
portion  of  the  peritonaeum  should  be  carefully  cleansed  with  soft  mops 
of  sterilised  gauze,  care  being  taken,  on  the  one  hand,  to  cleanse  the  parts 
as  thoroughly  as  possible,  and,  on  the  other  hand,  to  avoid  damage  to 
the  peritonaeum  by  using  undue  force. 

Some  surgeons  prefer  to  trust  entirely  to  mopping  in  this  way 
without  using  irrigation  at  all,  for  instance  Mr.  Barker  (Clin.  Soc. 
Trans.,  1900),  who  gives  a  list  of  12  cases  treated  by  mopping  alone, 
with  five  recoveries.  Mr.  Paterson  (Lancet,  vol.  i.  1906,  p.  574)  in  his 
Hunterian  lecture  does  not  recommend  irrigation,  because  he  believes 
that  it  increases  shock,  but  this  is  not  the  experience  of  most  surgeons. 
It  would  seem,  however,  wiser  on  the  whole  to  irrigate  thoroughly 
when  the  general  peritonseal  cavity  is  contaminated,  supplementing  this, 
if  necessary,  with  careful  wiping  to  get  rid  of  any  coarser  particles  that 
may  be  visible,  and  to  trust  entirely  to  wiping  only  when  the  extravasation 
is  localised.  It  is  not  easy  to  tell  the  extent  of  the  soiling,  and  it  is 
wise  to"  examine  the  kidney  pouch  in  every  case.  Before  closing  the 
abdominal  wound  the  question  of  drainage  will  arise.  The  necessity 
for  this  largely  depends  upon  the  particular  conditions  found  at  the 
operation.  If  the  case  has  been  operated  upon  quite  early,  if  the 
amount  of  extravasation  is  small  and  limited,  and  the  area  thoroughly 


PERFORATION   OF   GASTRIC    ULCER.  32] 

cleansed,  the  abdominal  wound  may  be  closed  without  drainage.  In 
the  ureal  majority  of  cases,  however,  drainage  will  be  necessary. 
Usually  gauze  drains  passing  in  various  directions  from  the  abdominal 
incision  will  meel  all  requirements  :  one  should  pass  down  to  the  Beat 
of  perforation  ;  another  upwards  between  the  stomach,  Liver,  and  gall- 
bladder;  and  another  downwards  beneath  the  abdominal  wall  towards 
the  umbilicus.  Others  may  be  added  if  though  1  advisable.  If  exten- 
sive extravasation  implicating  practically  the  whole  abdominal  cavity 
has  taken  place,  a  tube  should  be  passed  down  into  the  pelvis  through 
a  small  incision  above  the  pubes,  in  addition  to  the  gauze  drains. 
The  semi-sitting  attitude  should  be  adopted  as  soon  as  the  patient  is 
round  from  the  anaesthetic,  to  promote  drainage  and  to  lessen  the  risk 
of  pulmonary  complications  and  sub-diaphragmatic  abscess.  Shock 
should  be  treated  as  already  described  at  p.  305. 

Rectal  feeding  must  be  employed  for  at  least  forty-eight  hours, 
nothing  being  given  by  the  mouth  during  this  time  save  sips  of  tepid 
water.  It  will  be  well  to  watch  these  cases  for  a  long  time  after.  Thus, 
Mr.  Silcock  reports  a  case  treated  successfully  by  drainage,  the  ulcer 
not  being  found:  the  patient  "  has  suffered  since  from  impaired  locomo- 
tion of  the  stomach,  and  has  been  from  time  to  time  under  treatment 
as  an  out-  or  in-patient." 

Causes  of  Failure. — In  every  new  operation  especially  it  is  well  to 
bear  these  in  mind.  The  chief  are  :  (1)  Peritonitis  existing  before, 
and  not  removed  by,  the  operation.  This  has  been  the  most  frequent 
cause  of  death.  It  was  so  in  two  cases  on  which  I  operated.  Both 
were  under  the  care  of  Dr.  Newton  Pitt  : 

In  the  first  the  symptoms  of  shock  and  peritonitis  were  distinctly  subacute  and 
slightly  marked.  My  colleague,  however,  was  sure  of  his  diagnosis,  and  when  the 
abdomen  was  opened  an  open  ulcer  was  easily  seen  on  the  anterior  surface,  from  which 
a  greyish  liquid  was  continuously  gushing.  On  bringing  the  perforation  outside  the 
abdomen,  the  opening  was  felt  to  be  surrounded  by  a  large  callous  base.  Death  took 
place  from  peritonitis  forty-eight  hours  later  ;  at  the  necropsy  the  ulcer  was  found 
firmly  sutured.  In  the  second  case  operation  was  refused  at  first  when  urged  upon  the 
patient,  and  it  was  not  until  the  third  day,  when  the  abdomen  was  greatly  distended, 
tympanitic,  and  motionless,  that  the  patient  and  her  friends,  seeing  how  hopeless  the  case 
was  getting,  gave  their  consent.  When  the  abdomen  was  opened  the  stomach  itself  was 
greatly  distended.  The  peritoneal  sac,  especially  at  its  upper  part  under  the  liver, 
between  this  and  colon,  spleen,  and  kidneys,  was  filled  with  purulent  fluid,  in  which  the 
more  solid  part  of  the  last  meal  taken  (Scotch  broth)  could  be  seen  floating.  All  the 
viscera  seen  were  thickly  scattered  with  thick  yellowish  flaky  lymph.  This  was  especially 
present,  together  with  numerous  soft  adhesions,  between  the  lesser  curvature  and  the 
liver.  Had  I  broken  clown  and  searched  amongst  these  I  should  have  found  the  ulcer,* 
but  the  anterior  surface  being  sound,  and  the  stomach  greatly  distended.  I  examined 
the  duodenum  and  found,  as  I  thought,  a  minute  perforation,  a  softened  spot  on  the  anterior 
and  inner  part  of  the  first  portion,  into  which  a  probe  passed.  This  I  sutured,  and  sponged 
and  washed  out  the  peritonaeal  sac.  The  patient  was  in  a  most  critical  state  at  the  time 
of  the  operation,  and  sank  thirty-eight  hours  after.  At  the  necropsy  a  perforation  was 
found  on  the  lesser  curvature. 

The  surgeon  fortunately  gets  his  opportunity  earlier  now  than  he 
did  a  few  years  ago,  and  naturally  the  risk  of  death  from  peritonitis  in 

*  No  surgeon  should  leave  these  unexplored  in  the  hope  of  a  natural  cure.  This,  if 
accomplished,  will  very  likely  be  so  at  the  cost  of  a  sub-phrenic  abscess  and  septicaemia. 
See  also  the  remarks  above. 

S. — VOL.  II.  21 


322  OPERATIONS  OX  THE  ABDOMEN. 

spite  of  an  operation  is  considerably  diminished.  Two  recent  cases 
came  under  the  care  of  one  of  us  (R.  P.  R.),  one  within  five  hours 
and  the  other  after  nine  hours  from  the  onset  of  acute  symptoms. 

The  first  case  was  that  of  a  young  man  of  23  who  was  walking  home  hungry  over  the 
Tower  Bridge  when  he  was  suddenly  seized  with  such  a  severe  pain  in  his  abdomen 
that  he  was  obliged  to  lie  down  on  the  pavement.  He  was  promptly  brought  up  in  a 
collapsed  condition  to  Guy's  Hospital.  His  condition  soon  improved,  however,  and  then  he 
refused  operation  because  he  could  not  be  persuaded  of  his  peril.  He  wished  to  consult 
his  mother  first,  but  she  lived  far  away.  At  last  he  consented,  when  his  condition  was 
compared  with  that  of  a  drowning  man,  who  declined  to  grasp  a  rope  until  he  had 
obtained  his  mother's  sanction.  The  patient  gave  a  history  of  an  attack  of  appendicitis. 
The  pain,  tenderness,  and  rigidity  in  the  present  illness  was  more  marked  on  the  right 
side  near  the  appendix,  and  there  was  impaired  resonance  in  the  right  loin.  An  incision 
was  made  through  the  right  rectus  at  a  higher  level  than  is  adopted  for  appendicular  cases, 
because  it  was  felt  that  the  very  sudden  and  severe  onset  was  very  suggestive  of  perforation 
of  the  stomach.  Sero  pus  was  found  in  the  iliac  fossa,  but  the  appendix  was  not  actively 
diseased  ;  the  incision  was  enlarged  upwards,  and  a  good-sized  round  perforation  was  found 
and  closed  with  Lembert  sutures.  On  account  of  the  extensive  extravasation,  free  irriga- 
tion was  employed,  followed  by  the  insertion  of  cigarette  drains,  one  between  the  stomach 
and  the  liver,  and  another  in  the  right  kidney  pouch.  The  patient  was  quite  well  nine 
months  later. 

The  second  patient  was  a  girl  of  19,  who  had  suffered  severely  from  indigestion  for  six 
months.  She  also  gave  a  history  of  a  sudden  and  agonising  pain,  but  it  was  situated 
chiefly  in  the  left  hypochondrium.  She  was  given  a  dose  of  morphia  to  enable  her  to 
travel  in  comparative  comfort  from  a  fever  hospital  to  Guy's.  An  incision  made  through 
the  right  rectus  as  high  up  as  possible  disclosed  a  collection  of  sero  pus  and  gastric  contents 
between  the  liver  and  the  stomach  and  also  travelling  down  towards  the  left  kidney  pouch. 
A  perforation  was  discovered  on  the  anterior  surface  close  to  the  lesser  curvature,  very 
near  the  cardiac  orifice.  The  stomach  was  drawn  downwards  and  to  the  right,  and  an 
assistant  held  the  left  costal  margin  upwards,  while  another  retracted  the  liver  ;  and  after 
much  trouble  the  perforation  was  closed  by  inversion,  and  a  loose  flap  of  fatty  lesser 
omentum  was  turned  down  and  secured  over  the  sutures.  The  ulcer  was  a  chronic  one  of 
large  size  and  thick  walls,  so  that  inversion  was  not  easy,  apart  from  the  depth.  Irrigation 
was  not  adopted  because  the  extent  of  extravasation  was  not  great,  and  dry  swabbing  was 
used  instead.  A  cigarette  drain  was  left  in  front  of  the  stomach  near  the  perforation. 
The  patient  recovered. 

A  third  case  was  that  of  an  old  man  of  62,  who  was  admitted  iuto  Guy"s  Hospital 
over  forty-eight  hours  after  the  perforation  had  occurred,  and  after  a  long  journey  by  train. 
He  had  general  suppurative  peritonitis  with  tympanitis.  The  peritonaeum  was  rapidly 
cleansed  by  dry  mopping,  and  the  ulcer,  which  was  near  the  pylorus,  was  closed  by  inver- 
sion with  a  continuous  Lembert's  suture.  Cigarette  drains  were  placed,  one  near  the 
perforation  and  another  in  the  pelvis.  The  operation  only  took  twenty  minutes,  and  the 
patient  stood  it  very  well,  but  he  died  three  days  later,  after  seeming  to  do  well  for  two 
days.  He  occasionally  brought  up  some  black  vomit  (altered  blood),  however.  At  the 
autopsy  there  was  no  collection  of  pus  in  the  peritonaeum  ;  two  acute  ulcers  were  found, 
one  on  the  posterior  wall,  which  was  not  perforated,  and  the  other  on  the  anterior  wall, 
which  had  been  satisfactorily  closed  at  the  operation. 

(2)  Shock  of  the  operation  and  anaesthetic.  This  can  be  largely 
prevented  by  quick  operating  and  by  adopting  the  other  precautions 
mentioned  at  p.  305.  Soon  after  the  operation  infusion  is  often  of 
great  use. 

(3)  Abscess  between  the  stomach  and  liver  causing  septicaemia  or 
leading  to  empyema. 

The  treatment  must  be  efficient  drainage  ;  an  incision  being  made  in  front,  in  the 
middle  line  or  over  any  epigastric  prominence.     Drainage  should  also  be  afforded  behind 


PERFORATION   OF   GASTRIC   ULCER.  323 

l,_v  resection  of  one  or  more  ribe  (  Lancet,  voL  i.  1893,  p.  1  15).  or  a  glass  drainage-tube  be 
employed  as  in  a  case  of  Dr.  Ewarl  and  Mr.  Bennett's  (Lancet,  vol.  ii.  [894,  p.  [147) 
Vide  also  chronic  perforation,  p.  324. 

(4)  A  second  perforation.  This  is  stated  by  Finney  {loc.  supra  cit.) 
to  be  present  in  20  per  cent,  of  the  cases,  and  a  careful  search  should 
therefore  always  be  made  for  a  second  nicer.  Again,  a  second  perfora- 
tion may  take  place  after  the  operation,  for  when  the  nicer  is  very  large 
another  spot  may  give  way,  probably  from  softening  set  up  by  the  local 
inflammation  due  to  suturing. 

Mr.  Gould  {Brit.  Med.  Jimrn.,  vol.  ii.  1894,  p.  861)  mentions  a  case  of  Mr.  Pepper's  in 
which  a  perforation  had  been  sutured.  For  three  days  the  patient  did  well,  when  she 
suddenly  became  collapsed  and  quickly  died.     Tin:  necropsy  showed  (hat  the  perforation 

which  had  been  sutured  was  in  the  front  part  of  an  ulcer  the  si^e  of  a  crown-piece,  the 
line  of  suture  being  perfect  and  water-tight,  but  that  a  second  perforation  had  occurred  at 
its  posterior  part. 

(5)  Haemorrhage  from  the  same  or  another  gastric  or  from  a  duodenal 
ulcer. 

B.  Sub-acute  perforation. — The  perforation  may  be  very  small  or 
the  stomach  may  be  empty  at  the  time  of  the  perforation,  so  that  only 
a  comparatively  small  extravasation  occurs,  which  may  be  walled  off  by 
adhesions  for  a  time.  I  operated  on  a  case  of  this  kind  under  consider- 
able difficulties  with  Dr.  Gardiner  at  Dunmow.  The  perforation  had 
occurred  about  forty-eight  hours  before  the  operation,  at  which  a  collec- 
tion of  pus  was  found  between  the  liver,  the  anterior  surface  of  the 
stomach,  the  abdominal  wall  and  the  upper  half  of  the  great  omentum. 
A  small  perforation  was  found  near  the  pylorus ;  this  was  closed  and  the 
pus  was  mopped  up  and  drainage  emplo}Ted.  The  patient  recovered, 
and  was  well  a  year  later. 

The  Mortality  of  Perforation  of  a  Gastric  Ulcer. — Ten  years  ago 
it  was  a  very  rare  thing  for  one  of  these  patients  to  recover ;  now 
recoveries  are  quite  common,  and  so  diligently  are  the  successes 
published  that  it  is  quite  possible  to  underestimate  the  gravity  of  this 
serious  accident.  It  must  not  be  forgotten  that  fatal  results  are  rarely 
published,  although  much  more  might  be  learnt  from  them. 

Mr.  Crisp  English,  in  a  valuable  paper  (Med.-Chir.  Trans.,  1903, 
vol.  lxxxvii.),  published  the  results  of  50  consecutive  operations  for 
perforation  of  gastric  and  duodenal  ulcers.  The  operations  were 
performed  by  many  surgeons  at  St.  George's  Hospital  from  1892  to 
1903.  Out  of  the  42  cases  of  gastric  perforation,  52  per  cent,  recovered, 
only  three  of  the  first  ten  recovered,  but  six  out  of  seven  recovered  in 
1903. 

Mr.  Paterson  (loc.  supra  cit.)  collected  112  consecutive  cases  from  the 
records  of  two  London  Hospitals,  with  a  mortality  of  52  per  cent.  ; 
and  through  the  registrars  of  twelve  London  hospitals  he  found 
that  58  operations  were  performed  in  1904,  with  a  mortality  of  48 
per  cent. 

Mr.  Sargent  (St.  Thomas's  Hospital  Reports,  1904)  states  that  49  cases 
were  treated  by  operation  at  St.  Thomas's  Hospital  up  to  1904 ;  58  per 
cent,  of  these  recovered  after  suture  and  peritoneal  lavage.  The  average 
time  that  had  elapsed  before  the  successful  operations  was  twenty-three 
hours,  and  before  the  failures  32'6  hours. 

21 — 2 


324  OPERATIONS  ON  THE  ABDOMEN. 

There  is  no  doubt  that  the  results  are  now  better  than  these  valuable 
statistics  indicate,  for  they  extend  back  several  years.  Earlier  recog- 
nition by  the  general  practitioner  and  the  surgeon,  leading  to  earlier 
operation,  and  improvements  in  technique  have  reduced  the  mortality; 
and  in  private  practice  the  mortality  is  probably  lower  than  amongst 
the  poor,  for  the  patients  seek  treatment  earlier. 

Mr.  Moynihan  (Med.-Chir.  Trans.,  November,  1906)  records  27 
operations  for  perforated  gastric  and  duodenal  ulcers,  with  18  recoveries 
(66'6  per  cent.).  In  six  of  these  cases  gastrojejunostomy  was  performed 
immediately  after  the  closure  of  the  perforation,  with  five  recoveries. 

T.  S.  Kirk  (Med.  Press,  March  20,  1903)  records  11  cases,  in  10  of 
which  the  operation  was  performed  between  a  quarter  of  an  hour  and  ten 
hours  after  the  perforation,  and  all  recovered.  So  far  four  of  my  five  cases 
have  recovered,  but  these  numbers  are  too  few  to  found  evidence  upon. 

It  is  probable  that  the  recoveries  will  soon  amount  to  65  per  cent, 
in  skilful  hands. 

Mr.  G.  R.  Turner  and  Mr.  Crisp  English  (Lancet,  vol.  ii.  1904, 
p.  145)  publish  nine  cases  of  perforated  gastric  ulcer  with  eight 
recoveries.  Very  free  irrigation  and  drainage  were  employed  in  eight 
of  these  cases. 

C.  Chronic  Perforation. — Instead  of  sudden  perforation,  with  escape 
of  the  contents  of  the  stomach  into  the  general  peritonseal  cavit}r,  the 
perforation  here  is  associated  with  the  formation  of  adhesions  and  the 
production  of  a  localised  abscess.  This  may  be  brought  about  in 
several  ways.  In  some  cases  the  base  of  the  ulcer  becomes  adherent 
to  a  viscus — liver,  spleen,  or  pancreas, — subsequent  perforation  giving 
rise  to  an  abscess  which  slowly  burrows  first  into  and  then  beyond  the 
viscus  involved.  In  other  cases,  the  perforation  is  preceded  by  a 
plastic  peritonitis  resulting  in  the  formation  of  adhesions,  which  thus 
limit  the  diffusion  of  gastric  contents  when  perforation  occurs.  Again, 
the  leakage  of  gastric  contents  may  at  first  only  take  place  quite 
slowly,  owing  either  to  the  small  size  of  the  perforation,  to  the  stomach 
being  empty  at  the  time,  or  to  the  perforation  taking  place  during  the 
night.  The  abscess  so  produced  is  in  most  instances  of  the  sub-phrenic 
variety,  the  majority  of  which  are  caused  by  gastric  ulcers. 

The  limits  of  the  abscess  vary  according  to  the  site  of  the  perforation, 
as  will  be  understood  by  reference  to  the  accompanying  illustrations. 
Fig.  89  shows  the  boundaries  of  an  abscess  produced  by  perforation  of 
an  ulcer  in  the  anterior  wall  of  the  stomach.  It  will  be  seen  to  be 
limited  below  by  adhesions  between  the  great  omentum  and  the 
anterior  abdominal  wall,  and  above  by  the  diaphragm  and  anterior 
layer  of  the  coronary  ligament  of  the  liver.  Usually  the  abscess 
involves  one  side  only,  being  bounded  internally  by  the  falciform 
ligament  of  the  liver.  In  Fig.  90  is  shown  an  abscess  produced  by  a 
perforation  in  the  posterior  wall  of  the  stomach.  Here  the  abscess 
cavity  involves  the  lesser  sac  of  the  peritonaeum,  the  foramen  of 
Winslow  being  occluded  by  adhesions.  The  third  variety,  shown  in 
Fig.  91,  will  be  seen  to  be  in  reality  a  retro-peritonseal  abscess.  Such 
an  abscess  will  be  caused  by  a  perforation  in  the  posterior  wall  of  the 
stomach,  where  the  two  walls  of  the  lesser  sac  of  the  peritonaeum  have 
previously  become  adherent,  or,  in  some  cases,  by  perforation  of  a 
duodenal  ulcer. 


I'KKFOKATION    OK    (JAXTIJIC    ULCER. 


325 


Operation. — The  treatment  of  the  condition  resolves  itself  into 
drainage  of  the  abscess,  any  attempt  at  closing  the  perforation  in  the 
stomach  being  generally  out  of  the  question. 

If  a  diagnosis  of  Bub-phrenic   abscess  has  been  made,  and  the  limits 

Fig.  89. 


-PANCREA9 


<      ^-PERFORATION 

ft* 

H Tf— DUODENUM 


---PANCREAP 
rPERFCRATIOM 


DUODENUM 


Diagram  of  sub-phrenic  abscess  from 
perforation  of  the  anterior  wall  of 
the  stomach.     (Greig  Smith.) 


Diagram  of  snb-phrenic  abscess  from 
perforation  of  the  posterior  wall  of 
the  stomach.     (Greig  Smith.) 


of  the  abscess  can  be  ascertained,  it  may  be  opened  through  the  lower 
part  of  the  chest  wall,  portions  of  one  or  more  ribs  being  resected. 
Care    must,  however,   be   taken    to  prevent  infection    of  the  pleural 

Fig.  91. 


^-•PANCREAS 


DUODENUM 


Diagram  of  retro-peritonseal  sub-phrenic  abscess.     (Greig  Smith.) 


cavity,  by  suturing  the  two  layers  of  the  pleura  to  one  another,  it 
these  are  not  found  to  be  already  adherent.  It  is  far  better  to  avoid 
the  pleura  altogether  by  removing  a  piece  of  rib  which  is  known  to  be 
below  the  normal  level  of  the  pleural  reflection.     If  the  membrane  be 


326  OPERATIONS  ON  THE  ABDOMEN. 

found  unusually  low,  it  may  be  possible  to  displace  it  upwards.  By 
adopting  this  plan  the  grave  dangers  arising  from  pneumo-thorax  and 
empyema  may  be  avoided.  The  abscess  may  then  be  reached  by 
pushing  a  director  through  the  diaphragm  and  enlarging  the  opening 
with  dressing-forceps.  In  the  majority  of  cases,  however,  the  condition 
will  be  first  discovered  on  exploring  the  abdomen  by  means  of  a  median 
incision.  If  the  abscess  is  of  the  first  variety,  it  will  be  opened  at  once 
on  dividing  the  peritonaeum,  and  may  be  drained  entirely  through  the 
anterior  incision,  or  a  counter-puncture  majr  be  made  in  the  side. 
Should  the  abscess  involve  the  lesser  sac  of  the  peritonaeum,  it  may  be 
opened  through  the  gastro-hepatic  omentum  after  the  general  peritonaeal 
cavity  has  been  shut  off  by  careful  packing  with  iodoform  gauze,  but  it 
is  better  to  drain  it  through  the  left  loin. 

Infection  of  the  general  peritonaeal  cavity  can  be  avoided  either  by 
drawing  off  the  pus  with  an  aspirator,  or  by  making  only  a  small 
opening  and  then  carefully  mopping  up  the  pus  as  fast  as  it  escapes. 
After  the  cavity  has  been  completely  emptied  and  wiped  as  clean  as 
possible,  it  must  be  explored  by  the  finger,  and  a  counter-opening  for 
drainage  made  in  the  side.  The  soiled  gauze  surrounding  the  anterior 
opening  is  now  replaced  by  clean  iodoform  gauze,  and  the  wound  partly 
closed. 

PERFORATION    OF    DUODENAL    ULCER. 

This  occurs  much  more  frequently  in  men  than  in  women.  The 
symptoms  and  the  treatment  of  this  condition  differ  considerably  from 
those  of  perforating  gastric  ulcer,  because  of  the  site  of  the  perforation 
in  the  first  part  of  the  duodenum,  and  within  the  right  kidney  pouch  of 
the  peritonaeum  in  practically  every  case. 

Mr.  Rutherford  Morrison  described  and  drew  attention  to  the 
importance  of  this  pouch  in  1894  (Brit.  Med.  Journ.,  1894,  vol.  ii. 
p.  968). 

Mr.  Moynihan  (Lancet,  1901,  vol.  ii.  p.  1658),  in  a  valuable  paper, 
pointed  out  the  direction  in  which  extravasated  fluid  travelled  from  it 
towards  the  appendix,  giving  rise  to  symptoms  closely  simulating 
those  of  appendicitis.  In  the  51  cases  collected  by  him  a  correct 
diagnosis  was  only  made  in  two,  whereas  the  primary  incision  was 
made  over  the  appendix  in  19  cases.  Mr.  Maynard  Smith  (Lancet, 
1906,  vol.  i.  p.  895)  gives  an  interesting  account  of  an  experimental 
and  clinical  study  of  the  anatomy  and  pathology  of  the  kidney  pouch, 
and  its  bearing  on  perforating  duodenal  ulcer.  The  limits  of  the 
pouch  are :  in  front,  the  lower  surface  of  the  right  lobe  of  the  liver  and 
the  hepatic  flexcure  of  the  colon  ;  behind,  the  peritonaeum  covering,  the 
right  kidney,  and  the  posterior  abdominal  wall  which  slopes  backwards 
and  outwards  from  the  spine,  determining  the  flow  of  liquid  away  from 
the  foramen  of  "SYinslow,  which  with  the  duodenum  form  the  inner 
boundary.  The  abdominal  wall  forms  the  outer  limit ;  above,  the  pouch 
extends  behind,  to  the  right  and  in  front  of  the  right  lobe  of  the  liver. 
The  lower  boundary  is  less  complete,  consisting  partly  of  the  begin- 
ning of  the  transverse  meso-colon,  as  it  stretches  back  to  the  kidney 
and  second  part  of  the  duodenum  ;  to  the  outer  side  of  this  a  leak 
may  occur.    Maynard  Smith  found  that  liquid  which  had  been  introduced 


PERFORATION    OF    DUODENAL   ULCER.  327 

into  the  kidney  pouch  through  a  perforation  in  the  duodenum,  over- 
flowed downwards  along  the  outer  border  of  the  colon  towards  and 
ultimately  over  the  pelvic  brim,  and  in  cases  with  short  ascending 
meso-colon,  the  fluid  passed  forwards  over  the  front  of  the  ascending 
colon  near  the  liver,  and  then  passsd  downwards  towards  the  lower 
end  of  the  ileum  and  CflBCum  ;  the  obliquity  of  the  mesentery  and  the 
prominence  of  the  spine  preventing  any  flow  towards  the  left  until  the 
pelvis  had  been  flooded.* 

These  facts  have  an  important  bearing  upon  the  diagnosis  and  treat- 
ment of  perforating  duodenal  ulcer.  Such  perforations  may  be  roughly 
divided  into  acute,  subacute  and  chronic. 

In  the  acute  a  large  ulcer  may  tear  away  from  adhesions  and  a 
copious  extravasation  may  occur,  leading  to  a  diffuse  peritonitis.  In 
other  cases  the  extravasation  may  be  small  in  amount  and  become 
limited  temporarily  or  permanently  in  the  kidney  pouch. 

In  nearly  all  the  cases,  there  is  a  history  of  a  sudden  onset  of  severe 
abdominal  pain,  especially  severe  above  and  to  the  right  of  the  navel. 
In  12  out  of  14  of  Maynard  Smith's  cases,  the  initial  pain  was 
above  the  umbilicus,  and  in  8  of  these  it  was  to  the  right  of  the 
middle  line.  Shock,  more  or  less  severe  or  even  fatal  (Moynihan), 
soon  follows  ;  and  then  a  latent  period,  as  in  gastric  perforation,  may  be 
deceptive  and  cause  delay.  Soon  tenderness  and  rigidity  come  on, 
especially  of  the  right  side  and  the  right  flank,  and  the  appendicular 
region  may  become  immobile  and  dull,  so  that  appendicitis  is  diagnosed. 
Later  the  signs  of  general  suppurative  peritonitis  develop,  with  general 
distension  and  tympanites.  From  the  first  the  patient  looks  gravely 
ill,  and  his  pulse  after  the  initial  shock  becomes  gradually  quicker 
as  a  rule. 

A  previous  history  of  digestive  troubles  is  unusual,  which  is  a  contrast 
with  the  history  of  gastric  perforation. 

From  appendicitis  this  condition  may  be  distinguished  by  a  careful 
study  of  all  the  available  evidence,  the  history  of  a  very  sudden  and  severe 
onset  is  against  appendicitis,  although  a  latent  abscess  may  occasionally 
burst  and  give  rise  to  very  sudden  symptoms. 

Maynard  Smith  mentions  the  interesting  case  of  a  man  who,  whilst 
cycling,  was  seized  with  severe  and  agonising  epigastric  pain,  and  faint- 
ness.  He  was  admitted  into  the  hospital  in  a  collapsed  condition,  with 
rigidity  of  the  upper  half  of  the  right  rectus  ;  a  diagnosis  of  ruptured 
duodenal  ulcer  was  made,  but  the  operation  disclosed  "  a  gangrenous 
appendix  with  an  abscess  which  had  burst,  causing  general  peritonitis." 

The  diagnosis  is  rendered  more  difficult  because  the  appendix  may 
be  placed  higher  than  usual  and  moreover,  appendicitis  and  perforation 
of  a  gastric  and  duodenal  ulcer  have  been  shown  to  occasionally  co-exist 
or  follow  one  another  very  closely.  I 

*  Russell,  Wallace,  and  Box  (St.  Thomas's  Hosp.  Reports,  1897)  made  some  similar 
observations  on  the  anatomical  importance  of  the  "  peritonasal  watersheds." 

f  Warren  Low,  Bolton  Carter,  Lediard  and  Sedgwick,  Watson  Cheyne,  quoted  by 
Maynard  Smith  {Joe.  supra  rif.'),  and  Graham  {Ann.  of  Surg. ,  1904,  vol.  40,  p.  447).  Gutch 
(Lancet,  vol.  i.  1906,  p.  1243)  records  the  case  of  a  man  of  36  who  died  from  haemorrhage 
from  and  perforation  of  an  acute  ulcer  of  the  duodenum  ;  death  occurred  within  two  days 
of  an  operation  for  the  treatment  of  appendicitis  with  abscess  formation.  A  concretion 
was  found  in  the  appendix,  but  the  latter  could  not  be  removed. 


328  OPERATIONS  ON  THE  ABDOMEN. 

A  mistaken  diagnosis  of  intestinal  obstruction  has  been  made,  and 
several  cases  are  mentioned  by  Lockwood.*  The  rigidity,  fixation, 
tenderness  (especially  on  the  right  side),  and  other  signs  of  early  peri- 
tonitis, and  the  incompleteness  of  the  constipation  may  serve  to  prevent 
this  mistake  in  most  cases.     Leucocytosis  may  also  help. 

It  is  almost  impossible  to  tell  the  difference  between  a  perforation  of 
the  duodenum  and  a  similar  condition  of  the  pyloric  region  of  the 
stomach  in  some  cases,  for  the  fluid  may  pass  into  the  kidney  pouch 
and  travel  down  the  right  flank  exactly  as  in  duodenal  ulcer.  It  must 
not  be  forgotten  that  some  acute  diseases  that  may  be  confounded  with 
gastric  perforation  may  likewise  be  mistaken  for  perforating  duodenal 
ulcer  (ride  p.  315).  In  one  case  under  my  care,  the  patient  had  been 
thought  to  be  suffering  from  lead  colic,  and  had  been  treated  with  pur- 
gatives for  twenty-four  hours  before  I  saw  him. 

Treatment. — As  for  perforating  gastric  ulcer,  an  operation  should 
be  performed  without  delay  and  with  as  much  speed  and  care  as 
possible.  The  abdomen  should  be  opened  through  the  upper  part  of 
the  right  rectus  muscle,  and  the  fluid  mopped  away  and  the  wound 
well  retracted.     Bile-stained  fluid  often  escapes. 

The  ulcer  is  most  commonly  met  with  on  the  anterior  aspect  of  the 
first  piece,  and  is  thus  accessible.  Sometimes  it  is  on  the  posterior 
surface,  as  in  one  of  Mr.  Lockwood's  cases,  in  which  the  necropsy  showed 
that  it  would  not  have  been  seen  at  an  abdominal  exploration.! 

The  perforation  should  be  closed  by  means  of  one  or  two  layers  of 
sutures  as  in  the  treatment  of  perforated  gastric  ulcer.  It  is  especially 
important  here  to  pass  the  sutures  in  the  same  direction  as  the  axis  of 
the  bowel,  to  avoid  narrowing  of  the  canal  when  they  are  tied.  Excision 
is  less  to  be  recommended  than  in  gastric  cases,  for  it  may  be  difficult 
to  close  the  enlarged  aperture  without  constricting  the  duodenum. 
Moreover,  there  are  often  other  ulcers  in  the  duodenum  or  stomach  as 
pointed  out  by  Moynihan  (loc.  cit.).  An  omental  graft  may  be  used  to 
fortify  the  line  of  suture,  and  in  some  cases,  where  it  is  not  possible  to 
close  the  perforation,  or  this  involves  great  narrowing  of  the  lumen, 
a  primary  gastrojejunostomy  may  be  necessary,  but  it  should  not  be 
done  in  other  cases  unless  the  condition  of  the  patient  is  very  good. 
In  most  cases,  the  patient  cannot  stand  a  prolongation  of  the  operation, 
and  it  is  better  to  defer  gastro-jejunostoni}''  until  a  later  date,  and  until 
symptoms  indicate  the  need  of  it.  The  same  may  be  said  of  Finney's 
operation.  In  one  of  Mr.  Moynihan's  cases,  in  which  primary  gastro- 
jejunostomy was  performed,  the  patient,  who  had  no  general  infection 
but  only  a  little  jdastic  local  peritonitis,  recovered  ;  but  in  another, 
"  the  patient  never  rallied  from  his  collapse." 

Irrigation  may  or  may  not  be  advisable  according  to  the  extent  of 
the  extravasation,  but  in  most  cases,  it  is  better  to  use  it.  In  five  out  of 
the  seven  recoveries  recorded  by  Maynard  Smith,  irrigation  was  per- 
formed, and  the  four  cases  in  which  mopping  of  the  general  peritonaeum 
was  employed  all  died,  but  these  cases  were  also  later  in  their  disease 


*  Lancet,  1904,  vol.  ii.  p.  968. 

t  So,  too,  in  a  specimen  brought  by  Dr.  Pye-Smith  before  the  Pathological  Society 
(Lancet,  vol.  ii.  1893,  p.  1443),  it  is  distinctly  stated  that  the  ulcer  could  not  have  been 
reached  by  operation. 


PERFORATION    OK    TYNIo||>     lUKl;. 


329 


so  that  the  contrast  in  the  results  is  not  entirely  due  to  the  adoption 
or  otherwise  of  irrigation. 

Draniage  ia  even  more  important. — Cigarette  drains  should  be  pa 
through  the  loin  into  the  right  kidney  pouch,  and  if  the  pelvis  has 
been  soiled  another  should  be  inserted  through  a  suprapubic  wound. 
If  the  perforation  has  been  sutured  and  drainage  established  posteriorly, 
the  anterior  incision  may  be  safely  closed,  and  the  risk  of  ventral 
hernia   thus  diminished. 

In  Mr.  Maynard  Smith's  collection  of  cases  two  were  drained 
through  the  exploratory  wound  only,  and  both  died  ;  four  had  epigastric 
and  pelvic  tubes  :  two  of  these  died,  and  one  of  the  others  needed 
secondary  lumbar  drainage;  five  had  epigastric,  lumbar  and  supra- 
pubic drainage,  and  three  of  these  recovered. 

The  semi-sitting  attitude  of  Fowler  should  also  be  adopted,  especially 
if  no  lumbar  drain  is  used.  Feeding  per  rectum  should  be  adopted 
for  some  days  to  prevent  irritation  of  the  ulcer. 

Prognosis. — Only  seven  of  Mr.  Moynihan's  collection  of  51  cases 
recovered,  and  the  first  was  the  one  operated  upon  by  Mr.  Dunn  at 
Guy's  Hospital  in  1896. 

Since  1901,  when  Moynihan's  classical  paper  was  published,  he  has 
operated  on  five  more  cases,  bringing  his  total  up  to  seven  {Lancet, 
vol.  i.  1905,  p.  340).  Five  of  these  patients  recovered,  but  several  of 
the  cases  were  subacute  and  unaccompanied  by  extravasation,  and  this 
is  true  also  of  the  case  which  recovered  after  primary  gastrojejunos- 
tomy. Five  recoveries  occurred  in  the  14  cases  recorded  by  Maynard 
Smith. 

Crisp  English  (Joe.  supra  cit.)  found  that  two  out  of  eight  cases 
recovered  at  St.  George's  Hospital  in  the  ten  years  preceding  1903. 

D'Arcy  Power  (Brit.  Med.  Joum.,  Jan.  10,  1903)  records  four  cases, 
with  three  deaths.  In  one  of  these  drainage  was  not  used,  and  an 
unsuspected  collection  of  pus  was  found  between  the  liver  and  stomach. 

Other  successful  cases  are  recorded  by  Gibbon  {Ann.  of  Surg., 
1904,  vol.  xli.  p.  109),  Elder  (idem,  vol.  i.  1906,  p.  390),  and  Angus 
{Brit.  Med.  Joum.,  Jan.  17,  1903). 

There  is  little  doubt,  however,  that  the  prognosis  of  perforated 
duodenal  ulcer  is  much  more  grave  than  that  of  gastric  ulcer,  and  this 
is  due  chiefly  to  delay  in  the  treatment,  owing  to  the  deceptive 
nature  of  the  symptoms,  which  may  very  closely  simulate  those  of 
appendicitis.  Weir  found  that  of  13  patients  treated  by  operation 
after  thirty  hours  all  died,  but  that  of  12  operated  upon  before  the 
thirtieth  hour  66  per  cent,  recovered. 


PERFORATION  OF  TYPHOID   ULCER. 

The  diagnosis  of  this  accident,  which  occurs  in  about  2*5  to  4*9 
per  cent,  of  all  cases  of  enterica,  is  very  important.  Perforation  accounts 
for  at  least  a  third  of  the  deaths  from  typhoid  fever  (Harte  and  Ashhurst, 
Ann.  of  Surg.,  1904,  vol.  xxxix.  p.  8;  Goodall,  Lancet,  vol.  ii. 
1904,  p.  9). 

Unfortunately  it  is  very  difficult  to  arrive  at  a  diagnosis,  for  few  of 
the  classical   symptoms  and    signs  of  perforation   present  themselves 


330  OPERATIONS   ON   THE   ABDOMEN. 

when  perforation  occurs  during  the  depressed  and  almost  moribund 
stage  of  the  fever  ;  a  number  of  perforations  are  therefore  not  sus- 
pected until  they  are  discovered  at  the  autopsy.  In  others  the  diagnosis 
is  only  made  when  signs  of  peritonitis  become  evident,  and  an  opera- 
tion offers  but  a  forlorn  hope  ;  peritonitis  may  also  occur  without 
perforation. 

Perforation  practically  implies  certain  death,  although  rare  and  un- 
doubted cases  of  spontaneous  recovery  have  been  recorded.  Goodall 
relates  one  interesting  case  of  this  kind  ;  the  recovery  occurred  in  one 
out  of  68  cases  which  were  not  treated  by  operation,  giving  a  rate  of 
recovery  of  1*4  per  cent,  for  this  series,  and  this  is  unduly  hopeful. 

The  results  of  operation  for  this  condition  have  during  recent  years 
undergone  a  steady  improvement.  In  a  list  of  83  cases  which  Keen 
(Surgical  Complications  and  Sequela  of  Typhoid  Fever)  gives,  there 
were  16  recoveries;  10/2  per  cent,  of  the  operations^therefore,  were 
successful. 

Harte  and  Ashhurst  (he.  cit.)  collected  the  records  of  362  cases 
treated  by  operation,  and  found  that  26  per  cent,  of  these  had  recovered, 
but  these  figures  are  far  too  favourable,  for  all  the  successful  cases  are 
published  hurriedly,  whereas  the  records  of  failures  are  buried  in 
oblivion.  Goodall  (loc.  cit.)  mentions  49  consecutive  operations  at  the 
Metropolitan  Fever  Hospitals,  with  four  recoveries,  or  8  per  cent. 

Elsberg  (Ann.  oj  Surg.,  July,  1903)  records  25  cases  of  typhoid  per- 
foration in  children,  with  16  recoveries  ;  the  prognosis  is  known  to  be 
much  better  in  children. 

Woolsey  (Ann.  of  Surg.,  1906,  vol.  i.  p.  652)  records  17  consecu- 
tive hospital  cases,  with  a  mortality  of  76*4  per  cent.,  and  F.  T. 
Stewart  (Amer.  Journ.  of  Med.  Sci.,  May,  1904)  publishes  eight  cases, 
with  two  recoveries.  Meakins  (Montreal  Med.  Journ.,  October,  1905) 
records  1,230  cases  of  typhoid,  with  32  perforations,  20  operations, 
and  five  recoveries.  It  is  not  probable  that  the  percentage  of 
recovery  in  any  series  of  a  large  number  oj  consecutive  cases  will  be 
above  20  for  many  years  to  come,  but  this  would  be  a  brilliant 
success  for  a  condition  which  is  practically  certain  to  be  fatal  unless  an 
operation  is  done. 

This  improvement  is  doubtless  largely  due  to  earlier  diagnosis  of  the 
condition,  and  therefore  earlier  operation  ;  and  as  the  feasibility^  of  the 
operation  becomes  more  fully  recognised  by  physicians  and  surgeons 
alike,  a  still  greater  proportion  of  successes  will  no  doubt  be  obtained. 
Keen  may  be  quoted  on  this  point;  he  says,  "When  once  the  physi- 
cians are  not  only  on  the  alert  to  observe  the  symptoms  of  perforation, 
but  when  the  knowledge  that  perforation  of  the  bowel  can  be  remedied 
by  surgical  means  has  permeated  the  profession,  so  that  the  instant 
that  perforation  takes  place  the  surgeon  will  be  called  upon,  and,  if 
the  case  be  suitable,  will  operate,  we  shall  find  unquestionably  a  much 
larger  percentage  of  cures  than  have  thus  far  been  reported."  But, 
although  earlier  diagnosis  will  do  much  to  render  these  cases  more 
hopeful,  it  must  not  be  forgotten  that  many  of  them  will  still  be 
practically  hopeless  from  the  first,  both  on  account  of  the  serious  con- 
dition of  the  patient  and  of  the  technical  difficulties  which  the  surgeon 
will  have  to  face.  Some  of  the  cases  mentioned  later — for  instance, 
those  of  Thomas  and  Allingham — serve  to  emphasise  the  latter  point. 


PERFORATION   OF   TYPHOID    ULCER.  331 

The  sudden  onset  of  acute  pain,  especially  in  the  right  lower  quadrant 
of  the  abdomen,  accompanied  by  unusual  tenderness  and  rigidity, 
Btrongly  suggests  the  occurrence  of  perforation.  Shivering  is  also  an 
early  sign,  which  Goodall  lays  stress  on.  Collapse  of  any  marked 
degree  is  unusual,  and  its  absence  should  not  be  allowed  to  mislead. 
A  blood  count  is  of  no  certain  value  except  that  the  absence  of  any 
marked  decrease  in  the  number  of  red  corpuscles  indicates  that  the 
symptoms  are  not  due  to  hidden  intestinal  haemorrhage.  Leucocytosis 
does  not  develop  soon  enough  to  be  of  value.  An  obliteration  of  the  liver 
d ulness  if  it  occurs  when  the  abdomen  is  flat  may  be  of  importance  in 
confirming  the  diagnosis  in  a  few  cases,  but  its  absence  is  not  to  be 
depended  on.  It  should  not  be  forgotten,  however,  that  symptoms  of 
perforative  peritonitis  may  come  on  insidiously  in  typhoid  fever,  and 
that  a  patient  may  die  with  unsuspected  general  suppurative  peritonitis; 
also  that  the  collapse  and  exhaustion  of  the  third  week  may  simulate 
perforation. 

Every  effort  must  be  made  to  arrive  at  an  early  diagnosis,  however, 
and  for  this  reason  a  surgeon  should  be  asked  to  see  the  case  when 
any  suspicion  arises,  so  that  he  may  share  the  responsibility  and 
operate  without  delay  if  necessary.  When  there  is  a  strong  suspicion 
of  the  occurrence  of  a  perforation,  an  exploration  should  be  undertaken 
and  carried  out  as  rapidly  as  possible  if  a  capable  surgeon  is  available. 
A  blank  exploration  under  favourable  circumstances  is  not  necessarily 
a  very  serious  thing.  Harte  and  Ashhurst  give  the  following  account 
of  operations  of  this  kind  : 

"Of  26  such  operations  in  which  no  peritoneal  lesions  were  found, 
16  patients  eventually  recovered  ;  only  10  died — a  mortality  of  38*46  per 
cent.  Of  the  nine  fatal  cases  in  which  the  duration  of  life  after  opera- 
tion is  known,  only  three  died  in  less  than  twelve  hours.  Of  these  three, 
1  (Finney)  died  from  pulmonary  embolism  following  iliac  thrombosis ; 
the  second  (J.  F.  Mitchell)  had  had  severe  hematemesis  and  enteror- 
rhagia  shortly  before  operation,  and  was  in  a  very  precarious  condition  ; 
while  in  the  third  case  (Le  Conte),  in  which  the  patient  lived  nearly 
seven  hours  after  operation,  the  toxemic  state  previously  existing 
persisted  without  material  change  until  death.  In  these  three  cases 
local  amesthesia  was  used,  and  in  no  way  can  the  exploratory  incision 
be  held  to  have  had  any  connection  with  the  fatal  termination." 

The  success  of  treatment  depends  very  much  upon  early  operation, 
without  waiting  for  reaction  from  any  collapse  that  may  be  present. 
Armstrong  (Ann.  oj  Surg.,  November,  1902)  found  that  ten  operations 
performed  during  the  first  twelve  hours  were  followed  by  four  recoveries, 
whereas  the  same  number  of  operations  done  during  the  second  twelve 
hours  were  followed  by  only  one  recovery.  All  those  operated  upon 
after  twenty-four  hours  died.  Harte  and  Ashhurst's  figures  do  not 
show  the  same  striking  effect  of  delay  : 

Analysis  according  to  Duration  op  Perforation  before  Operation. 

Cases  operated  on.                                 Recovered.  Died.  Total.  Mortality. 

First    12  hours  after  perforation      ...         ...     35  95  130  73*0  % 

Second  „            „                  „                22  62  84  73-8  % 

Third     „             „                   „                 2  29  31  935  % 

Over  36  hours                       „                18  37  55  67-2% 

(_ II arte  and  Ashhurst) 


332  OPERATIONS   ON   THE   ABDOMEN. 

and  it  is  to  be  noticed  that  operations  performed  after  thirty-six  hours 
gave  a  mortality  of  only  67*2  per  cent.,  but  these  cases  were  the  few 
mild  cases  of  slight  and  localised  extravasation  that  had  survived 
long  enough  to  require  an  operation  at  this  late  period.  The  cases 
may  be  divided  into  two  different  classes — the  first,  in  which  perfora- 
tion takes  place  during  the  height  of  a  severe  attack  ;  the  second,  in 
which  the  perforation  occurs  during  convalescence  or  a  mild  relapse. 
In  the  former  class  the  prospect  is  almost  hopeless  from  the  first ;  in 
the  latter,  however,  there  is  a  considerable  chance  of  success. 

Two  anatomical  points  should  be  remembered  in  connection  with 
operation.  The  first  is,  that  the  perforation  nearly  always  occurs  in 
the  last  few  feet  of  the  ileum ;  according  to  Keen,  it  is  in  the  ileum  in 
81*4  per  cent.  Harte  and  Ashhurst  found  that  in  140  cases  out 
of  190  the  perforation  was  within  a  foot  of  the  csecum,  and  in 
only  four  was  it  more  than  a  yard  away  from  the  ileocecal  valve. 
The  appendix  was  found  perforated  in  eight  cases,  and  Meckel's 
diverticulum  in  three.  The  large  intestine  may  be  perforated  in 
rare  cases. 

The  other  point  is,  that  more  than  one  perforation  may  be  present. 
In  Keen's  list  there  were  two  or  more  perforations  in  16*7  per  cent. 
Harte  and  Ashhurst  found  that  more  than  one  perforation  had  occurred 
in  12  per  cent,  of  271  cases  (loc.  cit). 

Operation. — This  must  be  carried  out  on  the  same  lines  as  those 
described  for  perforation  of  a  gastric  ulcer,  and  as  speedily  as  possible. 
Every  precaution  having  been  taken  against  shock,  and  some  A.C.E. 
followed  by  ether  having  been  administered,  an  incision  is  made  through 
the  sheath  of  the  right  rectus  muscle,  beginning  a  little  above  the  pubis 
and  extending  upwards  for  three  or  four  inches,  the  deep  epigastric 
artery  being  avoided  if  possible. 

Eucaine  or  cocaine  local  anaesthesia  may  be  used  in  some  cases,  (a)  For  exploratory 
purposes  in  cases  of  grave  doubt,  a  small  incision  may  be  made,  and  the  lower 
three  or  four  feet  of  the  ileum  rapidly  examined,  and  a  rubber  tube  passed  into  the 
pelvis  and  aspirated  to  find  if  any  free  fluid  is  present  there  ;  (b)  for  bad  cases,  where  a 
general  anaesthetic  may  be  considered  too  hazardous.  Dr.  G.  L.  Hays  (Amcr.  Med., 
Sept.  6,  1902)  records  seven  cases  treated  under  cocaine  anaesthesia.  Three  of  his  patients 
recovered.  The  handling  of  the  intestines  and  the  retraction  of  the  wound  are  painful, 
and  the  mental  distress  produces  shock,  however  (Woolsey,  loc.  cit.~).  Goodall  found 
eucaine  to  be  unsatisfactory  in  the  only  case  in  which  he  tried  it. 

When  the  peritonaeum  is  opened  the  caecum  must  be  taken  as  a  guide 
to  the  lower  end  of  the  ileum.*  Enlarged  mesenteric  glands  or  zones 
of  intense  inflammation  may  also  be  guides  to  the  perforation.  As 
soon  as  this  is  found  the  coil  should  be  safely  brought  outside  the 
abdomen,  packed  around  with  hot  sterilised  towels  or  gauze  tampons, 
and  the  perforation  closed  according  to  the  general  and  local  conditions 
which  the  surgeon  has  to  face.  Thus,  (1)  if  the  perforation  is  single, 
small,  and  the  surrounding  intestine  in  a  condition  to  hold  sutures,  the 
perforation  should  be  closed  with  sterilised  silk,  a  continuous   suture 


*  In  an  instructive  case,  nearly  successful,  as  the  patient  lived  until  the  sixth  day 
after  the  operation,  under  the  care  of  Dr.  Cayley  and  Mr.  Bland  Sutton  (Clin.  Soc.  Tra/ns.^ 
vol.  xxvii.  p.  137),  the  loop  with  the  perforation  in  it  was  found  in  the  pelvis. 


ABDOMINAL   SECTION    IN    PERITONITIS.  333 

first  and  then  Lembert's  sutures  if  there  be  time.  (2)  An  omental 
graft  may  serve  to  plug  and  close  some  perforations  of  considerable 
size  and  with  friable  walls  (Le  Conte,  Phil,  Med.  Journ.,  I  tec.  13,  1902). 
(3)  If  it  is  clear  that  the  tissues  are  too  friable  to  hold  sutures,  the 
perforation  must  he  brought  a  little  outside  the  abdominal  wound  and 
fixed  by  sutures  which  take  up  healthy  bowel.  Later  on  this  artificial 
anus  can  be  closed.  (4)  Where  the  mischief  is  very  extensive,  part  of 
the  intestine  may  be  removed,  and  the  ends  united  by  a  Murphy's 
button,  or  both  brought  outside  and  Paul's  tubes  fixed  in  them  {vide 
infra). 

In  a  case  recorded  by  Dr.  Thomson,  of  Texas  (Med.  Citron., 
September,  1895),  the  caecum  was  so  disorganised  as  to  require 
removal.  The  two  ends  were  brought  outside.  Death  took  place 
eight  hours  later.  Another  case,  showing  how  terribly  altered  the 
tissues  with  which  we  have  to  deal  may  be,  is  mentioned  by  Mr.  H. 
Allingham  (Lancet,  vol.  i.  1894,  p.  675).  Here  the  ileum  was  adherent 
to  the  sigmoid  flexure  and  tore  to  pieces  when  touched.  Suturing  of 
the  perforation  being  impossible,  it  was  fixed  in  the  wound.  Death 
occurred  twenty-four  hours  later.  Liicke,  of  Strasburg  (Deut.  Zeit.  f. 
Chir.,  Bd.  xxv.  Hft.  1,  2,  December,  1886),  excised  a  wedge-shaped 
piece  of  the  intestine.  The  operation  took  nearly  two  hours,  and  the 
patient  never  rallied,  dying  nineteen  hours  later. 

Owing  to  the  condition  of  the  patient,  any  such  steps  as  suturing  and 
resection  will  be  quite  out  of  the  question  in  most  cases.  Perhaps  the 
plan  that  will  give  most  successes  will  be  to  keep  the  perforation  outside 
while  the  peritoneal  sac  is  being  thoroughly  irrigated,  and,  a  day  or 
two  later,  to  deal  with  it  by  suture  or  resection.  Liicke,  whose  fatal 
case  of  resection  I  have  referred  to,  advises  that  this  step  should  be 
performed  in  two  stages.  Drainage  is  required  in  most  cases  by  means 
of  a  cigarette  drain  passed  into  the  pelvis,  and  another  towards  the 
perforation.  In  cases  of  local  extravasation  only,  mopping  may  be 
sufficient,  irrigation  or  drainage,  or  both,  being  dispensed  with. 


ABDOMINAL    SECTION    IN    PERITONITIS. 

A.  In  Septic  Peritonitis. 

In  dealing  operatively  with  a  case  of  peritonitis  the  surgeon  may  find 
the  following  classifications  useful : 

(A.)  Cause.*— i.  Peritonitis  set  up  by  mischief  in  the  intestinal  tract, 
whether  accompanied  by  perforation  or  not.  Instances  of  this  group 
would  be  hernia,  appendicitis,  intestinal  obstruction,  malignant  disease,  a 
caseating  mesenteric  gland,  gastric  ulcer,  duodenal  ulcer,  typhoid  perfor- 
ation, ii.  Peritonitis  set  up  by  mischiej  in  other  viscera  than  the  intestine, 
whether  accompanied  by  a  perforation  or  not,  e.g.,  a  suppurating  ovarian 


*  It  is  plain,  I  think,  from  such  carefully  reported  cases  as  one  by  Dr.  S.  West  {Clin. 
Soc.  Trans.,  vol.  xix.  p.  36),  that  cases  of  idiopathic  purulent  peritonitis  do,  very  occasion- 
ally, occur.  Dr.  Hilton  Fagge  (Guy's  Hasp.  Rep.,  1875)  stated  that  in  an  experience  of 
twenty  years  he  had  only  met  with  two  cases  of  acute  peritonitis  in  which  no  local  cause 
could  be  found.     The  pneumococcus  as  a  possible  cause  must  also  be  remembered. 


334  OPERATIONS  ON  THE  ABDOMEN. 

cyst, twisted  ovarian  pedicle,  salpingitis,  septic  metritis,  puerperal  perito- 
nitis,* ruptured  bladder,  suppurating  gall-bladder  or  spleen,  iii.  Trau- 
matic jwritonitis  from  the  effects  of  contusion,  gunshot  or  other  injuries 
(p.  422).  iv.  Tubercular  peritonitis;  tins  will  be  taken  by  itself, 
v.  Pneumoccal  peritonitis.  (B.)  Extent  and  -Progress. — In  the  first  three 
classes,  which  are  always  septic,  the  two  distinct  varieties  of  Mickulicz 
(Centr.f.  Chir.,  No.  29,  1889),  which,  though  they  run  into  each  other, 
form  two  types,  should  always  be  distinguished  in  practice,  viz.,  (1)  the 
diffuse  septic  peritonitis,  in  which  a  large  portion  of  the  peritonaeal 
surface  is  quickly  infected,  and,  no  adhesions  being  formed,  the  infec- 
tion spreads  rapidly  ;  (2)  progressive  peritonitis,  where  the  peritonaeum 
is  only  affected  at  first  in  the  neighbourhood  of  the  cause.  This  focus 
is  at  first  shut  off  by  adhesions,  but  as  the  process  gradually  spreads, 
larger  or  smaller  quantities  of  purulent  exudation  are  encapsuled 
between  the  glued  viscera.  Mickulicz  thinks  that  the  treatment  in  the 
two  must  be  different.  In  the  first  the  whole  peritonaeum  must  be 
disinfected  as  far  as  possible.  In  the  second,  not  the  peritonaeum 
in  its  whole  extent,  but  each  inter-peritonaeal  focus  must  be  opened 
separately. 

Operation. — We  will  take  here  a  case  where  the  septic  peritonitis  is 
diffused,  where  the  surgeon  is  in  doubt  as  to  its  cause,  and  where  he 
is  met  by  that  combination  of  ominous  conditions  which  confront  us  in 
these  cases,  viz.,  peritonitis  and  effusion,  a  septic  condition,  distended 
paralysed  intestines,  and  exhaustion  from  pain,  vomiting,  &c. 

In  no  case  is  the  need  of  meeting  shock  more  imperatively  needed, 
viz.,  bandaging  the  limbs  in  cotton-wool,  a  hot-water  mattress,  or  hot 
bottles  to  feet  and  trunk.  A  hot  brandy  or  port  wine  enema  should  be 
given  immediately  before  the  operation,  and  saline  fluid  should  be 
injected  into  the  cellular  tissue  of  the  axillae  either  during  the 
operation  or  soon  after  it  is  finished.  In  the  gravest  cases,  a  solution 
of  dextrose,  6  per  cent.,  should  be  injected  into  a  vein,  at  a  maximal 
rate  of  a  pint  in  ten  minutes  (Dr.  Beddard,  Guy's  Hosp.  Gaz., 
1905,  vol.  xix.  p.  311).  No  more  than  two  pints  should  be  injected  at 
a  time.  It  is  better  to  repeat  the  injection  if  necessary,  than  to  over- 
load the  vascular  system.  In  the  worst  cases  no  general  anaesthetic 
should  be  given,  but  the  local  anaesthesia  of  cocaine  or  eucaine  made 
use  of.  If,  however,  it  is  deemed  advisable  to  induce  general 
anaesthesia,  ether  or  the  A.C.E.  mixture  should  be  used,  and  only 
enough  given  to  keep  the  patient  quiet.  There  should  be  a  plentiful 
supply  of  hot  water  which  has  been  boiled,  and  care  must  be  taken 
that  no  instruments  or  towels  come  in  contact  with  the  patient's  vitals, 
either  cold,t  or  just  out  of  irritating  chemical  solutions. 

*  I  fear  the  pathology  and  the  published  cases  in  which  abdominal  section  have  been 
resorted  to  here  are  alike  most  unfavourable.  If  the  surgeon  interfere  early,  he  will 
probably  only  find  a  congested  condition  of  the  peritonaeum.  If  he  wait  till  tympanites 
and  purulent  effusion  be  present,  his  efforts  at  relief  will,  I  fear,  be  equally  futile  in  the 
face  of  this  severe  general  septic  infection. 

f  A  temperature  of  105°  will  be  sufficient  for  instruments,  towels,  &c.,  and,  as  I  have 
said  before,  if  any  viscus  has  to  be  withdrawn  outside  the  abdomen  it  should  be  the 
duty  of  one  assistant  to  keep  its  temperature  from  falling,  and  of  one  more  to  keep  him 
supplied  with  towels  or  tampons  previously  sterilised  and  wrung  out  of  sufficiently 
hot  water. 


ABDOMINAL   SECTION    IN    PERITONITIS.  335 

The  skin  having  been  well  cleansed,  the  abdomen  is  opened  by  a 
sufficiently  free  incision  near  the  middle  line.  Now,  and  throughout  1  be 
operation,  every  manipulation  is  to  be  carried  out  as  quickly  as  possible. 

Slow  operation  means  failure  (Lockwood).* 

When  the  peritonaeum  is  opened  the  next  steps  will  depend  upon  the 
history  of  the  case,  and  the  fluid  or  gas  which  escape.  If  either  of  the 
latter  he  fecal,  the  ileo-caecal  region  is  first  examined,  owing  to  the 
frequency  with  which  the  chief  causes  of  inflammatory  or  mechanical 
obstruction  are  found  here.  If  none  are  found,  and  the  caecum  is  dis- 
tended, it  is  clear  that  the  obstruction  is  in  the  large  intestine,  or  is 
inflammatory.  To  settle  this  point  the  sigmoid  flexure  is  next 
examined.  If  it  he  distended,  and  if  there  be  no  obstruction  in  the 
rectum — a  point  previously  ascertained — the  case  is  clearly  not  one  ot 
mechanical  obstruction  (Lockwood).  The  odourless  gas  and  acid  fluid 
mixed  with  recently  taken  food  which  escapes  from  a  gastric  perforation, 
the  brownish  acid  fluid  (occasionally  faecal)  which  may  come  from  a 
similar  lesion  in  the  duodenum,  have  been  alluded  to  above.  Gelatinous- 
looking  fluid  probably  indicates  a  ruptured  cyst.  Bloody  ascitic  fluid 
ordinarily  points  to  haemorrhage,  or  a  malignant  growth,  or  strangulation 
by  a  band  or  aperture. 

In  other  cases,  the  history,  the  age,  or  the  presence  of  enlarged 
mesenteric  glands  may  point  to  the  rupture  of  an  abscess  due  to  a 
caseating  gland,  or  a  rounded  body  in  the  pelvis  to  a  suppurating  ovary 
or  fallopian  tube. 

We  will  next  suppose  a  perforation  closed,  or  some  other  cause 
removed,  and  now  we  have  before  us  how  best  to  deal  with  the  condi- 
tions remaining,  viz.,  the  distended  paralysed  intestines,  the  removal 
of  the  septic  fluid,  and  the  question  of  drainage. 

I  have  already,  under  the  treatment  of  acute  intestinal  obstruction, 
dwelt  upon  the  necessity  of  emptying  the  intestines  before  the  abdomen 
is  closed,!  otherwise  death  is  almost  certain,  from  the  continued  toxaemia 
from  the  persisting  passage  of  organisms,  of  which  the  bacillus  coli 
communis  is  only  one,  and  from  the  interference  with  the  action  of  the 
lungs  and  heart  by  the  pushed-up  diaphragm. 

The  emptying  of  the  intestines  may  be  affected  by  multiple  punctures 
(this  being  only  safe  if  gas  alone  is  present),  with  a  fine  trocar,  such  as 
a  Southey's,  the  puncture  being  made  obliquely.  If  the  coats  are 
softened  and  the  puncture  is  not  effaced  by  some  of  them  gliding  over 
the  others,  a  drop  of  intestinal  contents  will  very  likely  ooze  out  and 
continue  to  leak.  This  spot  should  be  at  once  closed  by  a  suture,  with 
a  very  fine  round  needle,  otherwise  matters  will  only  be  made  worse. 
"Where  fluids  are  also  present,  a  temporary  enterostomy  tube  (vide 
p.  132)  may  be  fixed  in  the  most  distended  coil  and  allowed  to  drain 
into  a  basin  at  the  side  of  the  table,  during  the  greater  part  of  the 


*  Mcd.-Chir.  Tram.,  vol.  xxviii.  Here  will  be  found  one  of  those  rare  cases  of  diffuse 
septic  peritonitis  saved  by  surgery.  The  cause  was  an  unexplained  perforation  of  the 
ileum. 

t  Travers,as  Sir  F.Treves  (luc.mjrra  cif)  calls  him,  "  the  father  of  intestinal  surgery," 
long  ago  insisted  upon  the  need  of  this,  and  urged  that  if  the  intestines  were  distended 
the  operation  was  incomplete  without  this  step.  More  recently  Mr.  Greig  Smith  Mr. 
Lockwood,  and  Mr.  Baker  have  drawn  attention  to  the  need  of  this 


336  OPERATIONS  ON  THE  ABDOMEN 

operation,  as  recommended  by  Carwardine  (Practit.,  January,  1905). 
Mr.  Carwardine's  tube  is  expensive  and  may  not  be  at  band,  so  that  I 
use  a  simple  flanged  metal  tube  of  small  calibre  or  a  Paul's  tube,  to 
either  of  which  a  long  piece  of  thin  rubber  tubing  has  been  previously 
tied.  In  grave  cases  the  tube  can  be  left  in  position  for  twem^-four 
hours  or  more,  and  the  small  aperture  on  the  free  border  of  the  intestine 
can  then  be  closed  by  inversion.  Failing  a  suitable  enterostomy 
tube  incising  one  of  the  most  distended  coils  is  preferable  to 
the  use  of  a  large  trocar,  which,  however  sharp,  is  liable  to  leave 
lacerated  edges.  The  incisions  should  be  about  three-quarters  of  an 
inch  long  and  made  in  the  long  axis  of  the  bowel,  on  the  aspect 
opposite  to  the  mesentery.  As  I  have  before  said,  even  after  boldly 
incising,  the  amount  of  relief  secured  is  often  disappointing.  This 
is  due  in  part,  as  the  late  Mr.  Greig  Smith  pointed  out,  to  the  acute 
flexures  in  which  the  distended  intestines  are  held  by  the  mesentery,  in 
part,  also,  to  the  easily  paralysed  condition  of  the  bowel.  The  opening 
being  brought  well  outside,  and  safely  kept  there  by  an  assistant,  the 
surgeon,  partly  by  tracing  up  and  squeezing  adjacent  coils,  partly  by 
elevating  one  end  and  lowering  the  other  of  each  distended  loop,  aids 
the  evacuation.  As  each  coil  is  emptied  it  is  cleansed  and  returned, 
but  any  incised  loop  is  kept  outside  till  the  last,  then  closed  with 
Lembert's  sutures  and  dropped  back,  unless  drainage  for  a  longer 
time  is  indicated. 

In  some  cases  an  appendicostomy  may  be  done  for  drainage  as 
recommended  by  Keetley. 

Where  any  perforation  is  present  it  may  be  simply  enlarged  for 
drainage — a  plan  adopted  by  Mr.  Lockwood  in  his  successful  cases. 
Where  a  patch  is  gangrenous  and  there  is  no  time  for  resection,  a 
Paul's  tube  may  be  inserted — a  plan  adopted  in  a  case  of  acute 
intestinal  obstruction  due  to  bands,  with  great  distension  of  the  small 
intestines,  under  the  care  of  Dr.  Perry  at  Guy's  Hospital,  in  1895. 
The  lad  recovered  with  a  faecal  fistula,  which  was  subsequently 
closed  (p.  419). 

The  next  step  is  the  cleansing  of  the  peritonaeal  sac.  The  surgeon 
must  here  remember  the  distinction  (p.  334),  made  b}r  Mickulicz, 
between  a  septic  'peritonitis,  already  diffuse  and  general,  or  one  shut  off 
here  and  there  by  adhesions,  and  so  spreading  more  slowly.  In  the  cases 
ivhere  the  peritonitis  tends  to  be  of  a  plastic  character,  where  the  intes- 
tines are  matted  here  and  there  with  lymph  of  varying  tenacit}r,  other 
parts  of  the  peritomeal  space  appearing  healthy,  the  surgeon  has  to 
face  the  following  dilemma.  If  he  separate  the  adhesions  he  will  set  up 
troublesome  bleeding,  he  may  break  down  important  repair,  and  he 
may  infect  peritonaeum  still  uncontaminated.  On  the  other  hand,  by 
not  disturbing  the  adhesions,  he  may  leave  pools  of  septic  fluid,  and  he 
may  miss,  just  when  it  is  within  his  reach,  the  chance  of  closing  some 
perforation,  or  of  removing  some  other  cause  of  all  the  trouble.  I  have 
mentioned  such  an  instance  at  p.  321,  in  the  treatment  of  perforated 
gastric  ulcer. 

Sir  F.  Treves's  authoritative  opinion  in  these  cases  inclines  (loc. 
supra  cit. ;  Brit.  Med.  Journ.,  vol.  i.  1894,  p.  519)  to  "doing  no  more 
than  is  necessary,  or  as  little  as  is  obvious.  A  clump  of  adherent 
intestines  will  often  cover  and  protect  a  perforation,  and  the  ubiquitous 


ABDOMINAL    SKCTIO.N     IN     I'KULTONITIS. 


337 


Lymph  will  many  times  close  such  an  opening  with  more  speed  and 
security  than  are  provided  by  any  system  of  suturing.*   ....  The 

main  purpose  of  the  operation  is  to  allow  a  noxious  exudation  to  escape, 

and,  if  possible,  to  free  the  peritonfflum  of  the  cause  of  its  trouble 

[f  the  operator  can  rid  the  serous  cavity  of  the  effects  of  the  per- 
foration, lie  may  very  often  leave  the  breach  itself  to  be  dealt  with 
by    natural    means/' 

Sir  F.  Treves  goes  on  to  say  that  irrigation  is  certainly  not  suited 
to  this  class  of  case — peritonitis  partially  localised  by  adhesion — gauze 
sponges  forming  here  the  best  means  of  cleansing  the  peritonaeum. 
Drainage  is  seldom  required,  and  when  employed  is  best  provided  for 
by  strips  of  iodoform  gauze  passed  among  the  coils  to  the  necessary 
depth.  The  same  authority  recommends,  in  this  form  of  perforation, 
a  liberal  dusting  of  the  serous  membrane  with  iodoform,  save  in  the 
case  of  children. 

My  own  opinion  with  regard  to  these  cases  of  septic  peritonitis 
partially  localised  by  adhesion  is,  that  the  chief  point  is  drainage, 
especially  where  the  fluid  is  purulent  and  fetid.  Drainage  must  here 
be  secured  at  all  hazards,  both  by  gauze  drains  and  tubes  from  in  front, 
and  by  incisions  behind.     Repeated  operations  may  be  required. 

It  is  in  cases  of  diffuse  septic  'peritonitis  that  the  question  of  the  best 
means  of  cleansing  the  peritoneal  sac  will  especially  arise.  There  is 
still  considerable  difference  of  opinion  on  this  point,  some  surgeons 
strongly  recommending  and  always  practising  irrigation,  whereas  others 
condemn  it  and  rely  entirely  on  sponging  ;  others,  again,  make  use 
of  neither  (vide  infra).  Even  laying  individual  opinion  on  one  side,  it 
is  no  easier  to  judge  from  results,  since  successful  cases  treated  by 
either  method  are  necessarily  few  and  far  between.  Moreover,  in 
studying  recorded  cases  it  becomes  quite  evident  that  the  condition 
described  by  different  surgeons  under  the  heading  of  general  septic 
peritonitis  is  not  always  really  the  same. 

Again,  it  should  be  borne  in  mind  that  the  result  in  any  given  case 
depends  largely  upon  two  important  factors,  namely,  the  virulence  of 
the  infection  and  the  resisting  power  of  the  individual,  neither  of  which 
can  be  in  any  way  gauged  by  the  appearances  on  abdominal  section  ;  so 
that,  on  the  one  hand,  in  a  case  of  infection  with  a  virulence  of  low 
type  in  a  patient  of  high  resisting  power,  either  irrigation  or  sponging 
may,  although  incomplete,  be  sufficient  to  turn  the  balance  in  the 
patient's  favour  ;  on  the  other  hand,  a  very  virulent  infection  in  a 
patient  whose  resisting  power  is  small  will  be  certainly  fatal,  and  this 
result  will  not  be  affected  in  the  least  by  either  irrigation  or  sponging. 
Finally,  it  must  be  borne  in  mind  that,  whichever  method  is  adopted, 
and  however  completely  it  is  apparently  carried  out,  anything  like  a 
bacteriologically  complete  cleansing  of  the  infected  surface  is  quite  out 
of  the  question. 

Where  the  fluid  is  non-infective,  e.g.,  blood,  hydatid,  bile,  &c,  where 
it  is  recent  or  not  widespread,  and  where  the  operation-area  can  be 
safely  circumscribed,  cleansing  of  the  peritonseal  sac  can  be  best  and 

*  Sir  F.  Treves  refers  to  Kaiser's  statistics  QDeutsch.  Arch.  f.  Idia.  Med.,  1876).  Here 
30  cases  of  operation  for  perforative  peritonitis  were  collected  with  11  recoveries.  In  five 
of  these  the  exact  site  of  the  perforation  was  not  ascertained. 

S. — VOL.    II.  22 


338  OPERATIONS  ON  THE  ABDOMEN. 

most  safely  accomplished  by  the  use  of  gauze  sponges,  either  used  dry 
or  wrung  out  of  boiled  water  or  salt  solution. 

Where,  however,  the  fluid  is  septic  and  widely  spread,  irrigation  with 
sterile  salt  solution  introduced  at  a  temperature  of  1050 — no°  F.  is 
probably  preferable,  a  small  incision  being  made  about  two  inches  above 
the  pubes  and  a  tube  inserted  to  facilitate  the  circulation  of  the  fluid. 
In  Sir  F.  Treves's  words  this  should  be  "introduced  at  low  pressure, 
but  in  a  wide  stream.  The  irrigation  tube  is  of  soft  rubber,  and  may 
have  a  diameter  of  three-quarters  of  an  inch.  The  tube  itself  is 
introduced  into  the  belly  cavity.  The  flow  through  it  can  be  regulated 
by  a  clip.  Any  form  of  rigid  nozzle  is  to  be  most  strongly  condemned. 
The  solution  should  flow  gently  into  the  abdomen.  The  peritoneal 
cavity  is  to  be  flooded,  and  not  to  be  scoured  out  with  a  violent  stream 
of  water  which  hisses  and  rushes  from  a  vulcanite  nozzle  like  a  minia- 
ture fire-hose.  When  the  belly  cavity  is  quite  full  of  fluid,  the  surgeon's 
hand,  which  is  already  in  position,  is  moved  to  and  fro  amongst  the 
intestines  with  great  gentleness.  By  a  movement  of  the  hand,  and 
pressure  here  and  there,  the  fluid  overflows  from  the  wound,  and  is 
replaced  by  the  steady  stream.  As  the  water  which  escapes  becomes 
clear,  the  upper  end  of  the  table  is  raised  so  that  the  shoulders  are 
much  elevated,  and  then  little  has  to  be  done  but  to  wash  out  the  most 
dependent  parts,  including  especially  the  pelvis.*  Finally,  what  fluid 
remains  in  the  pelvis  is  removed  with  sponges,  and  a  sponge  on  a  holder 
is  retained  in  the  bottom  of  the  pelvis  during  the  introduction  of  the 
stitches,  and  only  withdrawn  at  the  last  moment." t  It  is  important 
that  the  temperature  be  constant,  the  abdomen  not  over-distended,  and 
that  the  stream  be  not  directed  against  the  diaphragm.  If  these 
precautions  be  neglected  alarming  dyspnoea  may  take  place  (Reichel). 
Polaillon  has  noticed  three  cases  of  cessation  of  respiration  in  the 
human  subject  during  irrigation  (Treves).  The  most  suitable  fluids 
are  the  saline  infusion  already  advised,  or  boiled  water,  or  dilute  solutions 
of  boric  acid.  In  order  to  render  the  flushing  more  efficient  some 
surgeons  allow  the  intestine  to  escape  into  hot  moist  towels.  Mr. 
M'Cosh  (Ann.  of  Surg.,  vol.  i.  1897,  p.  686),  with  an  experience  of 
43  cases,  makes  a  practice  of  this,  except  where  the  distension 
is  enormous  and  the  heart's  action  very  weak.  He  says:  "Where 
possible,  however,  even  at  a  great  risk,  the  intestines  are  removed, 
and  if  well  protected  by  hot  towels,  I  have  not  found  that  this  eviscera- 
tion increases  to  any  extent  the  shock  of  the  operation."  Dr.  Finney, 
again,  who  reports  a  brilliant  group  of  five  successive  cases,  all  of  which 
were  cured  (Johns  Hopkins  Hosp.  Bull.,  July  1897),  considering  the 
usual  means  adopted  inadequate,  goes  even  further  than  this,  and, 
before  returning  the  intestines,  thoroughly  cleanses  each  loop  with  gauze 
wrung  out  of  hot  salt  solution,  using  "  considerable  force."  It  maybe 
mentioned  that  Dr.  Finney  considers  thorough  wiping  with  sponges 


*  From  first  to  last  the  whole  peritonaeal  sac  and  its  contents  must  be  gone  over  as 
methodically  as  possible.  For  ensuring  this  the  excellent  directions  of  Dr.  Maclaren,  of 
Carlisle  (p.  320),  should  be  remembered. 

t  There  are  some  who  hold  that  irrigation  fluid  may  safely  be  left  behind,  as  the 
peritonaeum  has  well-known  powers  of  absorption.  Such  too  often  forget  that  here  we 
are  dealing  with  a  damaged  sac,  not  the  healthy  one  of  experimenters, 


ABDOMINAL   SECTION    IN    PERITONITIS.  339 

more  useful  than  flushing.  General  experience  has  now  shown  that 
evisceration  is  to  be  avoided,  whenever  possible,  for  it  greatly  increases 
shock  and  lengthens  the  time  of  the  operation.  Moreover,  sponging 
or  rubbing  away  adherent  lymph  is  neither  necessary  nor  wise,  fortius 
only  removes  nature's  protection  and  exposes  raw  surfaces  for  fresh 
infection  and  absorption. 

Drainage.— Where  the  fluid  was  septic  this  should  be  employed. 
First  as  to  site.  As,  at  a  necropsy,  fluid  is  always  found  in  the  pelvis, 
and  sometimes  only  there,  a  drainage-tube  containing  a  wick  of  gauze 
should  always  he  placed  in  the  pelvis,  and  in  the  female  a  drainage- 
tube  should  be  inserted  into  Douglas'  pouch  through  the  posterior  wall  of 
the  vagina.  Other  rubber  tubes,  of  appropriate  size  and  properly 
fenestrated,  should  be  placed  in  those  areas  which  have  been  most 
disturbed  (Treves),  or  where  especially  septic  collections  were  found, 
or  where  bleeding  may  be  going  on.  These  must  be  brought  out 
in  front,  or,  by  counter-puncture,  laterally  or  behind.  Provisional 
sutures  must  always  be  inserted.  The  tubes  may  usually  be  removed 
in  forty-eight  hours.  If  the  discharge  that  comes  out  of  any  of  them 
be  free  or  foul,  the  tubes  should  be  cleansed  and  reinserted.  Irrigation 
by  the  tube  may  produce  fatal  collapse,  and  it  is  difficult  to  make 
certain  of  the  return  of  the  fluid  sent  in. 

Gauze  drains  are  made  of  strips  of  iodoform  gauze  about  one  inch  and 
a  half  wide  and  containing  five  or  six  layers.*  They  are  largely  used  by 
Continental  surgeons.!  The  objection  to  this  form  of  drainage  is  the 
risk  of  poisoning,  the  difficulty  and  pain  in  removing  them,  and  the 
greatly  increased  risk  of  hernia.  As  it  is  certain,  however,  that  the 
necropsies  in  septic  peritonitis  show,  most  constantly,  inadequate  drain- 
age, I  am  of  opinion  that  the  above  means  of  drainage  should  be  much 
more  extensively  employed,  until  replaced  by  treatment  more  satisfac- 
tory. The  great  importance  of  drainage  in  these  cases  is  emphasised 
by  the  fact  that  of  10  cases  of  generalised  septic  peritonitis  treated  by 
Dr.  Van  Arsdale  by  drainage  only,  recovery  took  place  in  eight  (Ann.  of 
Surg.,  vol.  ii.  1897,  p.  238).  Neither  flushing  nor  sponging  was 
employed  here,  but  simply  the  making  of  two  incisions  and  introducing 
"large  rubber  drainage-tubes  in  different  directions  through  the 
openings,  and  packing  with  iodoform  gauze."  The  recent  results  of 
Murphy  and  others  also  show  the  great  value  of  simple  incision  and 
drainage.  Le  Conte  (Ann.  of  Surg.,  1906,  vol.  i.  p.  231)  states  that  by 
adopting  this  method  Murphy  has  only  lost  one  of  his  last  29  cases 
of  general  suppurative  peritonitis.  Great  care  was  taken  in  the  after- 
treatment  in  every  way  (ride  p.  305). 

Where  the  peritonseal  surface  has  been  unavoidably  damaged,  as  in 
the  separation  of  adhesions,  the  treatment  must  vary  according  to  the 


*  Jalaguier  {Bull,  de  Mem.  de  la  Soe.  de  Chir.,  1891,  p.  800)  is  quoted  by  Sir  F.  Treves 
as  having  passed  these  strands  in  all  directions  amongst  the  intestinal  coils  from  the 
diaphragm  to  the  pelvis  with  a  good  result. 

f  The  Mickulicz  drain  or  tampon  is  used  to  check  dangerous  abdominal  hasmorrhage, 
to  close  extensive  breaches  in  the  peritonaeum,  or  to  shut  off  structures  which  are  septic. 
It  is  a  sheet  of  iodoform  gauze  placed  in  .situ  as  an  open  bag,  and  stuffed  with  strips  of 
the  same  material.  These  are  removed  piece  by  piece  after  the  first  forty-eight  hours  ; 
a  few  days  later,  when  empty,  the  bag  itself  is  removed, 

22 — 2 


340  OPERATIONS  ON  THE  ABDOMEN. 

severity  of  the  lesion.  In  slight  cases  suture  or  inversion  may  be  done, 
in  severer  ones  an  omental  graft  employed,  or  tamponnading  with 
iodoform  gauze.  The  latter  is  the  most  generally  applicable,  and  that 
with  the  least  delay. 

After-treatment. — Two  points  only  will  be  referred  to  here.  They 
are  the  most  important.  One,  the  need  of  persevering  persistence  in 
combating  shock  and  collapse  ;  the  other,  the  value  of  aperients.  If 
tympanites  and  distension  supervene  or  continue,  the  paralysed, 
thinned  intestinal  walls  probably  allow  of  the  passage  through  of 
bacteria  or  their  products,  which  are  taken  up  from  the  peritonseal  sac, 
thus  giving  rise  to  a  toxic  state.  The  passage  of  the  long  tube,  the 
introduction  of  enemata  containing  ol.  ricini  ^ij.,  ol.  terebinth,  gss.,  or 
mag.sulph.  31  j.  ;  or,  if  the  patient  can  swallow,  the  administration  of 
calomel  j>r.  ij.  every  two  hours  may  be  very  useful.  Dr.  M'Cosh  (loc. 
supra  cit.)  advocates  injections  of  magnesium  sulphate  into  the  intestine 
at  the  close  of  the  operation.  He  makes  the  injection  into  the  small 
intestine  as  high  upas  possible,  and  uses  a  saturated  solution  containing 
between  one  and  two  ounces  of  magnesium  sulphate,  the  needle  puncture 
being  closed  with  a  Lembert's  suture.  Where  the  bowel  has  been 
emptied  by  incision  or  enterostomy  tube  the  above  may  not  be 
required. 

B.  In  Tubercular  Peritonitis. 

Although  the  question  of  the  advantage  of  operation  in  this  disease 
has  been  much  debated,  there  can  now  be  little  doubt  that,  in  suitable 
cases,  great  benefit  has  often  resulted  from  operation.  It  is  still  very 
difficult  to  determine  the  actual  percentage  of  permanent  cures,  owing 
to  the  small  number  of  cases  that  have  been  efficiently  followed  up. 
Dr.  H.  P.  Hawkins  (St.  Thomas's  Hasp.  Rep.,  1892),  from  an  examina- 
tion of  100  cases  treated  consecutively  at  St.  Thomas's  Hospital,  came 
to  the  conclusion  that  there  is  but  little  difference  in  the  mortality 
whether  operation  is  resorted  to  or  not.  Such  slight  difference  as  does 
occur  is  infavour  of  operation.  The  following  figures,  quoted  by  Mr. 
Watson  Cheyne  (Lancet,  vol.  ii.  1899,  p.  1725),  are  distinctly  more 
favourable.  In  1895,  Roersch  published  358  cases  with  the  following 
results.  The  deaths  immediately  due  to  the  operation  numbered  32, 
deaths  at  a  later  period  (within  eighteen  months)  and  due  to  extension 
of  the  disease,  general  tuberculosis,  &c,  numbered  51.  In  the  rest  of 
the  cases  improvement  followed,  and  many  were  apparently  cured.  For 
instance,  in  53  cases  two  years  and  upwards  had  elapsed  since  the  opera- 
tion, and  the  patients  were  apparently  quite  cured.  According  to  these 
figures,  improvement  or  cure  therefore  results  in  75  per  cent,  of  the 
cases  operated  on.  As  pointed  out  by  Mr.  Watson  Cheyne,  this  per- 
centage is  too  high,  since  many  cases  relapse  even  after  prolonged 
periods  of  apparent  cure,  and,  moreover,  the  successful  cases  are  more 
likely  to  be  published  than  the  failures. 

Mr.  Watson  Cheyne,  as  a  result  of  his  own  valuable  experience,  con- 
siders that  improvement  takes  place  in  about  50  per  cent,  of  the  cases, 
and  he  states,  moreover,  that  in  many  the  rapid  improvement  after 
operation  was  most  remarkable.  He  says  :  "  I  must  confess  that  I  have 
been  surprised  at  the  recovery  of  some  of  these  cases.  On  opening  the 
abdomen  one  finds  tubercles  everywhere,  the  intestines  protrude  from 
the  wound  and  are  seen  to  be  red,  inflamed,  and  covered  with  tubercles, 


ABDOMINAL   SECTION    IN    PERITONITIS.  341 

bob f  them  sometimes  of  considerable  size,  the  abdominal  cavity  feels 

like  :i  bag  of  rice;  and  yet  in  these  cases  recovery  may  follow.  In  two 
cast's  in  which  I  made  a  very  bad  prognosis  alter  the  operation,  on 
account  of  the  size  and  the  number  of  the  tubercles  scattered  all  over 

the  intestines  ami  abdominal  cavity,  recovery  took  place  rapidly,  and 

apparently  completely." 

Halstead  {Amer.  Med.,  dan.  31,  1903)  states  that  over  1,500  cases 
of  tuberculosis  of  the  peritonaeum,  treated  by  operation,  have  been 
recorded.  The  percentage  of  recoveries  in  the  ascitic  form  is  from 
40  to  50  per  cent.,  and  in  the  adhesive  form  about  25  per  cent.  After 
five  years'  freedom  from  recurrence,  the  disease  may  he  considered  to 
he  cured. 

Lobsingier  (New  York  Mai.  Journ.  Dec.  5,  1903)  states  "that 
statistics  show  50  per  cent,  cured  and  25  per  cent,  greatly  henefited 
after  the  lapse  of  from  four  to  five  years  from  the  date  of  the  laparotomy." 
Death  often  occurs  from  tuberculous  lesions  in  other  parts  of  the  bod}-. 

From  the  point  of  view  of  surgical  interference  in  this  disease,  the 
following  classification  of  the  principal  types  of  the  affection  is  important. 

A.  The  Ascitic. — Here  the  inflamed  peritonaeal  sac  and  its  contents 
are  studded,  as  far  as  can  be  seen,  with  hosts  of  grey  "sago  grain" 
granulations,  tending  to  become  confluent.  Caseation  is  absent,  or  only 
present  in  a  very  early  stage.  The  fluid  is  rarely  sero-purulent.  Adhe- 
sions are  absent  or  insignificant.  The  fluid  here  may  he  localised  and 
encysted.  The  ascitic  form  may  come  on  very  insidiously,  and  is  not 
uncommonly  the  subject  of  a  mistake  in  diagnosis.  B.  The  Caseating 
and  Purulent. — Here  caseation  is  always  present;  the  amount  of  pus 
varies.  Usually  this  is  abundant,  and  is  too  often  encysted,  imperfectly, 
in  many  collections.  More  rarely  the  caseation  is  dry,  unattended  with 
effusion,  the  intestines  being  matted  together  by  adhesions  which  are 
themselves  infiltrated  and  caseating.  If  the  adhesions  are  separated, 
hosts  of  small  loculi  present  themselves,  with  scanty  fluid,  usually 
purulent.  The  caseating  is  the  variety  which  we  see  so  typically  in 
wasted  children  with  hectic,  vomiting,  and  diarrhoea.  C.  The  Fibrous. — 
This  is  the  rarest,  but  a  favourable  variety.  The  bacilli  are  probably 
few.  Caseation  is  absent,  and  any  fluid  present  serous  and  scanty. 
In  this  form  and  the  second,  if  such  parts  as  the  omentum  and 
mesentery  are  densely  infiltrated,  a  new  growth  may  be  closely 
simulated. 

The  amount  of  improvement  after  operation  that  maybe  expected  in 
any  ease  of  tuberculous  peritonitis  depends  chiefly  upon  two  considera- 
tions— (1)  the  stage  which  the  disease  has  reached,  and  (2)  the  type  of 
disease  that  is  present. 

(1)  The  Stage  of  the  Disease. — It  is  most  important  that  the  operation 
should  be  undertaken  before  the  vitality  of  the  patient  has  been  much 
diminished  by  general  failure  of  nutrition,  hectic,  or  tuberculous  disease 
of  other  parts,  &c,  in  order  that  the  effect  of  the  operation  itself  may  he 
quickly  recovered  from.  For  in  the  advanced  stages  of  the  disease  the 
shock  alone  of  the  operation  may  be  sufficient  to  bring  about  a  fatal 
result,  or  in  any  case  to  hasten  the  end.  Mr.  Watson  Cheyne's  advice 
(loc.  supra  cit.)  on  this  point  may  be  quoted:  "I  should  say  that  in 
practically  all  cases  where  improvement  does  not  follow  under  medicinal 
treatment  after  a  reasonable  time,  say  in  from  four  to  six  weeks  in 


342  OPERATIONS  ON  THE  ABDOMEN. 

acute  cases  to  from  four  to  six  months  in  chronic  cases,  the  abdomen 
should  be  opened  whether  there  be  ascitic  fluid  or  not.  The  operation 
may  do  good  in  cases  where  it  is  least  expected  to  do  so,  and  it  is  but 
seldom  that  it  can  do  any  real  harm.  Do  not  in  any  case  allow  the 
patient  to  go  downhill  too  much,  otherwise  one  cannot  expect  good 
results  to  follow,  and  it  is  fair  neither  to  the  patient  nor  to  the 
surgeon." 

(2)  The  Type  of  Disease. — The  most  favourable  cases  are  those 
belonging  to  Class  A,  where  there  is  free  fluid  and  the  adhesions  are 
few.  Class  C  is  also  favourable  for  operation,  but  Class  B  is  distinctly 
unfavourable.  Here  the  operation  may  do  much  harm,  for  adhesions 
are  numerous  and  the  wall  of  the  bowel  often  much  thinned.  The 
result  of  manipulation  is  frequently  the  production  of  one  or  more  faecal 
fistulae,  with  perhaps  the  setting  up  of  acute  suppuration.  Improve- 
ment has,  however,  resulted  even  in  some  of  these  cases,  for  Mr. 
Watson  Cheyne  points  out  that  there  is  no  class  of  cases  in  which  some 
improvement  has  not  taken  place,  so  that  it  is  very  difficult  to  absolutely 
exclude  any  case  from  operation. 

Operation. — In  the  majority  of  cases  this  consists  simply  in  opening 
the  abdominal  cavity  by  means  of  a  median  incision  and  letting  out  the 
fluid.  The  escape  of  the  fluid  may  be  facilitated  by  turning  the  patient 
on  to  his  side,  and  also  to  some  extent  by  sponging.  Where  the  fluid  is 
loculated  by  means  of  adhesions,  the  separate  loculi  may  be  made  to 
communicate  by  gently  breaking  through  such  of  the  adhesions  as  may 
be  necessary  for  this  purpose.  No  extensive  disturbance  of  the  adhesions 
beyond  this  is  either  necessary  or  advisable.  There  is  nothing  to  be 
gained  by  either  washing  out  the  abdominal  cavity  or  by  drainage,  so 
that  as  soon  as  all  the  fluid  has  escaped  the  abdominal  wound  should  be 
closed  in  overlapping  layers,  and  the  dressings  applied.  In  carrying 
out  this  operation,  in  some  cases  an  obvious  primary  seat,  such  as  a 
tuberculous  Fallopian  tube  or  caecum  or  appendix,  ma}T  be  discovered. 
This  may  be  removed  should  the  condition  of  the  patient  be  such  as 
to  admit  of  the  necessary  prolongation  of  the  operation,  and  if  the 
adhesions  are  not  so  numerous  as  to  render  the  procedure  very  difficult. 
In  many  cases,  however,  in  which  such  a  primary  focus  is  found,  it 
will  be  firmly  fixed  to  other  important  structures  or  embedded  in  a 
mass  of  adhesions ;  in  such  cases  the  wiser  course  will  generally  lie  in 
making  no  attempt  at  a  radical  operation,  but  in  resting  content  with 
letting  out  the  ascitic  fluid  as  described  above. 

If  on  opening  the  abdomen  the  case  is  found  to  belong  to  Class  B, 
great  care  and  gentleness  must  be  used  in  opening  up  and  dealing  with 
abscess  cavities,  for  the  walls  of  the  intestines  are  frequently  thinned 
and  softened  by  the  disease,  so  that  any  undue  roughness  in  handling 
is  extremely  liable  to  result  in  rupture  of  the  bowel,  either  at  the  time 
or  later,  causing  feecal  abscess  or  fistula.  No  attempt  should  be  made 
in  such  cases  at  eradicating  the  disease,  but  abscess  cavities  may  be 
treated  as  tuberculous  collections  elsewhere  are  treated,  by  evacuating 
the  contents,  gently  swabbing  out  the  cavity  with  pledgets  of  sterilised 
gauze,  introducing  sterile  iodoform  emulsion,  and  then  closing  the 
cavit}\  If  the  pus  is,  however,  found  to  be  faeculent  owing  to  infection 
from  the  bowel,  the  abscess  must  be  either  drained  with  a  tube  or 
stuffed  lightly  with  tampons  of  iodoform  gauze. 


PNEUMOCOCCIC    PERIT( ) N  I T I S. 


343 


PNEUMOCOCCIC    PERITONITIS. 

Dr.  W.  F.  Annaud  and  Mr.  W.  H.  Bowen  (Lancet,  1906,  vol.  viii. 
p.  1591)  have  recorded  four  eases  of  this  rare  disease,  and  they  were 
able  to  collect  91  cases,  including  their  own ;  all  these  patients 
were  children  under  the  age  of  15  ;  the  disease  is  much  less 
common  in  adults.  In  30  cases  the  peritonitis  was  secondary  to  a 
lesion  elsewhere, 'especially  in  the  lungs  and  pleura.  Primary  infections 
had  occurred  in  the  throat  or  middle  ear  in  several  cases. 

In  45  patients  the  peritonitis  was  considered  to  be  primary, 
possibly  due  to  infection  from  the  intestines,  especially  from  the 
appendix.  In  44  cases  there  was  such  a  rapid  spread  of  the 
infection  that  it  was  impossible  to  decide  upon  any  primary  seat. 

The  pus  is  nearly  always  thick  and  odourless,  and  it  may  have 
fibrinous  or  jelly-like  masses  floating  in  it,  and  layers  of  greenish- 
yellowish  lymph  are  deposited  on  the  peritonaeum  and  intestinal  coils. 
The  peritonitis  may  be  localised  or  diffuse,  sub-acute  or  acute.  The 
sub-acute  form  generally  starts  acutely,  but  there  is  a  great  tendency 
towards  the  formation  of  circumscribed  sub-acute  abscesses,  so  that 
a  diagnosis  of  tuberculous  peritonitis  is  quite  likely  to  be  made.  The 
acute  form  is  generally  mistaken  for  peritonitis  due  to  appendicitis, 
unless  a  primary  pneumococcal  lesion  is  known  to  exist.  The  character 
of  the  pus  and  the  absence  of  any  discoverable  source  of  the  peritonitis 
should  make  the  diagnosis  clear  during  the  operation. 

Treatment. — Localised  abscesses  should  be  incised  and  drained.  In 
the  acute  diffuse  form,  the  diagnosis  will  only  be  made  when  the 
abdomen  is  opened  for  peritonitis  of  uncertain  cause.  Bowen  advises 
mopping  out. the  pus,  and  closing  the  wound  completely  if  the  pus  be 
sweet ;  but  if  the  pus  be  evil  smelling  indicating  mixed  infection 
drainage  should  be  adopted.  I  should  be  inclined  to  leave  a  tube  in 
the  pelvis  in  every  case,  and  Von  Bruns  believes  drainage  to  be 
necessary. 

The  Prognosis. — The  following  table  from  Annaud  and  Bowen 
speaks  for  itself. 


O 

ss 

0   g 

S  S  g 

S          CD 

IS! 

asg 

3  c3  CD 

O 
I 

II 

14 
0 

3 

Result. 

Variety  of  peritonitis. 

0 

cS 

Q 

.  .5* 
s'3 

CD 

Primary  local 

Secondary  local  ... 

Primary  diffuse   ... 

Secondary  diffuse 

(local 
Origin  uncertain    \ 

(diffuse 

26 
11 

21 
19 

8 
6 

26 

10 

10 

5 
8 

3 

22 

9 
2 

3 

6 
1 

3 

1 

19 

16 

2 

5 

I 
I 
O 
O 

0 

0 

Total 

9i 

62 

29 

43 

46 

2 

344  OPERATION'S  ON  THE  ABDOMEN. 

"  Forty-five  of  the  gi  eases  had  encysted  peritonitis,  of  which 
44  were  operated  on,  and  of  these  37  recovered  and  six  died ; 
in  two  the  result  is  uncertain.  The  other  46  cases  were  of  the 
diffuse  variety,  of  which  18  underwent  operation.  Of  the  18  cases 
operated  on  six,  or  33*3  per  cent.,  recovered,  whereas  all  those 
not  operated  on  died.  The  one  case  of  the  local  variety  not 
operated  on  recovered  by  spontaneous  evacuation  of  the  pus.  The 
above  table  shows  that  recovery  occurred  in  86  per  cent,  of  those 
with  the  encysted  form,  whilst  only  14  per  cent,  of  the  cases  with 
the  diffuse  variety  survived." 

It  is  probable  that  this  form  of  peritonitis  is  more  common  than  is 
suspected  at  present,  and  that  a  more  general  bacteriological  examina- 
tion of  the  pus  in  cases  of  peritonitis  will  prove  this  assertion. 


ENTEROSTOMY— FORMATION     OP     AN     ARTIFICIAL    ANUS 
IN    THE    SMALL    AND    LARGE    INTESTINE. 

This  subject  has,  in  part,  been  already  considered  under  Colotomy  ; 
I  now  allude  to  it  again  to  aid  my  readers  when  they  have  to  face  the 
following  indications  : 

A.  Chiefly  referring  to  the  Small  Intestine  and  Acute 

Intestinal  Obstruction. — Either  a  temporary  or  a  permanent 
opening  may  be  made.  Temporary  drainage  is  called  for  (1)  when 
the  surgeon  decides,  owing  to  the  patient's  condition,  not  to  perform 
an  ordinary  abdominal  section,  but  to  relieve  the  distension  as  a 
temporary  measure  by  opening  the  bowel  above  the  obstruction  ;  (2)  in 
those  cases  (already  referred  to,  p.  264)  in  which  distension  of  the 
small  intestine  is  considerable,  and  in  which  the  obstruction  has  been 
successfully  relieved. 

A  permanent  opening  will  be  necessary  when  the  surgeon  cannot 
detect  the  site  of  obstruction,  or  where  he  finds  it,  but  cannot  remove 
it  or  make  a  short  circuit.  Under  these  circumstances  he  may  be 
driven  to  open  the  small  intestine.  The  opening  must  be  as  near  the 
caecum  as  possible,  in  order  to  avoid  the  danger  of  death  from  starva- 
tion which  would  be  caused  by  an  opening  high  up  in  the  small 
intestine.  The  only  certain  way  of  localising  any  part  of  the  small 
intestine  is  to  trace  it  to  or  from  one  or  other  end.  If  valvulae  conni- 
ventes  can  be  felt  by  drawing  the  bowel  between  the  fingers  and 
thumb,  then  it  is  certain  that  the  loop  is  above  the  middle  of  and  far  too 
high  in  the  small  intestine,  for  making  either  an  artificial  anus  or  intes- 
tinal anastomosis.  The  thinner  walled  and  smaller  of  calibre  the  loop 
is  found  to  be  in  comparison  with  others,  the  more  likely  is  it  to  be  low 
down  in  the  ileum,  but  too  much  faith  must  not  be  placed  in  this,  for 
hypertrophy  from  obstruction  may  make  the  test  of  little  value.  Dr. 
Monks  {Trans.  Amer.  Surg.  Assoc,  1903,  p.  405)  has  pointed  out  that 
any  loop  picked  up  in  the  upper  and  left  third  of  the  abdomen  probably 
belongs  to  the  upper  third  of  the  jejunum,  any  in  the  lower  and  right  third 
to  the  lower  ileum,  and  any  in  the  middle  third  to  the  middle  third  of 
the  small  intestine.  The  more  fatty  the  mesentery,  and  the  more  com- 
plicated the  arrangement  of  its  blood  vessels,  and  the  shorter  the  vasa 
recta,  the  more  certain  is  the  loop  to  belong  to  the  ileum  low  down. 


ENTEROSTOMY. 


145 


These  operations  are  merely  palliative,  and  are  only  to  be  made  use  of 
when  the  adoption  of  other  and  more  desirable  courses  is  impossible, 
or  when  the  surgeon  feels  sure  he  can  open  the  small  intestine  low 
down.  It  lias  been  urged  by  those  who  have  recommended  such 
operations — e.g.,  Nelaton,  [840 — that  some. obstructions  relieve  them- 
selves  if  a   temporary   outlet   has  emptied   the    accumulation    above. 

This  may  he  true  of  a  very  small   number  of  cases — ('.(/.,  volvuli  which 

have  not  gone  too  far,  and  Loops  which  are  incarcerated  rather  than 
strangulated.  Another  point  urged  in  favour  of  this  operation  is  that 
it  involves  much  less  shock  and  disturbance  of  the  abdominal  con- 
tents.    This  lust  is  true.     But,  from  what  I  have  seen,  this  operation 


Fig  92. 


V 


B 


To  show  Greig  Smith's  method  of  performing  temporary  enterostomy. 
B,  Bowel.     M,  Mesentery.     T,  Rubber  tube.     P,  Peritonaeum.     1,  Strapping 
fixing  dressing.     2,  Pin  holding  bowel  and  tubing  in  position,     x — x,  Enlarged 
view  of  plan  of  fixing  bowel  and  tube  by  pin  and  suture.     (Greig  Smith.) 

usually  fails,  by  leaving  irrecoverable  mischief  behind  in  the  very  cases 
to  which  it  is  best  suited — viz.,  acute  obstruction  where  the  lesion 
cannot  be  found,  or  where  it  cannot  be  dealt  with,  or  is  beyond 
recovery.  Even  if  it  succeed  it  is  at  the  cost  of  great  and  lasting 
inconvenience.  Owing  to  the  liquid  state  of  the  contents,  control  is 
very  slight,  and  the  raw  and  eczematous  condition  of  the  tissues 
adjacent  to  the  opening  is  productive  of  great  discomfort.  Unless  the 
condition  of  the  patient  is  very  grave,  it  is  far  better  to  perform  some 
form  of  lateral  anastomosis,  than  to  make  an  artificial  anus,  especially 
in  the  small  intestine.  When  the  obstruction  is  acute  and  irremov- 
able, it  may  be  safer  to  form  a  temporary  enterostomy,  than  to  short- 
circuit   at  once,  but  a  secondary  anastomosis  should  be  undertaken  if 


346 


OPERATIONS   ON   THE   ABDOMEN. 


possible  to  relieve  the  patient  of  the  intolerable  nuisance  of  a  per- 
manent faecal  fistula,  especially  in  the  small  intestine.  In  some  malig- 
nant obstructions  within  the  pelvis  this  may  not  be  practicable. 

Temporary  Drainage  of  the  Small  Intestine  (Figs.  50  and  51). — The 
following  method,  in  which  rubber  tubing  is  used  to  carry  off  the  con- 
tents of  the  bowel,  was  described  by  the  late  Mr.  Greig  Smith  (Abdom. 
Surg.,  p.  687),  and  will  be  found  to  be  easy,  rapid,  and  satisfactory.  It 
is  described  as  follows  : — "  Between  the  second  and  third  fingers  of  the 
assistant's  left  hand  and  the  same  fingers  of  his  right  hand,  held  back 
to  back,  a  V-shaped  piece  of  the  intestinal  border  is  compressed  and 
excluded.  On  the  free  border  of  this  Ibid  the  incision  is  made  large 
enough  to  admit  the  tubing.  If  the  bowel  is  properly  held  no  gas 
or  fluid  escapes.  With  fine  peritonaeal  catch-forceps  the  mucous  mem- 
brane on  each  side  of  the  small  incision  is  grasped  and  pulled  out  a 
little  way,  and  the  tubing,  stretched  over  a  blunt  probe,  is  pushed 
through  the  opening.  The  tubing  is  at  once  fixed  to  the  margin  of 
the  incision  by  a  safety-pin  or  two,  or  in  the  manner  shown  in  the 

Fig.  93. 


A  B  C  D  E 

A,  Flange  of  inner  tube.     B,  Flange  of  outer  tube.     C,  Spring  which  by  com- 
pression releases  the  clutches.     D,  Fly  nut  to  protect  spring  (optional).     E,  End 
of  inner  tube  to  which  india-rubber  tubing  is  attached. 
Carwardine's  enterostomy  tube. 

diagram  (vide  Fig.  92).  If  it  fits  accurately  there  will  be  no  escape 
of  intestinal  contents  by  its  side.  The  fingers  of  the  assistant  are  now 
removed,  and  the  gases  and  fluids  permitted  to  escape.  When  the  bowel 
has  collapsed  the  loop  is  cleansed  and  returned  into  the  abdomen, 
leaving  outside  about  an  inch  of  bowel  containing  the  tubing.  The 
tubing  should  at  its  inner  extremity  clear  the  parietes,  but  need  go  no 
further  inside.  The  parietal  sutures  already  placed  are  now  tied,  all 
save  one,  which  is  to  be  tied  in  a  few  days  when  the  extended  loop  is 
returned." 

Carwardine's  self-retaining  enterostomy  tube  is  a  great  improvement 
upon  the  rubber  tubing,  but  it  may  not  be  available.  Lilienthal's 
self-retaining  trocar  and  cannula,  although  complicated,  may  be  found 
useful  (Ann.  of  Surg.,  1906,  vol.  i.  p.  912). 

Instead  of  the  above  the  following  method  may  be  used.  The  abdo- 
minal incision  is  closed  with  the  exception  of  an  inch  and  a  half  at 
the  lower  part.  Here  the  parietal  peritonaeum  is  first  united  to  the  skin 
by  a  few  points  of  suture.  The  loop  of  intestine  which  it  is  intended  to 
drain  is  then  carefully  attached  to  the  parietal  peritonaeum  b}r  a  con- 
tinuous silk  suture,  picking  up  the  serous  and  muscular  coats  of  the 
bowel  on  the  one  hand,  and  the  parietal  peritonaeum  on  the  other, 
as  shown  in  Fig.  94.     The  sutured  edges  are  then  sealed  with  collodion. 


ENTEROSTOMY.  347 

The  bowel  is  now  punctured  by  a  trocar  and  cannula  which  have  been 
passed  through  a  piece  of  thin  india-rubber  sheeting,  the  contents  of  the 
bowel  being  allowed  cither  to  pass  into  the  dressings  or  being  led  away 
to  a  suitable  vessel  hy  means  of  a  tube  attached  to  the  cannula,  or  a 
small  Paul's  tuhe  may  he  inserted  within  an  area  encircled  by  a  purse- 
string  suture,  which 'serves  to  fix  the  tube.  A  tuhe  made  for  me  by 
Down  Brothers  has  the  advantage  of  having  an  oval  flange,  which  allows 
the  tuhe  to  he  introduced  through  a  small  incision,  which  is  a  distinct 
advantage  for  temporary  enterostomy.  Pliahle  rubher  tubing  can  also 
be  fixed  to  the  end  of  the  tuhe  with  ease  (vide  Fig.  56,  p.  133). 

Formation  of  a  Permanent  Artificial  Anus  in  the  Middle  Line 
(Fig.  95). — The  contents  of  the  peritoneal  sac  having  been  shut  off  by 
gauze  tampons  and  sponges,  the  surgeon  makes  an  artificial  anus  in  one 
of  the  following  ways  : — A  loop  of  intestine,  as  near  the  obstruction  as 

Fig.  94. 


Fjecal  fistula.  The  parietal  and  intestinal  peritoneum  have  been  united  by 
a  continuous  suture  (Kocher).  This  figure  should  be  contrasted  with  Fig.  96, 
which  shows  an  artificial  anus.  Here  there  is  no  prolapsus  and  no  spur,  this 
opening  being  intended  for  temporary  purposes. 

possible,  being  chosen  by  its  distension,  congestion,  &c,  it  is  brought 
outside,  and  as  much  of  the  median  incision  as  is  feasible  is  safely  closed 
with  sutures.  Those  sutures  which  have  to  be  placed  nearest  the 
intestine  should  not  be  tied,  but  kept  clamped  with  Spencer  Wells's 
forceps,  so  that  the  surgeon  may  easily  draw  out  or  replace  some  of  the 
intestine  as  he  requires.  The  intestine  is  now  fixed  either  by  some 
form  of  rod  and  sutures,  or  by  sutures  alone.  In  either  case,  if  there  be 
time,  the  parietal  peritonaeum  may  be  sutured  here  and  there,  by  points 
of  fine  silk  passed  with  round  needles,  to  the  peritoneal  coat  of  the 
intestine  so  as  to  shut  off  the  general  peritoneal  sac,  great  care  being 
taken  not  to  perforate  the  lumen  of  the  bowel.  Then  a  piece  of  suitable 
bougie,  glass  rod,  &c,  which  has  been  boiled,  is  passed  through  the 
mesentery,  avoiding  any  vessels,  so  as  to  keep  the  loop  well  out  of  the 
abdomen.  If  too  much  bowel  has  been  withdrawn  some  is  now  returned, 
the  parietal  wound  closely  sutured  up  to  the  projecting  gut,  and  a  lew- 
sutures  placed  between  the  intestine  and  the  margin  of  the  wound. 
These  must  not  enter  the  lumen  of  the  bowel.     Finally,  there  must  be 


348 


OPERATIONS  ON  THE  ABDOMEN. 


no  twisting  of  the  gut  as  it  is  brought  out.  If  the  rod  is  used,  care 
must  be  taken  that  too  much  of  the  gut  is  not  prolapsed,  a  point  rather 
difficult  to  secure  by  this  method.  The  smaller  the  prolapsus  consistent 
with  safety — i.e.,  non-contamination  of  the  peritonaea!  sac — the  less  the 
irritation  and  bleeding  from  friction  of  the  dressings,  &c,  in  the  future, 
and  the  smaller  the  opening  to  be  closed  by  any  subsequent  operation  if 
this  prove  feasible.  If  sutures  alone  are  used,  most  of  the  above  steps 
are  the  same,  but  extra  care  must  be  taken  in  closing  the  parietal  wound, 
so  as  to  support  the  intestine  which  is  to  form  the  artificial  anus,  and 
additional  sutures  must  be  passed  between  the  edges  of  the  wound  in 


Fig.  95. 


Formation  of  an  artificial  anus. 
B,  Bowel  on  proximal  side  of  spur.     B',  Bowel  below  spur.     T,  Rubber  tubing. 
Sp,  Spur  ;   at  the  top  the  black  circular  spot  represents  a  section  of  the  sup- 
porting  rod.     1,    Strapping.     2,   Gutta-percha   tissue.      3,   Absorbent   dressing. 
(Greig  Smith.) 

the  parietes  and  the  bowel.  If  this  be  distended  much  caution  will  be 
required  lest  the  lumen  is  opened  and  the  wound  infected.  The  employ- 
ment of  the  continuous  suture  is  shown  in  Fig.  96. 

Opening  the  Bowel. — If  it  be  possible  a  few  hours  should  be  allowed 
to  elapse.*  But  if  immediate  relief  is  required  one  of  the  following 
methods  may  be  adopted.  The  whole  of  the  wound,  save  where  the 
opening  is  to  be  made,  is  covered  with  iodoform,  and  the  sutured  edges 
may  be  sealed  with  collodion  and  iodoform.     (1)   The  bowel  may  be 

*  If  this  delay  is  possible,  a  guiding-stitch  should  be  inserted  (not  entering  the  lumen 
of  the  bowel)  at  the  point  where  the  opening  will  be  made.  This  renders  easy  what 
otherwise,  owing  to  the  rapid  alterations  in  the  surface  of  the  bowel  and  landmarks,  may 
prove  very  difficult. 


KNTKROSTOMY. 


149 


opened  byatrocarand  cannula  which  have  been  passed  through  a  piece 
of  thin  india-rubber  sheeting  (Cripps),  so  that  the  fluid  faeces  do  not 

Hood  the  wound,  \c.  A  very  useful  precaution  is  to  insert  a  temporary 
suture  into  the  intestine,  (dose  to  where  the  opening  is  to  be  made,  so 
that  by  pulling  on  this  the  surgeon  can  keep  the  bowel  forwards  and 
the  flow  away  from  the  wound.     (2)  A  self-retaining  enterostomy  tube, 

Fig.  96. 


/>'; 


Formation  of  an  artificial  anus.  A  continuous  suture  has  been  used  (Kocher). 
It  is  evident  that  there  will  be  a  good  spur  and  plenty  of  prolapsus  ;  much  of  this 
will  be  cut  away  later  on.  This,  which  is  intended  for  a  permanent  opening, 
should  be  contrasted  with  Fig.  94,  which  shows  a  fiecal  fistula  only. 


Fig.  97. 


which  does  not  allow  any  leakage,  may  be  employed.  (3)  A  piece  of 
rubber  drainage-tube  may  be  inserted  into  the  bowel,  as  described 
above  in  Greig  Smith's  operation  for  making  a  temporary  fistula  (vide 
Fig.  92).  (4)  A  fourth  method  is  to  make  use  of  a  Paul's  tube 
(Fig.  97).  I  have  already  referred  to  the  use  of 
the  larger  size  in  the  performance  of  colotomy 
(p.  132). 

The  glass  tubes  are  made  in  two  sizes.  That 
used  for  the  colon  or  rectum  (Fig.  97,  1)  has 
been  improved  in  shape  by  Messrs.  Wright  & 
Co.,  of  New  Bond  Street,  wdio  have  succeeded 
in  bending  it  at  the  proper  angle,  which  avoids 
all  strain  on  the  bowel.  It  measures  5  inches 
in  length  by  1  in  diameter,  has  a  double  rim 
at  the  bowel  end  and  a  single  rim  at  the 
distal  end,  and  is  bent  at  a  right  angle.     The 

tube  for  the  small  intestine  (Fig.  97,  2)  is  as  light  as  is  consistent  with 
sufficient  strength.  It  measures  2\  inches  by  \  inch,  and  is  bent  at  a 
right  angle  at  the  distal  end.  In  either  case,  the  end  with  the  double 
rim  is  introduced  into  a  small  incision  made  in  a  loop  of  intestine, 
drawn  out  if  possible,  and  safely  shut  off  with  aseptic  gauze  packing. 
The  end  thus  inserted  is  then  securely  tied  in  wdth  a  silk  ligature  of 
sufficient  stoutness.  While  this  is  being  tied,  an  assistant  with  two 
pairs  of  dissecting-forceps  should  keep  the  edges  of  the  opening  in  the 
bowel  well  pulled  up  over  the  rim  of  the  tube.     Fasces  from  the  large 


350  OPERATIONS  ON  THE  ABDOMEN. 

tube  are  received  into  a  jaconet  bag  containing  wood-wool,  or  other 
absorbent  material,  except  the  first  rush  in  cases  of  obstruction, 
which  is  best  received  into  a  basin.  To  the  small  one  an  india- 
rubber  tube  is  attached,  which  conveys  the  liquid  fasces  of  the  small 
intestine  into  a  bottle,  beneath  an  antiseptic  fluid  (Paul,  Liverpool 
Med.-Chir.  Joimi.,  July,  1892).  Two  objections  have  been  made  to  the 
use  of  these  tubes.  One,  that  it  is  difficult  to  insert  the  tube  without 
the  risk  of  letting  some  fasces  escape  over  the  wound.  This  is  certainly 
true  when  the  intestine  is  distended  and  the  fasces  fluid.  If,  however, 
the  loop  to  be  opened  is  emptied  into  adjacent  bowel,  and  temporarily 
clamped  if  possible,  the  introduction  of  the  tube  is  greatly  simplified ; 
otherwise  the  operator  may  safely  trust  to  drawing  out  the  bowel 
as  much  as  possible  and  isolating  it  with  gauze.  The  other  objec- 
tion is  that  the  silk  ligature  may  cut  its  way  through  too  quickly, 
especially  if  the  bowel  is  much  congested.  Thus,  the  tube  may  be  loose 
in  two  or  three  days  ;  but  it  not  infrequently  remains  for  a  week  firmly 
adherent,  partly  because  some  of  the  circulation  becomes  re-established 
beyond  the  ligature,  and  partly  owing  to  the  copious  exudation  of 
lymph,  which  covers  the  bowel  to  the  very  end,  quite  concealing  the 
ligature  (Paul).  The  use  of  a  purse-string  suture  to  fix  the  tube  in  the 
bowel,  and  the  prevention  of  undue  tightness  in  tying  in  the  tube,  will 
help  to  lessen  this  trouble.  If  the  tube  becomes  loose  too  soon,  two 
or  three  Spencer  Wells's  forceps  should  be  applied  to  the  margins  of 
the  opening  in  the  bowel,  so  as  to  keep  this  forward  until  the  parts 
are  more  firmly  healed. 

I  have  given  (p.  418)  an  instance  in  which,  in  1895,  after  dividing  two  bands  in  a  case 
of  acute  intestinal  obstruction  admitted  on  the  fourth  day,  I  drained  the  intestines  by 
a  Paul's  tube  tied  into  the  worst  of  three  gangrenous  patches  present.  Vomiting  with 
some  tympanites  continuing,  I  had  an  ounce  of  castor  oil  given  by  the  tube.  Abundant 
flatus  was  soon  passed  per  rectum,  and  recovery  steadily  followed.  Owing  to  the 
patient's  brutish  behaviour— he  was  discovered  on  the  point  of  drinking  his  urine, 
he  took  solid  food  from  other  patients,  and  five  days  after  the  operation  pulled  the 
tube  out  of  the  bowel— a  fsecal  fistula  followed,  which  I  closed  by  the  method  given 
at  p.  418. 

Nelaton's  Operation.     Right  Iliac  or  Inguinal  Enterostomy. 

Operation. — A  horizontal  incision,  about  two  inches  long,  is  made  a 
little  below  the  centre  of  a  line  drawn  from  the  umbilicus  to  the  right 
anterior  iliac  spine,  or  one  lower  down  parallel  with  the  outer  part  of 
Poupart's  ligament.  The  cascum  having  been  made  out  to  be  empty, 
the  relation  of  this  to  the  distended  coils  which  are  present  in  the 
wound  should,  if  feasible,  be  made  out,  so  that  the  small  intestine  may 
be  opened  as  low  down  as  possible  (vide  p.  344) .  In  making  the  opening 
those  details  already  fully  given  (p.  346)  must  be  followed. 

B.  Conditions  chiefly  affecting  the  Large  Intestine  and 
bringing  about  Chronic  Intestinal  Obstruction.— Enterostomy 
under  these  conditions  has  been  already  referred  to  in  the  account  of 
colotomy. 

Given  a  case  in  which  the  obstruction  is  somewhere  in  the  large 
intestine,  where,  though  perhaps  the  onset  has  been  given  as  acute,  the 
surgeon  is  clear,  from  the  age,  history,  &c,  that  it  is  really  a  case  of 
acute  or  chronic  mischief,  the  following  course  should  be  followed. 


UNION    OF   DIVIDKD    oil    INJURED    INTKSTINR  351 

An  incision  being  made  below  the  umbilicus,  the  surgeon  examines 
first  the  sigmoid  and  then  the  large  intestine  up  to  the  cecum.  The 
obstruction  having  been  found,  the  Burgeon  must  deal  with  it  according 
to  the  patient's  condition  and  his  own  surroundings.  .Many  will  prefer 
to  close  the  median  incision  and  perform  a  lumbar  colotomy  on  the 
right  or  left  side,  according  to  the  position  of  the  obstruction.  <  >th<  rs 
will  bring,  it'  possible,  the  caecum  or  sigmoid  or  transverse  colon  into 
the  median  incision  and  establish  the  artificial  anus  there.  I  have 
stated  at  p.  Ei8  mv  objections  to  thus  drawing  a  piece  of  rather  fixed 
large  intestine  up  into  the  middle  line.  For  my  own  part,  having  made 
out  the  (d)struction,  I  should  prefer  to  deal  with  it  as  follows,  mention- 
ing only  the  more  usual  sites  (footnote,  p.  118).  If,  as  is  most 
frequent,  it  is  in  the  sigmoid,  I  should  close  the  median  incision,  and 
bring  out  the  sigmoid  with  the  obstruction,  and  keep  the  loop  outside 
with  a  rod  and  sutures  (p.  126),  and  open  it  at  once  or  a  little  later. 
This  would  give  the  opportunity  of  resecting  the  affected  loop  later  on. 
Another  course  would  be  to  close  the  median  incision  and  perform  a 
left  lumbar  colotomy.  If  the  obstruction  was  in  the  splenic  flexure  I 
should  try  to  bring  the  transverse  colon  out  into  the  top  of  the  median 
incision  prolonged  upwards,  and  open  this  intestine  (p.  139).  If  the 
disease  is  in  the  hepatic  flexure,  a  right  lumbar  colotomy  would  be 
indicated,  the  median  wound  being  closed.  If  lower  down,  the  caecum 
must  be  opened.  I  have  pointed  out  at  p.  138  the  chief  objection  to 
this  step,  viz.,  the  liquid  character  of  the  escaping  fasces,  but  a  valvular 
csecostomy  minimises  this  trouble,  and  an  appendieostomy  may  do  the 
same  (vide  p.  140).  If  the  growth  is  found  to  be  irremovable  and  placed 
above  the  middle  of  the  sigmoid  flexure,  some  form  of  ileocolostomy 
should  be  preferred  to  a  permanent  artificial  anus  ;  but  if  the  condition 
of  the  patient  and  that  of  the  distended  intestine  are  bad,  a  faecal  fistula 
may  have  to  be  established. 

Operation. — Wherever  the  opening  is  made,  the  details  already  so 
fully  given  at  pp.  120  and  126  will  suffice. 


UNION   OF  DIVIDED   OR  INJURED   INTESTINE  BY 
SUTURE   OR    OTHERWISE. 

By  Suture- — The  methods  devised  are  very  numerous ;  most  have 
quickly  become  obsolete.  I  shall  only  refer  to  a  few  here,  as  those  with 
which  I  am  personally  acquainted,  and  those  which  will  be  found,  on 
the  whole,  the  simplest  and  the  most  efficient.  And  first  as  to  the 
essentials  of  a  good  intestinal  suture.     The  chief  are — 

(1)  It  must  be  simple,  one  that  can  be  rapidly  introduced,  and  one 
which  will  effectually  close  the  wound,  and  hold  it  securely  until  the 
parts  are  firmly  healed.  It  must  also  be  haemostatic.  (2)  In  its  intro- 
duction attention  must  be  paid  to  the  following,  (a)  The  sutures,  when 
applied  from  and  knotted  outside,  must  not  pass  through  the  mucous 
coat,  otherwise  they  may  draw  septic  fluids  from  within  the  bowel  to 
the  peritonaeal  surface,  (b)  When  the  sutures  pierce  all  the  layers  of 
the  intestinal  wall,  the  knots  should  be  upon  the  mucous  surface,  and 
none  of  the  sutures  when  tied  should  be  visible  upon  the  serous 
surface,  but  should  lie  entirely  hidden    by  the  inversion  which    they 


352 


OPERATIONS  ON  THE  ABDOMEN. 


should  produce.  When  these  precautions  are  taken,  there  is  little 
risk  of  infection  of  the  peritonaeum  by  fluids  travelling  by  capillary 
attraction  along  the  sutures  from  the  interior  of  the  bowel. 

In  any  case  each  suture  should  take  a  sufficiently  firm  hold,  so  as 
not  to  cut  out  when  any  strain  is  put  upon  it, — e.r/.,  by  peristalsis  or  dis- 
tension. Sero-muscular  stitches  are  very  apt  to  tear  out  when  the 
tissues  become  inflamed  and  softened  after  three  or  four  days,  and  the 
submucous  coat  cannot  be  included  with  any  certainty  or  even  probability, 
for  it  is  much  thinner  than  the  intestinal  needle  in  common  use.  The 
submucous  and  mucous  coats  are  far  more  fibrous  and  durable  than 
their  outer  coverings  ;  therefore  it  is  necessary  to  pierce  them  in  order 
to  obtain  a  firm  and  lasting  hold  for  the  sutures.       The  success  of  the 

Fig.  q8. 


I 


PERITONEUM 
LOtiCr  MUSCLE 
CIRCULAR     *J 

SU3MUC0SA. 

MUSCUL.ARIS 

MUCOSA- 

MUCOUS 


JJL 


Diagram  to  show  good  and  bad  methods  of  inserting  sutures. 

A,  Bad  method.     Suture  holds  only  muscle,  and  is  liable  to  cut  out. 

B,  Not  good  method  ;  too  little  hold  of  submucosa,  and  too  sloping. 

C,  Proper  method  ;  takes  a  good  hold  of  the  tough  submucosa.     (Greig  Smith.) 

The  submucosa  is  shown  to  be  far  too  thick  here. 


Maunsell  and  Connell  sutures  is  chiefly  due  to  the  fact  that  they  are 
passed  from  the  inside  through  the  inverted  edges  of  the  bowel.  They 
are  also  tied  within  the  lumen,  and  this  determines  capillary  drainage 
inwards  towards  the  knots,  and  facilitates  the  discharge  of  the  threads 
into  the  intestinal  canal  without  risk  of  peritonaeal  infection.  It  is 
more  than  probable  that  many  so-called  sero-muscular  sutures  pierce 
the  mucosa  of  the  small  intestine,  (c)  Attention  must  be  paid  to  the 
risk  of  sloughing  along  the  edges  if  too  many  sutures  be  used,  or  if 
they  be  tied  with  strangling  tightness,  (d)  The  material  used  must  be 
aseptic  and  sufficiently  durable.  Fine  silk,  or  Pagenstecker's  thread 
should  be  used  for  the  sero-muscular  suture,  and  catgut  for  the  deep 
or  penetrating  one.  The  sutures  are  best  introduced  by  the  ordinary 
fine  round  sewing-needle,  the  aperture  of  which  is  at  once  plugged  by 
the  thread  which  follows,  while  its  round  shaft  does  not  wound  small 


t  Mn\    <>K    DIVIDED    OR    I  N.I  I  RED    INTESTINE. 


353 


jels  like  the  ordinary  triangular-pointed  needle,  which  is  not  Deeded 

here  owing  to  the  readiness  with  which  the  intestinal  mats  are 
penetrated.  Fine  curved  needles  must  be  used  t<>  introduce  the 
Butures  from  within.     It  will  save  much  time  to  have  several  needles 

threaded  and  secured  on  aseptic  lint  in  carbolic  acid  lotion.  If 
possible,  as  many  should  he  threaded  as  there  will  lie  sutures,  hoth 
continuous  and  interrupted.     These  should  he  kept  apart. 

Chief  Varieties  of  Suture. — (i)  Lembert's  Suture  (Fig.  99). — 
The  value  of  this  depends  on  the  fact  that  it  fulfils  in  an  eminent 
degree  the  condition  first  pointed  out  hy  the  introducer,  that  to  ohtain 
union  of  an  intestinal  wound  it  is  absolutely  needful  to  bring  and  keep 
the  serous  surfaces  in  contact.  Each  suture  should  be  inserted  not 
less  than  one-third  of  an  inch  from  the  cut  edge,  and  run  along  deeply 
in  the  muscular  or  in  the  submucous  coat ;  it  is  then  made  to  emerge 


Fig.  99. 


Fig.  100. 


.    \ 

Lembert's  suture  as  used 
by  Sir  W.  MacCormac  in 
two  successful  cases  of  intra- 
peritoneal rupture  of  the 
bladder. 

A  continuous  Lembert's 
suture  is  better. 


To  the  left  the  contiuuous  suture  is  shown. 
The  right-hand  figure  shows  the  continuous 
one  inverted  and  buried  by  a  row  of  Halsted's 
sutures.     (Jessett.) 


just  wide  of  one  cut  edge,  reinserted  just  beyond  the  opposite  edge, 
then  at  once  made  to  travel  between  the  coats  and  to  emerge  as 
before. 

A  continuous  suture  inserted  in  the  same  way  as  Lembert's  inter- 
rupted stitch  is  more  often  used  now,  and  has  the  advantage  of  being 
far  more  quickly  applied.  The  objections  that  have  been  brought 
against  it  are  chiefly  : — 

(a)  If  one  part  of  it  becomes  loose,  the  whole  is  liable  to  become 
insecure,  (b)  It  is  difficult  to  secure  even  tension  all  along  the  line, 
unless  care  is  taken  to  keep  the  thread  always  taut,  (c)  If  the  bowel 
contract,  the  whole  suture  may  become  loosened,  and  the  wound  gape  ; 
this  calamity  is  far  more  likely  to  occur,  because  the  suture  cuts  its 
way  out,  for  it  may  not  get  a  firm  enough  hold  to  keep  the  parts  in  appo- 
sition long  enough  for  good  union  to  occur.  Therefore  few  surgeons 
now  trust  to  this  stitch  alone,  and  most  prefer  to  use  a  deep  suture, 
which  pierces  the  whole  thickness  of  the  wall. 

s. — vol.  ir.  23 


354 


OPERATIONS   ON    THE   ABDOMEN. 


The  continuous  suture  shown  in  Fig.  ioo,  a  is  even  less  to  be  trusted, 
but  if  reinforced  by  Lembert's  or  Halsted's  sutures,  it  may  be  found 
useful  in  cases  of  perforation  of  the  intestine  or  rupture  of  the  urinary 
bladder. 

(ii)  The  Czerny-Lembert  Suture. — This  is  only  Lembert's  suture 
reinforced  by  a  deep  row  in  order  to  bring  together  accurately  the 
margins  of  the  mucous  membrane,  as  well  as  to  approximate  more 
perfectly  the  serous  surfaces.  The  introduction  of  the  first  or  deep  row 
is  shown  in  Fig.  122.  It  will  be  seen  that  these  sutures  are  knotted 
within  the  lumen  of  the  bowel,  which  is  a  safeguard  against  infection. 
The  mucous  membrane  being  loose,  is  very  apt  to  prolapse  and  evert, 
and  this  may  lead  to  approximation  of  epithelial  surfaces  and  weak 
union,  although   this   danger  may  be  lessened  by  excision  of  some  of 


Fig.  ioi. 

Deep  3titch 


Needle  introducing 
Cashing  suture 


fllfffff 


Cushing's  sero-muscular  suture  (modified  from  Dowd,  Ann.  of  Surg.'). 


the  mucous  membrane.  It  is  difficult  to  prevent  a  leak  at  the  mesenteric 
border  by  this  method,  and  the  hold  obtained  by  the  deep  stitch 
is  not  so  secure  as  the  one  gained  by  a  suture  which  pierces  all  the 
coats.  Most  surgeons  have  given  up  the  Czerny-Lembert  suture  for 
simpler  and  safer  methods. 

Mr.  Stanmore  Bishop  {Lancet,  1903,  vol.  ii.  p.  350)  mentions  a 
fatality  from  obstruction  due  to  oedema  of  the  diaphragm  that  is  apt  to 
form  when  the  Czerny-Lembert  method  is  used. 

(iii)  Halsted's  Quilt  or  Mattress  Suture  (Fig.  100,  b). — The  distin- 
guished surgeon  who  introduced  this  method  claims  for  it  that  (1)  it  is 
so  safe  that  a  single  row  of  it  will  suffice  ;  (2)  it  constricts  the  tissues 
less  than  Lembert's  sutures ;  (3)  it  tears  out  less  readily  if  submitted 
to  tension. 

(iv)  Cushing's  Continuous  Stitch  is  simpler,  more  expeditious, 
and  buries  itself  better,  although  it  is  not  so  firm  as  Halsted's  inter- 
rupted suture  ;   the  needle  is  passed  in  a  direction  at  right  angles  to 


UNION    OF    DIVIDED    OB    l\.ii  RED    INTESTINE. 


355 


the  axis  of  the   bowel,  ami   picks  up  the  serous  and   muscular  c 
(vide  Fig.  101). 

(v)  Maunsell  and  Connell's  Stitch. — These  pierce  all  the  layers 
of  the  intestinal  wall,  and  thus  tend  to  secure  a  firm  union,  arrest 
haemorrhage,  and  prevent  the  ends  parting,  which  is  the  commonest 


Pig-.  102. 


Peritoneum 

Muscle  — ^ 

Submucoaa 

Mu.-o.-a 


Connell  mattress  suture 


^LemJoert  stitch 
Longitudinal  section  of  intestine,  showing  some  methods  of  suturing  it. 

cause  of  death  after  anastomosis.  In  all  of  thern  the  sutures  are 
knotted  internally  to  prevent  the  leakage  at  the  knot,  which  is  the 
commonest  site  of  leakage  in  other  methods  according  to  Chlumsky's 
experiments.  Connell's  stitch  differs  from  that  of  Maunsell  in  that  it 
is  not  an  overstitch,  but  a  mattress  one,  which  secures  more  inversion 

Fig.  103. 


Division  of  mesentery  as  it 
approaches  the  intestine. 


Triangular  space  filled  with 
fat,  connective  tissue,  ves- 
sels, and  nerves. 

Base  of  the  triangle  formed 
by  the  muscular  coat  of  the 
intestine. 

Serous  coat  

Muscular  coat 

Mucous  membrane 


-Artery. 


Section  through  jejunum.     (MacCormac.) 


of  the  edges,  and  is  more  haemostatic  ;  experience  has  shown  that  it 
does  not  lead  to  sloughing  of  the  edges  (vide  Fig.  102). 

Continuous  perforating  sutures  are  the  best  for  arresting  hemorrhage, 
and  for  this  purpose  the  turns  should  not  be  more  than  one-eighth  of 
an  inch  apart. 

(vi)  The  plan  adopted  by  most  English  surgeons  at  the  present  day 
is  to  make  use  of  a  double  line  of  suture  :   an  inner  continuous  one  of 

23—2 


356 


OPERATIONS  ON  THE  ABDOMEN. 


catgut  or  silk,  taking  up  all  the  coats  of  the  bowel ;  and  an  outer  row, 
consisting  of  a  second  continuous  sero-muscular  one  of  silk  or 
Pagenstecher's  thread.  Which  of  the  above  methods  will  be  finally 
judged  to  be  the  best  is  uncertain. 

In  performing  the  operation  the  following  points  require  especial 
attention :  (i)  The  sutures  should  be  inserted  about  one-eighth  of  an 
inch  from  each  other.  (2)  Adequate  inversion  of  the  edges  and  contact 
of  the  serous  surfaces  must  be  secured,  this  being  effected  by  entering 


Fig 


Mattress  suture  at  the  mesenteric  border.  The  triangular  interval  is  abolished,  and 
the  edges  of  the  intestine  are  inverted  by  the  thread,  which  is  knotted  on  the  mucous 
surface.     (After  Lee,  Ann.  of  Surg,,  vol.  xxxiii.,  1901,  p.  28.) 


the  sero-muscular  sutures  at  a  sufficient  distance  from  the  edges,  and 
holding  the  thread  always  taut,  or,  if  interrupted  sutures  be  used,  by 
an  assistant  aiding  the  inversion  by  dipping  in  the  surfaces  just  before 
each  batch  of  sutures  is  tied.  Inversion  is  also  obtained  by  holding 
the  edges  together  in  this  position,  and  passing  and  tying  the  sutures 
from  within,  as  in  Maun  sell's  and  Connell's  methods.  The  forceps  of 
Allis,  O'Hara,  or  Horsley  may  serve  the  same  purpose  as  the  suspending 
or  temporary  retaining  sutures  of  Connell  and  Maunsell. 

However  circular  enterorraphy  be  employed,  close  attention  must  be 
paid  to  these  points  shown  in  Fig.  103.  The  first  is  the  triangular 
space  which  is  formed  by  the  divergence  of   the   two  layers  of  the 


UNION    OK    DIVIDKD    OR    IN.M'UKD    INTESTINE. 


157 


mesentery  at  their  junction  with  the  bowel.  This  is  occupied  by  i';it, 
connective  tissues,  vessels,  and  nerves.  In  the  suturing  of  resected 
intestine  this  space  must  he  obliterated,  as  shown  in  Fig.  104.  The 
thickness  of  the  bowel  is  also  to  be  noted.  The  muscular  layer  is 
(Fig.  103)  comparatively  thick,  and  sutures  here  are  easy  of  intro- 
duction. In  the  ileum  this  coat  would  be  much  thinner  and  the  whole 
tube  smaller. 

The  Operation. — The  mesentery  having  been  tied  oft'  up  to  the  level 
o(  the  portions  of  bowel  to  be  united,  and  the  growth  or  damaged  bowel 
having  been  clamped  and  excised,  the  ends  are  thoroughly  cleansed, 
and  gauze  packings  are  used  to  isolate  them.  A  mattress  suture  of 
catgut  or  silk  is  inserted  near  the  mesenteric  border  and  tied  within 

Fig.  105. 


Appearance  of  the  intestine  when  two-thirds  of  the  first  row  of  sutures  have 
been  tied.  Dr.  Dowd  knots  the  thread  after  every  third  insertion  of  the  needle 
to  prevent  narrowing  of  the  lumen.  Only  one  of  the  threads  leading  from  the 
knot  to  the  needle  is  cut,  so  that  a  fresh  suture  is  not  required  if  the  original  one  is 
long  enough.  This  precaution  is  not  necessary  if  the  thread  is  always  kept  taut. 
(After  Dowd,  Ann.  of  Surg.,  vol.  xxxvi.  p.  54.) 


the  bowel,  as  shown  in  Fig.  104.  This  stitch  obliterates  the  mesenteric 
triangle,  where  the  intestine  is  uncovered  with  peritonaeum,  and  also 
inverts  the  edges  of  the  bowel.  The  clamp  forceps  are  held  close 
together  by  an  assistant  or  locked  together  (Carwardine's  forceps,  vide 
Fig.  138),  and  one  end  of  the  long  mattress  suture  is  used  as  a  con- 
tinuous stitch  to  unite  the  edges  which  lie  in  contact,  and  are  inverted. 
The  thread  passes  through  all  the  coats  and  secures  a  good  bite,  with 
an  interval  of  one-eighth  of  an  inch  between  the  sutures,  which  pass  over 
the  free  edges.  It  is  easy  enough  to  place  the  first  half  or  more,  but 
towards  the  end  it  becomes  more  and  more  difficult  to  produce  proper 
inversion.  When  two-thirds  of  the  circumference  of  the  bowel  has 
been  sewn  by  means  of  one  end  of  the  suture,  the  other  end  is  used 
to  close  the  remainder,  so  that  the  finishing  point  may  be  well  away 
from  the  mesenteric  border,  and,  therefore,  more  easy  to  see  and  invert 
sufficiently.    Both  ends  should  terminate  on  the  mucous  surface,  so  that 


358 


OPERATIONS  ON  THE  ABDOMEN. 


they  can  be  tied  together  so  as  to  leave  the  knot  within  the  lumen  of  the 
bowel,  as  shown  in  Figs.  106,  107.     To  secure  proper  inversion  with 


Fig.  106. 


Last  loop  of 
i*t  suture 


Both  ends  of  the  continuous  deep  suture  are  hooked  out ;  the  ends  are  to  be 
pushed  into  the  lumen  of  the  bowel  after  the  knot  is  tied  firmly.  (After  Dowd, 
Ann.  of  Surg.,  vol.  xxxvi.  p.  56.) 


Fig.  107. 


ConneLTs  method  of  tying  the  last  knot  upon  the  mucous  surface.  (After  Lee, 
Ann.  of  Surg.)  Both  ends  of  the  continuous  deep  suture  are  drawn  through  the 
suture  line,  some  distance  away  from  the  finishing  point,  by  means  of  a  needle 
and  thread.  When  the  knot  is  tied  the  ends  immediately  disappear  into  the 
lumen  as  the  bowel  regains  its  circular  shape. 

the  last  few  sutures  the  right-angular  perforating  stitch  recommended 
by  Lee  and  Horsley  may  be  found  very  useful  (vide  Fig.  112,  B). 

*  A  continuous  Lembert  or  dishing  suture  is  now  rapidly  inserted 
after  moving  the  clamps  further  away  from  the  suture  line,  so  that 
inversion  may  be  more  readily  accomplished  (ride  Fig.  101,  p.  354). 


UNION    OF    DIVIDKD    OB    [NJURED    [NTESTINE. 


350 


The  mesenteric  cleft  is  then  sewn  up,  and  a  graft  of  mesentery  or  of 
omentum  if  available  may  be  fixed  over  the  line  of  suture  in  Bome  ca 

or  a  few  additional  Lembert  sutures  may  be  used  to  strengthen  any 
weak  spot.  The  intestine  and  mesentery  are  thoroughly  cleaned,  and 
the  intestine  replaced  within  the  abdomen  after  the  gauze  packs  have 
been  removed.  Firm  union  is  most  likely  to  take  place  when  the 
joined  intestine  is  completely  surrounded  by  peritonaea!  surfaces  which 
soon  adhere  to  and  protect  the  line  of  suture.  When  this  desirable 
protection  is  not  available,  failure  of  union  and  the  formation  of 
fistula  are  not  uncommon.  For  this  reason  it  is  rarely  wise  either  to 
leave  sutured  intestines  exposed  in  the  wound,  or  to  insert  a  drain 
quite  down  to  the  suture  line. 

Connell's  Method  of  End  to  End  Union. — In  this  method,  which  has 


Fig.  108. 
Traction  suture? 


Mattress  suture 
(interrupted) 

Connell's  method  of  end  to  end  union.     (Modified  from  Connell.  Medicine,  April,  1901.) 

been  largely  and  successfully  used  by  many  American  surgeons,  the 
edges  are  joined  together  by  a  single  row  of  sutures,  which  pierce  the 
whole  thickness  of  the  intestinal  wall,  and  thus  secure  a  firm  hold. 
The  stitches  are  "  square  "  or  mattress  sutures,  which  do  not  pass  over 
the  edges,  and,  therefore,  they  secure  more  inversion  and  better  serous 
apposition  than  the  usual  circular  or  over-stitch  provides  (vide  Fig.  102)  ; 
but  the  latter  brings  the  edges  into  better  apposition. 

All  the  knots  must  lie  upon  the  mucous  surface,  to  lessen  the  risk 
of  sepsis  travelling  towards  the  peritonaeum,  and  to  facilitate  the  early 
discharge  of  the  sutures  into  the  lumen  without  the  same  amount  of 
risk  of  sloughing  and  leakage  as  if  the  knots  were  tied  upon  the  serous 
surface.  It  has  been  demonstrated  that  fluids  travel  towards  the  knots 
or  suture  ends,  which  should,  therefore,  be  within  the  bowel  (Chlumsky, 
Beitr.  Klin.  Chir.,  B.  xxv.  H.  3).  It  will  be  noticed  also  that  very 
little,  if  any,  of  the  suture  need  show  upon  the  serous  surface,  so  that 
the  danger  of  peritonitis  is  lessened,  and  adhesions  diminished. 


360 


OPERATIONS  ON  THE  ABDOMEN. 


For  these  reasons,  it  is  not  necessary  to  reinforce  or  bury  the  suture 
by  means  of  sero-muscular  stitches ;  thus  time  is  saved,  and  the  risk  of 
the    formation    of   a    diaphragm  is  smaller.     The  inverted  edges  are 

Fig.  109. 


Allis'  forceps. 
A.  The  tenaculum  or  basting  forceps.     B.  The  rat-toothed  forceps.     The  teeth 
are  at  the  side.     These  forceps  are  used  for  inverting  the  edges  during  the  inser- 
tion of  the  last  few  sutures.     (After  Allis,  Ann.  of  Surg.,  vol.  xxxv.  p.  353.) 

only  compressed   at  intervals,  so   that  their  nutrition  is  not  seriously 

interfered  with.     Either  continuous  or  interrupted  sutures  maybe  used. 

Mr.  Bishop,  in  1883,  devised  this  form  of  interrupted  suture,  and 

Fig.  no. 


The  edges  are  held  taut  and  inverted  by  a  pair  of  basting  forceps.     A  continuous 
Connell  stitch  is  being  introduced.     (Modified  from  Allis,  Ann,  of  Surg,") 


Dr.  M.  E.  Connell,  in  1892,  introduced  a  similar  but  continuous  one. 
Dr.  F.  G.  Connell  {Journ.  Amer.  Med.  Assoc,  October  12,  1901,  p.  953  ; 
Amer.  Med.,  January  24,  1903)  prefers  interrupted  sutures,  because  he 
considers  them  to  be  more  secure  and  without  risk  of  contracting  the 
orifice,     A  continuous  one  is  more  quickly  applied,    and  the  risk  of 


UNION    OF    DIVIDKD    OB    INJURED    INTESTINE. 


36l 


slipping  inul  pursestring  narrowing  of  the  lumen  lias  been  exaggerated, 
mid  it  can  be  avoided  by  taking  an  occasional  hack  stitch. 

A  continuous  suture  prevents  dilatation  of  the  intestine  at  the  circle 
of  union,  and  thus  acts  as  a  splint  which  protects  the  union  from  the 
stretching  effects  of  intestinal  distension.  Interrupted  sutures  do  not 
prevent,  stretching  between  the  individual  stitches. 

If  a  continuous  suture  tear  out  at  one  spot,  the  whole  circle  of  union 
is  endangered,  but  the  risk  of  this  accident  is  less  with  the  Council 
suture  than  with  the  usual  circular  stitch,  which  takes  a  poorer  hold. 

It  has  been  shown  by  Dr.  Horsley  and  others  that  the  Connell 
suture  holds  very    securely,    especially    during   the    critical  time    for 

Fig.  hi. 


Forceps  holding  the 
edges  inverted 


Advanced  stage  of  suturing  with  the  aid  of  Allis'  forceps. 
(Allis,  Ann.  of  Surg.') 


intestinal  sutures,  which  often  slough  out  and  allow  leakage  on  the  third 
or  fourth  day.  The  union  is  more  certain  and  secure  than  that  obtained 
with  mechanical  contrivances. 

Clinically  leakage  rarely  occurs  with  Connell's  method.  Connell 
(Amer.  Med.,  vol.  v.  p.  135)  gives  a  table  of  64  operations  performed  by 
different  surgeons  by  his  method.  Of  the  21  deaths,  only  one  was  due 
to  leakage  ;  all  the  others  were  due  to  shock,  previous  peritonitis,  &c. ; 
In  animals  Ferguson  found  that  out  of  300  anastomoses  performed  in 
this  way  by  post-graduate  students  the  mortality  was  only  3  per  cent. 
(Ann.  of  Surg.,  vol.  xxxiv,  1901,  p.  846). 

The  Operation. — The  intestine  is  clamped  at  some  distance  away 
from  the  sections,  and  the  exposed  ends  are  thoroughly  cleansed  as 
usual.  Lee's  mesenteric  stitch  is  inserted  to  secure  efficient  inversion 
and  obliteration  of  this  dangerous  area  (Fig.  104).     To  facilitate  the 


362 


OPERATIONS  ON  THE  ABDOMEN. 


introduction  of  sutures,  the  edges  of  the  intestine  are  kept  taut  and 
inverted  by  means  of  traction  sutures  or  tissue  forceps  (Figs.  108  to  in). 

This  object  may  also  be  attained  by  inserting  two  mattress  sutures 
on  either  side  of  the  mesenteric  border,  and  at  a  distance  of  one-third  of 
the  circumference  of  the  bowel  from  one  another.  The  ends  are  left  long 
and  used  for  traction  during  the  introduction  of  sutures  between  them. 
Each  suture  should  take  a  bite  of  one-eighth  of  an  inch,  and  the  same 
distance  should  separate  it  from  its  neighbours. 

Another  mattress  stitch  is  placed  at  the  remaining  point  of  trisection 
of  the  circumference,  and  used  for  traction  in  a  similar  way,  while  the 
second  third  of  the  circumference  is  sewn.     All  the  long  ends  are  then 

Fig.  112. 


Portion  of  bowel 
to  be  excised 


Dr.  J.  S.  Horsley's  method  of  end  to  end  union. 
A.  A  semilunar  piece  of  each  end  is  held  by  the  forceps  and  excised,  so  that  the 
circle  of  union  may  be  enlarged  to  counteract  any  subsequent  narrowing.     (After 
Horsley,  Aim.  of  Surg.) 

cut  off.  Personally  I  prefer  to  use  a  continuous  suture,  and  to  secure 
inversion  by  means  of  tissue  forceps.  So  far  the  sewing  is  easily 
accomplished,  but  the  remainder  is  more  difficult,  for  towards  the  end 
the  edges  cannot  be  held  in  contact  and  inverted  during  the  insertion 
of  the  needle  unless  this  is  done  from  the  serous  surface. 

When  this  difficulty  arises,  the  needle  should  be  passed  out  on  to  the 
serous  surface  on  one  side  of  the  wound,  then  across  the  gap  to  take  a 
bite  of  all  the  layers  of  the  other  margin,  as  seen  in  the  figure  (112,  B). 
This  process  should  be  repeated  on  the  other  side  and  continued 
alternately  on  the  two  sides  until  the  circle  is  completed.  By  adopting 
this  method  only  one  insertion  is  required  to  secure  each  bite,  and 
only  two  to  complete  each  square  stitch.     The  continuous  stitch  can 


MAI aski.i/s    MKTHOD    OF    E1NTERORRAPHY. 

be  held  t : » lit  all  the  time,  for  there  is  qo  need  to  pass  the  needle  from 
tlic  mucosa,  and  therefore  no  object  in  keeping  the  wound  open.  This 
stitch  differs  from  that  of  Cushing  by  piercing  all  the  coats,  find  it 
therefore  secures  a  far  tinner  and  more  permanent  hold.  When  the 
circle  has  been  completed,  the  thread  should  be  made  to  terminate 
upon  the  mucous  surface,  where  it,  can  be  tied  to  the  tail  thread  of  the 
first  knot  in  one  of  the  ways  illustrated  in    Figs.  106,  107. 

Horsley  does  not  place  the  last  knot,  within  the  lumen  of  the  bowel,  but, 
after  completing  the  circle,  he  continues  his  suture  for  a  few  turns  as 
a  sero-muscular  one.  This  serves  to  protect  the  weakest  spot  of  the 
union,  and  is  easier  and  quicker  than  placing  the  knot  upon  the  mucosa. 
The  last  Cushing  suture  is  taken  in  reverse  direction,  so  that  the 
knot  can  be  buried  between  the  serous  folds. 

Few  English  surgeons  like  to  dispense  with  a  sero-muscular  rein- 
forcing suture,  and  the  danger  of  the  formation  of  a  diaphragm  is 
small  in  the  human  subject,  although  it  is  considerable  in  experimental 
work  upon  intestines  of  small  calibre.  I  always  prefer  to  add  a  con- 
tinuous Lembert  or  Cushing  suture.  Horsley  excises  a  semilunar 
piece  from  each  of  the  intestinal  ends  in  order  to  enlarge  the  circle  of 
union,  and  thus  avoid  the  risk  of  stricture  formation  (vide  Fig.  112,  A). 
This  is  rarely  necessary  in  the  comparatively  large  intestines  of 
man.  Horsley  has  used  his  method  upon  19  dogs  without  a  death  or 
any  obstruction. 

The  advantages  and  disadvantages  of  circular  enterorraphy  are 
given  at  p.  380,  where  this  method  of  uniting  intestine  is  compared 
with  other  means,  such  as  Murphy's  button,  and  Mayo  Robson's 
bone  bobbins. 


MODIFICATIONS     OP     CIRCULAR    ENTERORRAPHY  ;     AIDS 
TO  ITS   PERFORMANCE   OR  MEANS   OP  REPLACING  IT. 

Owing  to  the  objections  which  some  have  raised  against  circular 
enterorraphy,  other  methods  have  been  invented.  I  propose  only  to 
describe  those  which  have  stood  the  test  of  successful  trials  in  the 
human  subject,  as  well  as  given  good  results  in  animals. 

Method  of  Maunsell.* — This  modification  of  circular  enterorraphy 
is  based  on  the  fact  that,  when  Nature  performs  enterorraphy  success- 
fully, she  does  so  b}T  the  process  of  invagination,  adhesive  inflammation, 
and  sloughing.     The  two  ends  of  the  bowelt  are  brought  together  by 

*  H.  Wirlenham  Maunsell,  late  Lecturer  on  Surgery,  Otago  University  (Amer.  Journ. 
Med.  Sri..  March,  1892).  The  inventor  used  his  method  first  as  long  ago  as  1886,  after 
resection  of  the  small  intestine  "for  cancer"  in  a  child  aged  6.  The  child  sank  on  the 
sixth  day  :  at  the  necropsy  the  segment  of  the  intestine  showed  no  evidence  of  leakage. 
Dr.  Wiggins  (New  Tori  Med.  Journ.,  Dec.  1,  1894,  and  in  his  pamphlet,  for  which  I  am 
indebted  to  him)  relates  a  successful  case  in  which  he  resected  six  inches  of  ileum  for 
contusion  and  perforation,  uniting  them  by  this  method.  The  patient  was  well  ten 
months  later.  Dr.  Wiggins  mentions  a  case  of  Dr.  Harley's  {New  York  Med.  ./num., 
vol.  lvi.  pp.  302  and  464)  in  which  this  method  was  also  successfully  employed  for  the 
resection  of  a  double  intussusception  and  carcinoma. 

t  The  preliminary  steps  as  to  clamps,  &c,  would  be  the  same  as  those  given  at  p.  388, 


364  OPERATIONS    ON    THE   ABDOMEN. 

two  long  temporary  sutures  passed  through  all  the  coats  of  the  intes- 
tine (D  D,  Fig.  113),  one  being  placed  at  the  mesenteric  junction,  and 
the  other  exactly  opposite.  These  sutures  secure  the  peritonseal  cover- 
ing of  the  intestine,  and  serve  later  to  effect  invagination.  A  slit 
about  an  inch  and  a  half  long  having  been  made  in  the  long  axis  of  the 
free  border  of  the  proximal  part  of  the  intestine,  about  an  inch  from 
the  divided  end  of  the  gut,  these  two  long  sutures  are  passed  up  through 
the  lumen  of  the  bowel  and  out  of  the  slit ;  when  pulled  upon,  the 
smaller  or  distal  end  of  the  bowel  will  be  invaginated  into  the  larger, 
and  drawn  out  of  the  opening  in  this  (Fig.  114).  From  this  figure, 
which  shows  the  relative  position  of  the  layers  invaginated,  it  will  be 
seen  that  the  peritonaeal  surfaces  are  in  accurate  apposition  all  round. 
While  an  assistant  holds  the  ends  of  the  temporary  sutures  up  and 
apart,  the  surgeon  passes  a  long,  fine,  straight  needle,  carrying  stout 
horsehair  or  very  fine  silkworm  gut,  through  both  sides  of  the  bowel, 

Fig.  113. 


WMW' 


This  and  the  next  three  figures  show  Maunsell's  modification  of  circular 
enterorraphy.  ABC,  Peritonaeal,  muscular,  and  mucous  coats.  F,  Mesentery. 
D  D,  Temporary  sutures  by  which  the  lower  is  invaginated  into  the  upper  end  ; 
they  are  seen  to  emerge  through  a  slit  in  the  latter.  (From  Walsham's  Surgery, 
copied  from  Maunsell,  loc.  supra  cit.) 

taking  a  good  grip  (a  quarter  of  an  inch)  of  all  the  coats  (Fig.  115). 
The  suture  is  then  hooked  up  from  the  centre  of  the  invaginated  gut, 
divided,  and  tied  on  both  sides.  In  this  way  twenty  sutures  can  be 
rapidly  placed  in  position  icith  ten  passages  of  the  needle*  The  tem- 
porary sutures  are  now  cut  off  short,  and  the  invaginated  gut  is  then 
pulled  back.t  Finally,  the  longitudinal  slit  in  the  gut  is  well  turned 
in,  and  closed  by  a  Lembert's  continuous  suture,  and  painted  and 
dusted  as  above.  The  appearance  of  the  gut  is  now  as  in  Fig.  116; 
the  serous  surfaces  should  be  in  accurate  apposition,  and  all  the  knots 


*  Mr.  Stanley  Boyd  introduced  here  two  or  three  modifications  of  this  important  stage, 
which  may  be  useful.  Finding  that  time  was  lost  in  drawing  up  the  loops  from  the  lumen 
of  the  bowel,  and  in  selecting  corresponding  ends,  he  passed  many  of  these  sutures  not 
across  the  lumen  of  the  bowel,  but  through  only  two  walls,  and  tied  the  sutures  as  they 
were  inserted.  He  found  that  great  care  was  needed  to  ensure  that  the  cut  edges  of  the 
peritonseal  coats  were  equally  drawn  up,  and  that  each  stitch  passed  a  good  quarter  of  an 
inch  below  them,  for  the  mucous  membrane  tends  to  prolapse  and  to  conceal  the  peritoneal 
edges,  which  are  of  chief  importance. 

f  If  now  there  is  any  doubt  about  the  line  of  suturing,  a  few  Lembert's  sutures  should 
be  added  externally,  especially  about  the  mesenteric  junction  ;  or  an  omental  graft  (p.  400) 
may  be  added  (Stanley  Boyd,  Med.-Chir.  Soc.  Trans.,  vol.  xxvi.  p.  345). 


MAUNSKU/S    MKTIIOI)    OK    KNTKROIMAIMI Y. 


365 


inside  the  bowel.     Dr.  F.  II.  Wiggins  (loc  supra  cit.),  comparing  this 

method  and  Murphy's  button,  pointed  out  the  following  as  requiring 
careful  attention  when  this  method  is  employed:  I.  The  mesenteric 
border  must  be  carefully  approximated.  2.  The  sutures  must  be 
interrupted,  and  not  placed  too  near  the  edge  of  the  intestine  ;  they 
should  be  placed  a  quarter  of  an  inch  from  it,  at  least.  3.  They  must 
not  be  tied  too  tightly.  4.  Too  much  force  must  not  be  used  in 
reducing  the  invagination,  or  the  sutures  may  cut  out.  5.  In  closing 
the  longitudinal  incision,  too  much  of  the  edges  must  not  be  turned  in, 
or  a  contraction  may  result. 

While  this  method  is  less  alluring  than  Murphy's  button,  and  cannot 


Fig 


G,  The  interior  of  the  lower  segment  which  is  invaginated  into  and  through 
the  opening  in  the  upper  segment.* 


Fig.  115 


k'ft 
A,  The  needle  introducing  two  sutures  by  a  single  transit.     G  and  H  as  before. 


be  used  so  rapidly,  it  has  certain  advantages  over  it  which  it  shares 
with  circular  enterorraphy,  and  certain  peculiar  to  itself.  Thus,  it 
needs  no  mechanical  device,  which  may  not  be  at  hand  just  when 
wanted.  It  requires  only  a  few  needles,  silk  or  durable  catgut.  Thus, 
in  Dr.  Wiggins's  account  of  his  own  case,  in  which  he  resected  six 
inches  of  the  ileum  for  contusion  and  perforation,  uniting  the  ends  b}r 
Maunsell's  method,  he  writes  (loc.  supra  cit.)  :  "  The  urgency  of  this 
case  was  great.  The  patient  was  in  a  country  farmhouse.  The  opera- 
tion could  not  have  been  safely  delayed  one  hour  longer  than  it  was ; 
consequently  there  was  no  time  to  procure  mechanical  devices  from  the 


*  Mr.  Stanley  Boyd  in  his  case  made  the  incision  in  the  distal  end,  and  invaginated, 
with  a  little  difficulty,  the  upper  larger  into  the  lower  small  end. 


366  OPERATIONS  ON  THE  ABDOMEN. 

city.  A  few  instruments,  a  paper  of  ordinary  sewing-needles  — 
milliners'  No.  6 — and  some  iron-dyed  silk  were  easily  procured,  and 
the  operation  was  promptly  performed,  and  the  patient's  life  saved." 
Dowel  (Ann.  of  Surg.,  1902,  vol.  xxxvi.  p.  47)  states  that  31  cases  of 
Maunsell's  operation  had  been  reported,  with  only  3  deaths,  but  several 
operators  had  used  a  few  reinforcing  sutures.  No  one  of  the  deaths 
was  attributable  to  any  fault  in  the  method,  all  the  patients  dying 
of  shock.  It  is  probable  that  unsuccessful  cases  have  not  been 
published. 

The  advantages  which  are  claimed  over  circular  enterorraphy  are 
that  this  modification  is  speedier  of  execution,  and  that  it  gives  easier 
command  over  the  haemorrhage.  A  third  is  that,  when  the  ends  are 
of  unequal  size,  they  can  be  more  readily  dealt  with  by  the  invagination 
of  this  method  than  by  circular  enterorraphy.  A  fourth  is  that  inver- 
sion of  the  edges  is  so  good  that  no  reinforcing  sero-muscular  stitch  is 
required.  The  chief  objection  to  be  brought  against  it  is  the  additional 
wound  through  which  the  temporary  invagination    has  to  be  made. 

Fig.  116. 


E^ 


'A 


V 


I 


1  n  s  111  ™  € 

This  shows  the  line  of  junction,  the  peritonaeum  well  turned  in,  and  the 
sutures  and  knots  nearly  all  inside  the  gut.  One  or  two  sutures  are  seen  in  the 
mesentery.  G  and  H  as  before.  Above  H  would  be  the  longitudinal  slit  sewn 
up  by  a  continuous  suture. 

Connell,  Wiggins,  and  others  have  since  devised  other  methods  of 
attaining  the  same  objects  without  having  to  make  an  additional 
wound,  which  is  difficult  to  close  satisfactorily  without  narrowing  the 
bowel.  Maunsell's  suture,  being  a  circular  one,  is  more  exposed  upon 
the  serous  surface,  and  is  therefore  in  more  need  of  reinforcement  than 
Connell's  suture.  Having  compared  this  method  with  Murphy's  button 
(p.  368),  it  is  right  that  I  should  add  that  Dr.  Ricketts,  of  Cincinnati 
{Ann.  of  Surg.,  vol.  i.  1894,  p.  473),  after  resecting  four  inches  of  the 
ileum  for  carcinoma,  on  attempting  "to  make  a  Maunsell  operation," 
found  that  the  distal  end  of  the  gut  was  so  fixed,  it  being  only  five 
inches  from  the  ileo-caecal  valve,  that  more  time  would  be  consumed 
than  was  for  the  good  of  the  patient.  He  accordingly  used  the 
Murphy's  button,  which  took  only  eight  or  ten  minutes.  The  patient, 
who  had  persistently  refused  operation,  sank  ten  hours  later.  Dr. 
Ricketts,  while  "  satisfied  that  the  button  was  the  most  appropriate  in 
this  case,"  is  "  thoroughly  convinced  that  the  Maunsell  operation  is 
the  one  to  be  used  in  the  majority  of  cases." 

Rogers'  Method  of  performing  Enterectomy  without  the  Aid  of 
any  Special  Apparatus. — At  the  present  time,  while  the  best  means 
of  performing  enterectomy  are  still  sub  judiee,  and  as  it  will  certainly 
have  to  be  performed,  under  widely  different  conditions,  in  very 
different  ways,  the  following  deserves  mention  for  the  sake  of  complete- 


ROGERS'    METHOD   OF    ENTERECTOMY.  367 

ness.  It  will  be  found  described  Brit.  Med.  Jowrn.,  c8g6,  vol.  i. 
p.  903.  The  method  consists  in  turning  back  the  peritonaea!  coat  of 
one  end  of  the  small  intestine,  suturing  the  muscular  coat  thus  exposed 
to  the  peritonea]  coat  of  the  other  end  of  the  intestine,  subsequently 
turning  down  the  reflected  portion  of  peritoneum  over  the  first  row  of 
BUtures,  which  are  thus  completely  buried,  and  suturing  the  deep 
surface  of  the  reflected  peritonaeum  to  the  unreflected  serous  surface  on 
the  other  end  of  the  intestine.  Thus  a  double  sero-fibrous  union  is 
obtained  which  will  unite  both  quickly  and  firmly.  The  inner  sutures 
are  passed  through  the  muscular  coat  of  one  end  and  the  muscular  and 
peritoneal  coats  of  the  other  end  of  the  bowel,  while  the  outer  sutures 
include  the  peritoneal  coats  only.  Each  row  of  sutures  is  a  continuous 
one.  The  second  one,  which  unites  the  peritoneum  reflected  off  one 
end  of  the  bowel  over  the  same  coat  unreflected  on  the  other,  begins 
by  uniting  the  triangular  gap  at  the  mesenteric  junction  (a  most 
important  spot,  p.  355,  Fig.  103),  and  then  travels  round  the  bowel. 

The  following  advantages  are  claimed  by  Dr.  Rogers  for  this 
method  :  (1)  It  can  be  done  with  the  aid  of  the  instruments  in  a  pocket- 
case,  ordinary  round  sewing-needles  being  used  (although  curved 
intestinal  needles  are  to  be  preferred),  and  with  very  little  assistance, 
and  is  therefore  likely  to  be  of  especial  service  in  military  surgeiy  or 
in  country  or  foreign  practice.  Yet  (2)  it  can  be  completed  in  about 
half  an  hour,  or  only  a  little  longer  than  the  time  required  with  the  aid 
of  such  special  appliances  as  plates,  buttons,  and  bobbins.  (3)  The 
junction  is  a  double  sero-fibrous  one,  and  hence,  as  the  late  Mr.  Greig 
Smith  believed  (loc.  infra  cit.),  will  combine  the  maximum  of  rapidity 
and  firmness.  (4)  The  mesenteric  junction  can  be  made  very  firm  by 
the  apposition  of  the  muscular  coat  of  one  end  to  the  peritoneum  of 
the  other,  and  subsequent  covering  up  of  this  suture  by  the  reflected 
peritoneum. 

The  chief  disadvantage,  on  the  other  hand,  lies  in  the  difficulty  in 
reflecting  the  peritonaeal  coat.  The  late  Mr.  Greig  Smith  said  :  "  This 
is  not  easy  to  do ;  it  takes  some  time,  and  causes  bleeding,  which  is 
long  in  stopping.  Also  it  often  causes  the  wounding  of  important 
blood-vessels." 

Another  method  somewhat  similar  to  the  above  is  Morisani's 
(Centralb.  fur  Chir.,  1899,  vol.  xxxii.).  This  consists  in  removing  a 
strip  of  mucous  membrane  from  4  to  6  cm.  wide  from  the  distal  end  of 
the  divided  bowel.  The  proximal  end  is  then  invaginated,  its  serous 
surface  thus  being  brought  into  contact  with  the  denuded  area  of  the 
lower  segment.  The  two  ends  are  held  by  two  or  three  fixation  sutures, 
and  union  completed  by  means  of  a  continuous  suture  piercing  the 
whole  thickness  of  the  distal  segment  and  taking  up  the  serous  and 
muscular  coats  of  the  proximal  segment.  This  method  would  appear 
to  be  thicker  than,  and  quite  as  reliable  as,  Rogers'  method.  Campbell 
(West  Med.  Review,  September,  1903)  has  revived  and  slightly  modified 
this  method,  turning  down  a  cuff  of  sero-muscular  tissue  5  cm.  long 
by  gauze  dissection,  dividing  the  mucosa  within  1  cm.  of  the  base  of 
the  cuff  which  is  on  the  distal  end.  The  proximal  extremity  is  then 
invaginated  into  the  cuff  and  secured  by  two  sets  of  sutures. 

I  do  not  recommend  any  of  the  last  three  methods,  which  have  no 
advantages  over  simple  end  to  end  union  by  direct  suture. 


368 


OPERATIONS  ON  THE  ABDOMEN. 


Fig.  117. 


Murphy's  button.  A,  Male  half. 
B,  Female  half.  p,  Spring-flange. 
s  s,  Springs  projecting  through  open- 
ings in  hollow  stem.  At  c,  part  of  the 
cap  of  the  small  half  has  been  cut 
away  to  show  the  circular  spring  which 
keeps  up  the  pressure  as  the  button 
does  its  work.  The  round  holes  in  the 
caps  are  for  drainage.  (This  and  the 
next  three  figures  are  borrowed  from 
Down's  pamphlet.) 


b,  Puckering  thread,  a  shows  the 
return  stitch  by  which  the  interval  be- 
tween the  two  layers  of  the  mesentery 
is  closed — a  very  important  detail. 


Murphy's  Button  (Figs.  117  to  120). 
— This,  one  of  the  most  ingenious 
inventions  of  the  last  century,  we  owe 
to  Dr.  J.  B.  Murphy,  of  Chicago  (New 
York  Med.  Record,  Dec.  10,  1892). 
Its  great  advantage  is  the  facility  and 
rapidity  with  which  end  to  end  approxi- 
mation can  be  effected  without  any 
sutures.  The  button  consists  of  two 
halves.  The  male  half  has  a  spring 
flange  for  keeping  up  pressure  on  the 
intestine  ends.  Two  springs  (s  s), 
projecting  through  openings  in  the 
hollow  stem,  act  as  a  male  thread  of 
a  screw,  when  the  male  half  is  tele- 
scoped within  the  female  half  of  the 
button.  When  the  button  is  used  to 
unite  resected  ends  of  bowel*  a  pucker- 
ing or  running  thread  is  passed  round 
each  side  to  and  from  the  attachment 
of  the  mesentery,  and  especial  care  is 
taken  to  close  the  triangular  interval 
which  exists  here  (Figs.  103  and  118) 
by  means  of  the  return  stitch.  One 
half  of  the  button,  held  as  in  Fig.  119, 
is  then  inserted  in  the  intestine,  and 
the  running  thread  so  tightened  as  to 
pucker  the  cut  end  of  the  intestine 
with  sufficient  closeness  and  tightness 
around  the  shaft  of  the  button.  The 
ends  of  the  thread  are  then  tied 
and  cut  short.  The  other  half  of  the 
button  having  been  secured  in  the 
opposite  end  of  the  intestine  (Fig.  120), 
the  two  halves  are  gently  pressed 
together,  the  surgeon  having  first  made 
sure  that  both  cut  ends  are,  all  along 
their  edges,  within  the  grasp  of  the 
button.  The  two  halves  are  pressed 
together  until  it  is  seen  that  the  peri- 
tonaea! surfaces  are  held  in  sufficiently 
close  and  accurate  contact.  Dr.  Murphy 
holds  that  it  is  needless  to  apply 
Lembert's  sutures  with  the  button 
between  the  serous  surfaces,  and  that 
scarification  of  these  is  also  unneces- 
sary, t 

*  Its  use  in  effecting  lateral  anastomosis  is 
given  at  p.  406. 

f  The  following  precautions  are  given  as  to 
the  button  and  its  use.  The  edge  of  the  cup 
should  never    be    sharp,   but   possess  a   line   of 


MIKI'IIVS    MUTTON. 


369 


Dr.  Murphy  (Lancet,  vol.  i.  1895,  p.  1040)  claims  for  his  button 
thai  in  resection  of  intestine  for  gangrenous  hernia  it  has  been  used 
twelve  times,  with  two  deaths.  In  resection  for  malignant  disease  there 
have  been  thirty  operations  with  seven  deaths,  these  thirty  including 
eight  eases  of  resection  of  the  caecum,  with  but  one  death.  With  regard 
to  two  of  the  cases  of  fatal  peritonitis,  Dr.  Murphy  points  out  that  in 
one  the  button  was  too  large  and  fitted  too  tightly.  To  prevent 
tension  the  button  should  lit  easily.  In  another  case  both  ends  of  the 
intestine  were  found  to  be 
gangrenous  at  the  necropsy. 
This  is  stated  to  have  been 
due,  not  to  the  button,  but 
to  the  length  of  time  during 
which  the  intestine  was 
clamped  during  the  opera- 
tion. Later  one  of  Murphy's 
assistants  collected  the  re- 
cords of  750  cases  of  entero- 
enterostomy  performed  by 
means  of  the  button,  and  found  the  mortality  to  lie  only  19  per  cent, 
in  all  the  cases,  and  14*4  per  cent,  in  the  non-malignant  cases  (Phila- 
delphia Med.  Journ.,  igoo,  p.  1271). 

The  modus  operandi  of  the  button  is  based  upon  the  following 
principles:  (1)  It  retains  apposition  automatically — that  is,  without 
suture.  Thus  the  danger  of  shock,  the  length  of  the  manipulation 
and  exposure  of  the  intestine,  the  risk  of  infection,  post-operative 
paralysis,  and  adhesions,  are  very  greatly  lessened,  and  an  immense 
saving  of  time    secured.     12)   The  pressure-atrophy    is    produced    by 


Showing  method  of  holding  button  for  insertion. 


Fig.  120. 


Murphy's  method  of  end  to  end  approximation  of  divided  intestine.  The  two 
halves  of  the  button,  each  secured  by  a  puckering  thread,  are  ready  to  be  pushed 
home. 

elastic  pressure  ;  this  being  uniform  and  continuous,  the  assurance  of 
adhesions  is  greater  and  the  risk  of  infiltration  less.  It  produces 
juxtaposition  of  the  edges  of  the  same  coats,  thus  minimising  the  inter- 
position of  fibrous  tissue,  and  perfecting  the  regeneration  along  the 


surface.  The  spring  must  not  be  too  stiff,  or  it  might  produce  too  rapid  sloughing.  The 
locking  should  be  easy.  Unnecessary  handling  of  the  buttons  should  be  avoided.  They 
should  be  left  partially  unscrewed  until  wanted  for  use. 

*  The  male  half  of  the  button  is  held  in  the  same  way.  The  figure  representing  the 
forceps  holding  the  male  half  of  the  button  has  been  omitted,  as  it  shows  the  forceps  in 
a  wrong  position.     Mr.  Cathcart,  of  Edinburgh,  has  kindly  drawn  attention  to  this  point. 

S. VOL.  II.  24 


370  OPERATIONS    OX    THE    ABDOMEN. 

line  of  union.  As  a  result,  the  union  is  accomplished  with  the  smallest 
possible  cicatrix,  and  therefore  must  yield  the  least  contraction  of  any 
operation.  Believing  that  he  had  absolutely  established  the  above,  Dr. 
Murphy  claimed  that  his  button  attained  the  best  results  in  intestinal 
approximation  because  it  best  attained  the  following  ends:  (a)  Ac- 
curate contact  of  surface.  (/?)  Speedy  and  permanent  adhesion  of  the 
approximated  surfaces,  (y)  An  opening  sufficiently  large  for  immediate 
purposes.  (8)  A  cicatrix  that  will  not  contract  harmfully  ;  the  forma- 
tion of  a  diaphragm  is  very  rare  after  the  use  of  the  button,  (e)  The 
accomplishment  of  all  these  in  the  most  simple  and  rapid  manner.  To 
these  may  be  added  that  the  button  is  especially  suitable  when  speed 
is  imperative,  and  when  the  anastomosis  has  to  be  made  in  the  depth 
of  a  wound,  because  it  is  not  possible  to  bring  the  intestine  outside  or 
even  well  into  the  wound.  I  found  the  button  very  useful  in  enabling 
me  to  join  the  ileum  to  the  adherent  and  atrophied  ascending  colon 
after  resection  of  the  caecum  for  multiple  fistulse  due  to  tuberculous 
disease  ;  the  patient  did  well. 

Objections. — Dr.  Murphy's  method  is  so  alluring  in  its  ingenuity,  the 
simplicity  and  readiness  with  which  it  can  be  applied  are  so  evident,  that 
there  is  some  danger  of  its  disadvantages*  being  lost  sight  of.  The 
following  appear  to  me  to  be  established  : 

(i)  Contraction  of  the  orifice.!  When  the  modus  operandi  of  the 
button  is  considered  this  risk  must  always  be  remembered.  In  the 
words  of  an  American  surgeon  who  has  taken  much  practical  interest 
in  intestinal  surgery  (Dr.  AIcGraw,  of  Detroit),  "in  the  operation  by 
Murphy's  button,  the  button  becomes  detached  by  crushing  the  rim  of 
tissue  around  the  opening  of  communication  until  it  sloughs  and  gives 
way,  leaving  behind  a  granulating  wound,  disposed  to  close  after  the 
nature  of  such  wounds"  (Ann.  of  Surg.,  vol.  ii.  1893,  p.  315).  A  case 
of  Prof.  Keen's  of  ileo-colostomy,  for  carcinoma  of  the  colon,  bjT  means 
of  the  button,  is  an  instance  of  the  truth  of  the  above  : 

The  button  had  been  passed  on  the  twelfth  day,  "  together  with  a  slough  consisting 
of  the  rings  of  tissues  between  the  two  halves  of  the  button.  The  patient  died  very 
suddenly  of  a  perforating  ulcer  of  the  colon,  forty-seven  days  after  the  operation,  and 
the  necropsy  showed  that  the  opening  had  already  contracted  to  one-half  of  its  original 
diameter. 

Prof.  Keen  considers  the  possible  contraction  of  the  anastomotic 
opening  "  the  pivotal  point  upon  which  rests  the  utility  of  the 
button." 

Dr.  Dawbarn,  of  New  York,  once  a  strong  advocate  of  vegetable  plates 
in  intestinal  surgery,  had  earlier  (Ann.  of  Surg.,  vol.  i.  1893,  p.  155) 
expressed  a  fear  which  this  case  of  Prof.  Keen's  proves  to  have  been 
well  grounded  :  "In  performing  cholecystenterostomy  it  "  (the  button) 
"  really  seems  an  ideal  plan  ;  but  upon  stomach  and  in  uniting  bowel  to 

*  Dr.  Murphy,  in  a  very  interesting  paper  on  "  Operations  with  the  Murphy  Button  " 
{Lancet,  vol.  i.  1895,  p.  1040),  makes,  I  think,  too  light  of  these.  Several  of  his  conclu- 
sions as  to  contraction  of  the  scar  left  by  the  button,  faecal  impaction,  and  sloughing,  are, 
it  seems  to  me,  not  justified  by  the  published  cases  (vide  infra). 

f  Dr.  Murphy  (Joe.  supra  cit.~)  states  first  amongst  the  conclusions  at  which  he  has 
arrived — "  The  cicatrix  produced  with  the  button  does  not  contract."  No  mention  is  made 
of  Prof.  Keen's  case  given  below. 


MURPHY'S    BUTTON.  ;7, 

bowel,  because  of  the  primary  small  calibre  of  the  new  opening  (still 
further  to  be  reduced  with  time),  I  venture  to  predict  a  justified  lack  of 
acceptance  by  the  profession."  The  following  case  of  Dr.  R.  Abbe,  <>f 
X.w  York  {Ann.  of  Surg.,  April,  1895),  shows  thai  even  after  chole- 

cystenterostomy  such  stenosis  may  follow  as  to  prevent  fluid  contents, 
such  as  bile,  from  passing: 

About  a  year  before,  Dr.  R.  Abbe  had  opened  the  gall-bladder,  establishing  a  fistula 
in  a  woman  who  bad  cancer  involving  the  head  of  the  pancreas  ami  first  part  of  the 
common  duct,  causing  obstruction  and  distension  of  the  gall-bladder.     The  patient's 

condition  having  greatly  improved  in  six  weeks,  Dr.  Abbe  established  an  anastomosis 
between  the  gall-bladder  and  duodenum  with  a  Murphy's  button.  This  was  passed 
on  the  twelfth  day.  The  patient  remained  in  excellent  health  for  eight  months,  when 
Symptoms  of  gall-stone  colic  recurred,  making  it  probable  that  stenosis  was  taking 
place.  The  symptoms  returned,  and  the  patient  died  in  the  third  attack  with  cholamia 
and  convulsions.  The  opening  created  between  the  gall-bladder  and  duodenum  had 
become  absolutely  closed  by  cicatricial  contraction  ten  months  after  its  establishment. 
The  malignant  disease  had  not  invaded  the  anastomosed  parts. 

(2)  Sloughing  at  the  line  of  junction,  and  extravasation  of  fasces. 
The  following  case  of  Dr.  Abbe's  (Ann.  of  Surg.)  is  a  proof  of  the  risk 
of  the  above  : 

The  patient  was  admitted  with  obstruction  due  to  carcinoma  of  the  sigmoid.  Owing 
to  the  distension  and  the  condition  of  the  patient,  a  lateral  anastomosis  above  and 
below  the  cancer  was  done  with  a  button.  Six  weeks  later  resection  was  undertaken, 
owing  to  the  pain  felt  locally.  The  anastomosed  gut  was  resected,  and  an  end  to  end 
anastomosis  made  "by  a  large  button  which  fitted  rather  snugly  in  the  lower  end."' 
The  cancer  had  by  this  date  invaded  the  lumbar  wall.  A  counter-opening  was  made 
behind,  and  the  anterior  one  closed.  On  the  fourth  day,  fasces  appeared  at  the  lumbar 
wound.  On  the  sixth  day  this  was  freely  opened,  and  the  intestine  found  to  be  slough- 
ing on  either  side  of  the  button.     On  the  seventh  day  the  patient  died  exhausted. 

It  is  only  fair  to  Dr.  Murphy  to  point  out  that  this  was  a  very  severe 
test  for  his  method.  The  patient  was  "  not  in  very  good  condition  after 
the  operation,"  and  it  is  possible  that  the  separation  of  adhesions  and 
the  extension  of  the  growth  had  interfered  with  the  blood  supply  of  the 
intestine,  though  this  is  not  stated. 

Moreover,  the  button  was  undoubtedly  a  large  one,  for  it  "  fitted 
rather  snugly,"  and  in  this  lies  the  answer  to  the  above  objection,  for  a 
button  which  in  any  degree  stretches  the  intestine  will  be  liable  to  cause 
sloughing  opposite  the  outer  rim.  This  has  undoubtedly  been  the  cause 
in  other  cases  where  this  accident  has  happened. 

(3)  Septic  peritonitis  due  to  sloughing  of  the  intestine  over  the 
button.  When  we  consider  that  in  anastomosis  of  the  intestine  we  can 
never  keep  the  field  of  operation  aseptic,  and  that,  whatever  method  we 
use,  needles,  sutures,  buttons,  &c,  may  all  be  the  means  of  increasing 
sepsis,  no  surprise  will  be  felt  when  occasionally  cases  are  published 
in  which  septic  peritonitis  has  followed  on  the  use  of  the  button. 
Its  modus  operandi  is  by  setting  up  a  limited  pressure-gangrene  or 
sloughing.  In  many  cases  this  process  will  be  limited,  but  it  is 
manifestly  impossible  to  control  or  limit  such  a  process,  and  occasionally 
fatal  results  will  be  met  with  from  this  cause. 

Mr.  Harrison  Cripps  (Joe.  supra  cit.~)  mentioned  a  case  in  which  the  patient  died  in 
two  or  three  days  from  acute  septic  peritonitis  due  to  sloughing  of  the  intestine  over 
the  upper  half  of  the  button, 

24 — 2 


372  OPERATIONS  ON  THE  ABDOMEN. 

Prof.  Semi  speaks  very  strongly  on  this  point  (Joum.  Amer.  Med. 
Assoc,  vol.  ii.  1893,  p.  232):  "It  is  impossible  to  effect  an  aseptic 
incision  in  the  interior  of  the  bowel;  the  dead  tissue  inhabited  by 
pathogenic  microbes  always  constitutes  a  source  of  danger.  It  is  easy 
enough  to  produce  gangrene,  but  we  are  powerless  in  limiting  its 
extension  in  this  locality.  The  limited  area  of  living  tissue  brought  in 
contact  outside  of  the  rings  of  the  Murphy  button  will  not  always  prove 
adequate  in  the  protection  of  the  peritonseal  cavity  against  perforation 
and  its  immediate  result — septic  peritonitis.  I  have  knowledge  of  a 
number  of  cases  in  which  the  parts  approximated  by  the  Murphy  button 
were  found  completely  separated  at  the  post-mortem  examination." 

(4)  Retention  of  the  button,  causing  obstruction.  I  shall  allude  to 
cases  under  the  heading  of  "  Gastrojejunostomy,"  where  the  buttons 
had  not  been  passed,  and  the  patients  were  not  relieved.  A  number 
of  similar  cases  have  been  recorded. 

The  following  show  that  the  button  may  cause  fatal  obstruction  : 

Dr.  R.  Abbe  (Ann.  of  Surg.)  has  related  a  case  of  resection  of  the  caput  coli  and 
ascending  colon  for  cancer  in  a  patient  aged  42.  An  end  to  end  anastomosis  was  easily 
made  with  a  medium-sized,  easy-fitting  Murphy  button.  At  the  end  of  the  second  day 
there  was  abdominal  pain,  with  tympanites  and  vomiting.  Strong  desire  to  defaecate  was 
futile,  even  with  the  aid  of  a  high  enema.  Saline  cathartics  were  useless.  On  the  third 
day  after  the  operation  the  greatly  distended  ileum  was  sutured  to  the  abdominal  wnll 
and  opened.  A  large  amount  of  fluid  freces  escaped  with  great  relief.  The  patient  died 
on  the  sixth  day.  The  necropsy  showed  no  peritnitis,  but  an  empty  colon  below  the 
button,  and  a  hard  plug  of  fasces  in  the  button,  which  caused  complete  obstruction. 

Dr.  Kammerer  (Ann.  of  Surg.)  has  recorded  a  case  in  which  the 
button  caused  trouble  by  not  passing  in  the  small  intestine. 

The  case  was  one  of  ffecal  fistula,  resulting  from  a  gangrenous  hernia.  Anastomosis 
had  been  made  by  a  Murphy's  button.  Thirteen  weeks  later  the  button  had  not  been 
passed,  but  could  easily  be  reached  from  the  fascal  fistula  which  still  persisted.  Dr. 
Kammerer  enlarged  the  fistula,  and  after  much  trouble  succeeded  in  extracting  the 
button.  The  patient  did  well  for  six  days,  when  she  developed  symptoms  of  sub- 
acute peritonitis  and  died.  The  necropsy  showed  general  peritonitis.  The  anastomosis 
had  separated  while  the  button  was  being  removed,  and  the  sharp  edges  of  the  incision 
into  the  bowel  showed  that  the  adhesions,  even  after  thirteen  weeks,  must  have  been 
very  slight.  Dr.  Kammerer  did  not  believe  that  the  peritonitis  was  due  to  a  separation 
at  this  point,  but  any  other  explanation  for  it  was  not  apparent. 

Mr.  Harrison  Cripps  (Brit.  Med.  Joum.,  vol.  ii.  1895,  p.  965)  mentioned,  in  the 
discussion  on  colectomy,  a  case  in  which  the  patient  died  on  the  eighth  day  from 
perforative  peritonitis  caused  by  the  button  having  become  impacted  six  inches  below  the 
point  of  anastomosis,  and  having  ulcerated  through. 

Mr.  F.  C.  Wallis  {Lancet,  Dec.  5,  1903)  records  an  interesting  case 
of  resection  of  a  chronic  intussusception  of  the  small  intestine,  in  which 
he  used  a  Murphy  button.  Three  weeks  later  the  button  gave  rise  to 
attacks  of  colicky  pain,  and  had  to  be  removed  from  the  lower  end  of 
the  ileum.  Wallis  thinks  that  the  button  used  was  too  large,  and  he 
has  not  had  any  other  trouble  from  the  use  of  Murphy's  button,  which 
he  has  employed  many  times.  A  similar  case  is  mentioned  under 
"  Gastrojejunostomy." 

(5)  Kinking  and  strangulation  from  the  weight  of  the  button.  This 
is  rare,  but  a  case  of  Dr.  Abbe's  is  related  of  this  kind  (Ann.  oj  Surg.)  : 

Five  inches  of  small  intestine  had  been  resected  for  gangrene  in  a  hernia.  The  two 
ends   having   been   joined   by  Murphy's   method,  the  loop   containing  the   button  was 


MAYO    ROBSON'S    BOBBIN. 


373 


replaced,  and  Bassini's  operation  performed.  Before  the  wound  was  entirely  closed, 
Dr.  Aiiin'  looked  in  and  noticed  thai  the  upper  end  of  the  gul  was  still  distended. 
This  was  doe  to  the  button  kinking  the  gul  as  it  lay  in  tip'  iliac  fossa.  The  loop  was 
accordingly  pushed  towards  the  middle  of  the  abdomen,  in  the  belief  thai  it  would 
and  real  easily  among  tin'  other  coils.  Symptoms  of  strangulation  recurred,  and 
forty-eight  hours  after  the  firsl  operation  Dr.  Abbe  reopened  the  abdomen  and  found 
the  kink  persisting,  the  bowel  having  gravitated  to  the  lowest  point  in  the  p 
The  patient  only  survived  the  operation  a  short  time.  It  seemed  that  the  weight  of 
the  button  had  given  rise  to  the  acute  obstruction  by  sharply  bending  the 
Probably  this  was  aided  by  the  paralysed  condition  of  the  bowel  so  common  in  these 
eases. 

(6)  Mr.  Mayo  Robson,  in  a  speech  at  the  Clinical  Society,  pointed 
out  that  if  any  error  was  made  in  applying  the  button,  it  might  be 
impossible  to  unfasten  it  for  readjustment.  He  stated  that  under 
such  circumstances  an  operator,  in  order  to  set  the  button  free, 
had  found  it  necessary  to  excise  afresh  the  portion  grasped  by  the 
button. 

(7)  Another  objection  of  a  very  different  kind  may  be  just  alluded 
to,  and  that  is,  its  expense,  and  the  difficulty  of  always  having  the 
right  size  at  hand.  This  in  no  way  detracts  from  the  ingeniousness  of 
the  button,  nor  do  I  bring  it  forward  as  a  serious  objection.  It  is  right, 
however,  that  it  should  be  mentioned  when  this  mode  of  intestinal 
junction  or  anastomosis  is  fairly  weighed  with  enterorraphy,  Robson's 
bobbin,  &c.  ;  this  last  is,  of  course,  required  in  several  sizes,  but,  being 
far  less  expensive,  will  be  more  readily  near  at  hand  in  sufficient 
variety. 

I  am  well  aware  that  these  cases  given  above  are  but  few  when 
compared  with  the  large  number  of  brilliant  successes  which  Dr. 
Murphy's  button  has  attained.  It  is  right,  however,  that  they  should 
be  published,  as  there  is  strong  reason  to  believe  that  the  button 
has  been  used  on  many  occasions  unsuccessfully,  these  cases  never 
being  published.  Again,  it  is  noteworthy  that  the  failures  which 
have  been  published  have  occurred  in  the  hands  of  most  skilful 
surgeons.  I  fear  that  the  extreme  ingenuity  of  the  button,  the  facility 
with  which  it  can  be  used,  may  tempt  men  far  less  competent  to  perform 
operations  for  which  they  are  unfitted,  with  results  that  will  not  be 
made  public.  Kbnig  (Centr.  f.  Chir.,  No.  4,  1895),  I  find,  has 
expressed  the  same  view.  Thus,  "  The  use  of  Murphy's  button  may 
extend  the  practice  of  resection,  and  so  enable  inexperienced  surgeons 
to  perforin  these  operations,  but  this,  from  the  patient's  point  of  view, 
is  lather  a  disadvantage  than  a  sign  of  advance." 

Mayo  Robson's  Bobbin  (Figs.  121,  122,  123). — This  method 
appears  to  me  likely,  for  the  present  at  all  events,  to  replace  all  the 
other  special  couplers  which  have  been  invented  to  aid  in  the  resection 
or  anastomosis  of  the  stomach  and  intestines. 

Mr.  Robson  (Brit.  Med.  Journ.,  vol.  ii.  1895,  p.  963)  states  that,  after 
using  or  seeing  used  all  the  other  usual  contrivances,  e.g.,  Senn's  plates, 
Murphy's  button,  and  Paul's  tubes,  he  has  returned  in  enterectomy  to 
the  use  of  the  bobbin,  which  "  I  infinitely  prefer,  not  only  on  account  of 
its  simplicity  and  safety,  but  because  it  can  be  employed  quickly,  secures 
an  immediately  patent  channel,  leaves  no  foreign  body  permanently  in 
the  passage,  avoids  stricture   by  securing  continuity  of  mucous  surface, 


374  OPERATIONS  ON  THE  ABDOMEN. 

and  can  be  adapted  to  any  of  the  operations  on  the  intestinal  canal."* 
Another  advantage  which  may  be  safely  claimed  is  that  these  bobbins 
are  much  more  easily  introduced  when  one  segment  of  intestine,  e.g.,  the 
lower  usually,  is  much  narrower  tban  tbe  upper.  Again,  from  their 
shape,  they  obviously  will  exert  much  less  tension  upon  the  intestinal 
wall  and  the  sutures  which  hold  them  together,  than  the  plates  of 
Prof.  Senn. 

The  decalcified  bone  bobbins  were  in  their  first  issue  like  a  cotton- 
reel,  the  rims  at  the  ends  being  (Fig.  122)  made  larger  than  its 
centre  in  order  to  prevent  the  body  shifting  from  its  place  until  its 
pressure  is  not  needed.  These  rims  being  found  too  prominent,  the 
bobbin  was  modified  as  shown  in  Fig.  121.  The  following  account  is 
taken  from  La  Sem.  Med.,  loc.  infra  cit.  (Figs.  122,  123) :  "It  seemed 
that  if  one  could  secure  continuity  of  the  mucous  coat  across  the  new 
aperture  by  means  of  a  continuous  suture  (Fig.  122)  sewn  around  a  tube 

without  the  risk  of  narrowing  the  size  of 
I21,  the  orifice,  one  would  be  able  to  avoid 

consecutive   cicatricial  narrowing.      The 
union   of  the   serous    surfaces    could  be 
assured  by  means  of  a  sero-serous  suture 
made   in  the  same  way  as  the  mucous, 
one  or  one  and  a  half  centimetres  from 
the  edges  of  the  incision,  so  removing  all 
risk   of  extravasation   (Fig.   123).      The 
operation  is  facilitated  by  beginning  with 
the  sero-serous  suture  for  the  posterior 
Mayo  Eobson's  decalcified  bone   half  of  the  incision,  then  putting  in  the 
bobbin.     These  are  made  in  five    muco-niucous  for  the  same  extent.     The 
sizes,  for  junction  of  gall-bladder    tube    ^    ^  ^       j  the    mucQ, 

and  intestine,  stomach  and  intes-  r  ,    .    \  -,  c      n 

tine,  to  unite  resected  small  intes-    »1UC0US  Sutu*'e  n«t  completed,  and  finally 
tine,  colon,  and  rectum.    The  above    the  anterior  hall  of  the  sero-serous. 
is  the  size  used  for  the  colon.  Mr-  Mayo  Eobson  (Brit.  Med.  Journ., 

vol.  ii.  1895,  p.  965)  stated  that  while 
usually  employing  two  sutures,  the  anucous  and  serous,  with  his 
bobbin,  he  has  not  hesitated  to  use  only  one  continuous  stitch  to  unite 
the  whole  thickness  of  the  gut  where  time  was  an  object  in  the  case. 
In  this  case  he  claims  that  the  bobbin-operation  can  be  done  more 
quickly  than  that  with  the  button,  and  at  the  same  time  he  believes 
that  it  will  give  greater  security  against  leakage  and  a  much  firmer 
bond  of  union.  "When  the  double  suture  is  used,  Murphy's  button  will, 
Mr.  Eobson  thinks,  only  save  three  or  four  minutes,  and  he  points  out 
that  his  five  cases  of  colectomy  are  living  examples  of  the  contrast  of  the 
after-progress  of  the  two  methods.  Thus  in  cases  i.,  ii.,  and  v.,  where 
the  bobbin  was  used,  an  uninterrupted  recovery  followed  ;  in  case  iii., 
Murphy's  button  took  forty-four  days  to  pass,  and  caused  partial  obstruc- 
tion on  several  occasions.  In  a  list  of  cases  which  Mr.  Eobson  prepared 
in  order  to  illustrate  a  paper  read  before  the  Clinical  Society  (Brit.  Med. 

*  It  will  be  a  rery  great  gain  if  surgeons  find,  as  claimed  by  Mr.  M.  Eobson  (La 
Semaine  Medicate,  1892.  p.  482),  that  there  is  one  contrivance  ready  to  their  hands  calling 
fur  much  the  same  technique  in  all  such  varied  operations  as  enterectomy,  intestinal 
anastomosis,  ileo-colostomy,  pvlorectomy.  p\  luroplasty.  cholecystenterostomy. 


MAYO   ROBSON'S    BOBBIN.  375 

Joil/rn.,  vol.  i.  1896,  p.  451),  the  bobbin  was  used  in  seven  casus  of 
enterectomy,  and  out  of  these  six  recovered.* 

The  following  advantages  of  this  method  have,  it  seems  to  me,  been 
fairly  established: — (1)  It  facilitates  and  simplifies  circular  enterorraphy. 

(2)  The  foreign  body  on  which  it  depends  is  safely  dissolved,  instead  of 
being  left  behind   to   come   away,   thus   often   giving  rise   to  anxiety. 

(3)  There  is  no  sloughing  connected  with  its  modus  operandi ;  it  pre- 
vents subsequent  stricture  by  establishing  a  continuous  mucous  canal, 
without  the  stage  of  healing  by  granulation.  (4)  Owing  to  the  size  of 
the  bobbin,  and  there  being  no  sloughing  connected  with  it,  the  opening 


Fig.  122. 


? 


The  continuous  muco-mucous  suture.     (Mayo  Robson.) 


r~> 


The  continuous  sero-serous  suture.     Below  is  seen  the  knotted  end  of  the  muco- 
mucous  stitch  which  will  shortly  be  shut  in.     (Mayo  Robson.) 

provided  is  sufficient  and  permanent.  (5)  Though  at  present  it  has  not 
been  very  largely  used,  the  percentage  of  successes  is  very  high.  In 
bis  paper,  read  before  the  Clinical  Society,  Mr.  Robson  showed  that  the 
use  of  the  bobbin  had  been  attended  by  a  mortality  as  low  as  8  per  cent. 
(6)  Last,  but  by  no  means  least  in  importance,  is  the  fact  that  the 
bobbin  is  adaptable  to  a  very  wide  range  of  operations.  The  chief 
objection  to  it  is  one  common  to  all  mechanical  devices — i.e.,  that  it  is 
not  always  to  hand.  In,  however,  its  cheapness,  its  great  variety  of 
sizes,  and  the  readiness  with  which   it  can   be  prepared,  it   contrasts 


*   Mr.  Bowlby,  in  the  discussion  which  followed  Mr.  M.  Robson's  paper,  emphasised 
the  advantage  of  the  bobbin  in  securing  the  immediate  passage  of  flatus  and  faeces. 


376 


OPERATIONS  ON  THE  ABDOMEN. 


very  favourably  with  Murphy  s  button  and    more   recent   mechanical 
contrivances. 

Allingham' s  Bobbin  (Figs.  124  to  127). — Mr.  H.  Allingham  has 
introduced  a  bone  bobbin  which  differs  from  Mr.  Robson's  in  shape  and 
structure.  It  consists  of  two  cones  with  the  apices  united  in  the  centre 
(Fig.  124).     They  are  decalcified  to  within  about  three-sixteenths  of  an 


Fig.  124.  Fig.  125 


Fig.  127. 


inch  of  their  centre.  The  junction  of  the  two  cones  is  hard  and  unyield- 
ing to  meet  any  pressure  from  the  sutures  when  tightened.  Besides  the 
advantages  of  other  bobbins,  it  is  claimed  that  this  one  cannot  slip  away, 
and  that  when  the  sutures  are  tied  the  parts  resected  are  brought 
together  without  excessive  pressure  on  the  edges  of  the  bobbin.  A 
purse-string  stitch  (Fig.  125)  is  run  round  each  end  of  the  gut;  then 


Fig.  128. 


For  side  to  side  union. 
Allingham's  bobbin. 


For  end  to  end  union. 
Stanmore  Bishop's  bobbins. 


one  end  of  the  bobbin  is  inserted  into  one  segment  of  the  intestine,  and 
the  suture  is  pulled  tight  by  a  knot  twice  threaded  (Fig.  126),  which 
will  not  slip,  but  the  final  tie  is  not  made  until  the  other  end  of  the 
bobbin  has  been  inserted  into  the  other  segment  of  intestine.  After  this 
each  suture  is  tightened  to  its  utmost,  the  ends  of  the  intestine  being 
thus  drawn  down  to  the  centre  of  the  bobbin  (Fig.  127),  which  from  its 
shape  ensures  that  the  tighter  the  sutures  are  drawn,  the  more  securely 
must  the  intestine  ends   be  drawn  to  meet  in  the  centre  of  the  bobbin. 


HAYES'    BOBBIN. 


377 


A  few Lembert*8  sutures  or  a  continuous  Lembert's  suture  maybe  used 
if  thought  desirable.  It  is  well  to  lightly  scarify  the  serous  coal  for 
half  an  inch  round  the  union  to  promote  exudation  of  lymph.  This 
button  has  been  successfully  used  on  the  human  aubject  by  Mr. 
Allingham. 

Mr.  Stanmore  Bishop's  button  (Lancet,  vol.  ii.  1902,  p.  505)  1ms  all 
the  advantages  of  that  of  Allingham,  and  is  much  more  easily  introduced 


Fig.  129. 

A     B 


Via.  130. 


-**=*- 


A  B,  Central  part  not 
decalcified,  partly  seg- 
mented by  saw-cut.  C, 
Lumen  in  decalcified  end. 


A  D,  Proximal  and  distal  intestine.  C  E,  Purse-string 
sutures.  B,  Sub-serous  purse-string  suture,  by  which, 
after  union  of  the  intestine,  one  part  is  invaginated  over 
the  other. 


Fig.  131. 


C,  Proximal  groove  in  which  the  two  marginal  sutures  secure  the  orifices  of 
the  two  parts  of  the  intestine,  A  and  B.     D,  Distal  groove  where  sub-serous  purse- 
string  presses  the  proximal  intestine  over  the  invaginated  distal  part. 
End  to  end  union  by  Haves'  bobbin. 


on  account  of  its  conical  ends,  and  it  facilitates  suturing  to  a  greater 
degree. 

Hayes'  Bobbin  (Figs.  129  to  131).— Mr.  Hayes  has  devised  (Lancet, 
vol.  i.  1895,  p.  1619)  another  ingenious  button,  partly  decalcified,  by 
which  he  obtains  additional  security  by  easily  invaginating  one  piece  of 
resected  intestine  within  the  other.  It  is  not  stated  whether  the  bobbin 
has  been  successfully  used  on  the  living  subject.  The  drawings  are  so 
char  that  they  explain  this  method  of  themselves. 

Numerous  varieties  and  modifications  of  bobbins  have  been  intro- 
duced, notably   by  Paul,  Bailey,  Jesset,  McLennan,   and  others;  but 


378 


OPERATIONS  ON  THE  ABDOMEN. 


most  of  them  are  difficult  to  prepare  and  procure,  and  but  few  of  thern 
are  capable  of  easy  and  rapid  application.  There  is  nothing  to  be 
gained  therefore  by  describing  any  more  of  them  here,  however 
ingenious  some  of  them  may  be. 

Paterson  (Lancet,  1905,  vol.  i.  p.  858)  has  described  a  soluble  button 
made  of  gelatin  hardened  in  a  solution  of  chrome  alum  ;  it  consists  of  a 
male  and  female  part,  like  Murphy's  button,  and  is  introduced  in  a 
similar  manner.  It  is  not  stated  that  it  has  been  used  in  the  human 
subject  yet. 

Simple  suture  is  more  generally  applicable  than  any  button  or  bobbin, 
and  it  should  be  the  surgeon's  aim  and  duty  to  perfect  himself  in  this 

Fig.  132. 


Lateral  anastomosis  by  Hayes'  bobbin.  E  and  F,  Apertures  to  receive 
the  bobbin.  D  and  C,  Marginal  sutures.  K  and  I,  Sub-serous  purse-string 
sutures. 


method,  which  makes  him  independent  of  foreign  bodies,  that  are  not 
always  suitable  or  available. 

O'Hara's  Forceps  {Ann.  of  Surg.,  1901,  vol.  xxxiii.  p.  179). — The 
following  description  of  this  instrument  is  given  in  Dr.  O'Hara's  own 
words : — 

"  The  instrument  consists  of  two  pairs  of  straight  forceps,  the  jaws 
of  which  are  very  slender  and  two  and  a  half  inches  long  for  ordinary 
work  ;  for  special  work  they  can  be  made  longer.  Instead  of  being 
roughened,  as  in  the  ordinary  haemostatic  forceps,  they  are  grooved 
down  the  centre  of  one  blade  ;  the  opposite  one  has  a  ridge  similar  to 
a  pile  clamp  :  both  forceps  are  held  together  by  means  of  an  adaptation 
of  the  serre-fine." 

The  serre-fine  having  been  removed,  the  forceps  are  applied  and 
locked  with  their  extremities  just  on  the  mesenteric  border,  as  shown 
in  the   figure.     The   intestine  is   divided  quite   close   to  the  forceps} 


O'HARA'S    KoRCKI'S. 


379 


the  portioD    removed    being  clamped    at    both   ends    to    prevent    any 
leakage  (vide  Figs.  133  and  134). 

The  two  forceps  are  brought  and  fixed  together  by  means  of  the 
serre-fine  clamp,  and  Halsted  sero-muscular  sutures  are  then 
inserted,  starting  from  the  free  border  of  the  bowel.  At  the  mesenteric 
border  some  care  is  necessary  to  produce  sufficient  inversion,  and  it  may 
be  necessary  to  nick  the  mesentery  and  push  it  back  a  little,  so  that  the 
bowel  can  turn  in  more  easily.  The  forceps  are  then  turned  over,  and 
sutures  are  passed  and  tied  as  shown  in  the  figure.  The  forceps  are 
undamped,  and  one  pair  is  unlocked  and  removed  by  traction ;  the 

Fig.  133. 


Showing  the  manner  of  placing  O'Hara's  forceps  in  resection  of  the  intestine. 
Note  that  the  ends  are  on  the  mesenteric  border.  The  forceps  should  be  placed 
more  obliquely,  so  that  more  of  the  free  border  of  the  bowel  can  be  excised. 
(After  O'Hara,  Ann.  of  Surg.) 


other  is  unlocked,  and  also  passed  up  and  down  within  the  intestinal 
canal  to  make  sure  that  none  of  the  sutures  have  included  both  walls. 
The  forceps  are  then  withdrawn,  and  the  opening  is  closed  by  one 
stitch.  A  continuous  Lembert  suture  may  be  used  either  instead  of 
the  Halsted  stitch  or  to  reinforce  it. 

The  advantages  claimed  for  this  method  are  (a)  that  the  union  can 
be  made  very  rapidly,  although  not  so  speedily  as  with  a  Murphy's 
button ;  (b)  that  the  danger  of  sepsis  from  soiling  with  faeces  is 
unusually  slight,  because  the  bowel  cavity  is  closed  off  at  the  very 
beginning  of  this  operation  ;  (c)  accuracy  of  apposition ;  it  may  be 
objected  that  the  inverted  ends  are  not  ioined  at  their  edges,  so  that 
fasces  may  soak  outwards  towards  and  infect  the  sutures  ;   (d)  simplicity  : 


38o 


OPERATIONS    ON    THE   ABDOMEN. 


in  this  it  compares  very  favourably  with  the  anastomosis  by  means  of 
the  Laplace's  forceps,  which  are  rarely  used  now  (Ann.  of  Surg., 
March,  1899) ;  (e)  wide  range  of  application  to  the  intestines,  stomach, 
and  gall-bladder. 

The  chief  objections  to  the  method  are — 

(a)  A  diaphragm  has  been  known  to  form  owing  to  the  large  amount 
of  inversion  that  may  be  produced.  F.  T.  Stewart  (Ann.  of  Surg., 
1903,  vol.  xxxviii.  p.  135)  records  a  fatality  from  this  cause.  The  forceps 
had  been  used  after  the  excision  of  gangrenous  intestine.     A  secondary 

Fig.  134. 


Forceps  brought  together  and  locked,  mattress  sero-muscular  stitches  inserted  ; 
some  of  them  have  been  tied.     (After  O'Hara,  Ann.  of  Surg.') 


resection  became  necessary  owing  to  the  obstruction  by  means  of  the 
diaphragm. 

(b)  The  sutures,  which  do  not  pierce  the  whole  thickness  of  the 
bowel,  may  yield  and  lead  to  leakage  about  tbe  fourth  day  ;  but  it  is 
only  fair  to  say  that  this  is  not  so  likely  to  occur  when  a  Halsted's 
stitch  is  employed  as  when  other  forms  of  sero-muscular  suture  are 
used. 

(c)  Tbe  pressure  of  the  forceps  may  damage  the  bowel  and  lead  to 
infective  necrosis  of  uncertain  limit. 

Comparison  of  Enterorraphy  with  the  Chief  Devices 
intended  to  Aid  or  Replace  it.  —  Enterorraphy  by  circular 
suturing  must  be  admitted  to  be  the  ideal  operation  from  its  simplicity, 
the  entire  absence  of  any  especial  apparatus,  and  the  fact  that  no  foreign 


MODIFICATIONS   OF   CIRCULAR    ENTERORRAPHY.         381 

body  is  left  behind  which  may  perhaps  give  trouble  ere  it  come  away. 
Those  who  condemn  it  as  unsu<  cessful  must  remember  (1)  that  it  has 
been  gradually  and  slowly  perfected,  being  often  laid  aside  for  some 
new  device  and  then  resorted  to  again,  and  that  it  was  very  largely 
used  in  the  earlier  and  darker  days  of  intestinal  surgery;  (2)  that  when 
used  by  skilled  hands  it  has  proved  most  effective  and  reliable  in  the 
time  of  emergency.*  When  used  by  such  hands — and  it  is  one  advan- 
tage of  this  method  that  it  is  easy  for  any  operating  surgeon  to  acquire 
skill  in  it — care  will  be  taken  to  fulfil  the  conditions  necessary  for 
successful  enterorraphy,  viz.,  (a)  sufficient  inversion  of  the  serous 
coats  ;  (b)  penetration  of  all  the  coats  by  one  of  the  rows  of  stitches, 
which  should  have  all  knots  on  the  mucous  surface;  (r)  careful  adjust- 
ment of  the  junction  of  the  intestine  and  the  mesentery  (Figs.  103, 
104,  142);   and  (d)  placing  of  the  sutures  in  healthy  tissues. 

It  is  right  to  state  clearly  here  that  many  excellent  judges,  men  well 
experienced  in  intestinal  surgery,  condemn  circular  enterorraphy. 
Thus  Dr.  A.  B.  Robinson  (Ann.  of  Surg.,  vol.  i.  1891,  p.  430)  states 
that  he  found  it,  from  experiments  on  dogs,  very  dangerous,  for  the 
following  reasons  :  (1)  It  paralyses  the  gut,  and  hence  does  not  so 
readily  relieve  the  faecal  obstruction  which  is  the  immediate  object  of 
surgical  interference.  To  this  it  may  be  replied  that,  as  shown  at 
p.  385,  the  joining  of  ends  of  intestine  resected  while  obstruction  is 
present  should  be  deferred  wdienever  possible ;  and  when  this  is  not 
possible — a  rare  contingency — the  intestines  should  be  thoroughly 
emptied  before  they  are  resected.  If  this  is  not  practicable,  union 
should  be  deferred  and  drainage  continued  by  Paul's  tubes  (Fig.  97, 
&.c).  (2)  A  faecal  fistula  is  apt  to  arise  at  the  point  of  suture. 
(3)  Gangrene  or  sloughing  may  arise  from  the  pressure  of  numerous 
sutures.  These  are  very  fair  criticisms.  They  must  each  be  met  by 
care  in  suturing,  and  by  attention  to  the  junction  of  the  intestine  and 
the  mesentery.  (4)  The  lumen  of  the  two  ends  may  be  unequal. 
When  this  difficulty  is  marked,  circular  enterorraphy  must  be 
abandoned  for  intestinal  anastomosis.  (5)  Pathological  changes  due 
to  obstruction  in  the  bowrel  may  offer  impediments.  The  gut  ma}r  be 
stretched  so  thin  that  a  needle  cannot  be  passed  between  the  muscular 
and  mucous  layers  without  danger  of  penetrating  the  mucous  layer  and 
causing  faecal  fistula,  but  with  Council's  suture  this  does  not  matter 
so  much.  I  have  pointed  out  elsewhere  (p.  385)  that  union  of  resected 
intestine  is  not  to  be  attempted  where  obstruction,  over-distension,  &c., 
are  present.  Where  the  distension  has  been  prolonged,  as  in  malig- 
nant disease  low  down  in  the  canal,  circular  enterorraphy  is  contra- 
indicated.  This  is  not  the  case  where  the  obstruction  has  been  of 
shorter  duration — e.g.,  in  gangrenous  herniae — as  shown  by  the  suc- 
cessful cases  given  at  p.  393.  (6)  Circular  stricture  followed  the 
experiments.  Some  of  the  strictures  were  so  severe  that  both  faeces 
and  gases  were  actually  obstructed.  This  is  a  very  rare  sequel  in  the 
human  subject,  as  shown  lately  by  W.  A.  Evans.     (7)  The  long  time 

*  To  mention  a  few  cases  only,  I  refer  my  reader  to  those  of  Mr.  Lockwood  and  to 
Dr.  McCosh's  four  successful  cases  of  circular  enterorraphy  after  resection  of  small  intes- 
tine for  gangrene.  To  such  urgent  emergencies,  circular  enterorraphy  is  especially  suited 
if  the  surgeon  has  had  sufficient  practice  to  rely  on  himself, 


382  OPERATIONS   ON   THE   ABDOMEN. 

required  for  a  circular  enterorraphy  militates  against  the  chances  of 
recover}'.  Of  all  surgery  in  the  world,  intestinal  surgery  should  be 
rapid  and  skilful.  Of  the  different  methods,  Dr.  Robinson  recommends 
Lembert's  sutures,  making  these  continuous  for  two,  three,  or  four 
stitches.  This  worked  well  and  saved  time,  three  to  five  interruptions 
of  Lembert's  sutures  completing  the  circle  round  the  gut.  In  this  way 
a  circular  enterorraphy  can  be  completed  in  less  than  half  an  hour. 
At  the  present  day  end  to  end  union  with  continuous  suture  can  be 
performed  in  less  than  half  this  time.  Dr.  Robinson  emphatically 
opposes  a  circular  enterorraphy  with  a  continuous  Lembert's  suture. 
"  This  was  carefully  tried,  and  the  worst  strictures  of  all  resulted;  not 
only  that,  but  the  thread  gradually  fell  into  the  gut  lumen,  and  its  end 
dangled  for  days  and  even  weeks  there  before  it  became  entirely  set 
free.  This  long  thread  will  certainly  be  a  dangerous  source  of  infection, 
as  infective  fluids  can  go  along  it  by  mere  capillary  attraction,  not  to 
speak  of  the  wider  faecal  fistula  it  may  create."  There  is  much  weight 
in  these  last  two  criticisms.  An  increasing  number  of  recent  success- 
ful cases  of  circular  enterorraphy,  amongst  these  being  one  byLockwood 
(P-  393)>  three  by  McCosh  (p.  393),  one  by  Ransohoff  (p.  393),  and 
many  by  Continental  surgeons,  show,  however,  that  they  are  not 
unanswerable. 

Dr.  Frank,  writing  in  1902  (Ann.  of  Surg.,  vol.  xxxv.  p.  36),  advocates 
the  use  of  mechanical  means,  such  as  the  Murphy  button  and  the 
Frank  coupler,  believing  that  these  methods  are  much  safer  than  direct 
suture.     This  does  not  agree  with  general  American  opinion,  however. 

Messrs.  Ballance  and  Edmunds  (Trans.  Med.-Chir.  Soc,  1896)  have 
carried  out  an  experimental  inquiry  with  especial  reference  to  the 
question  of  the  best  means  of  uniting  resected  intestine.  The  following, 
very  briefly  put,  are  some  of  the  conclusions  to  which  the  authors 
were  led  with  regard  to  enterorraphy,  and  other  methods  of  resecting 
intestine.  With  regard  to  end  to  end  union,  the  above-mentioned 
authors  prefer  simple  suturing  to  the  use  of  any  form  of  supporting 
apparatus.  They  recommend  either  the  Czerny-Lembert  or  Maunsell's 
method.  Of  five  experiments  on  dogs  performed  b}r  the  former  and 
two  by  the  latter  method,  all  did  well.  With  regard  to  the  Czerny- 
Lembert  method,  emphasis  is  laid  on  the  care  needed  at  the  mesenteric 
junction  and  on  the  following  facts.  In  the  small  intestine  eversion  of 
the  mucous  membrane  takes  place  to  such  a  marked  degree  that  the 
insertion  of  the  inner  row  of  sutures  only  results  in  apposition  of 
mucous  membrane  to  mucous  membrane.  Thus  the  integrity  of  the 
junction  depends  solely  on  the  Lembert  sutures.  The  result  of  the 
inversion  produced  by  these  is  a  ridge  which  remains  at  the  line  of 
junction,  sometimes  seriously  contracting  the  lumen  of  the  gut.  This 
untoward  result  is  especially  likely  to  be  brought  about  if  the  surgeon 
is  uncertain  about  the  efficiency  of  his  row  of  Lembert's  sutures,  and 
is  tempted  to  put  in  others,  still  further  diminishing  the  lumen  of  the 
bowel.  The  above  objection  does  not  apply  to  Maunsell's  method, 
which  produces  very  perfect  union,  mucous  coat  being  united  to  mucous, 
muscular  to  muscular,  and  serous  to  serous.  After  the  Czenvy- 
Lembert  method  a  circular  ridge  or  diaphragm  is  always  to  be  found 
on  laying  open  the  intestine.  This  is  not  so  after  the  Maunsell 
method :    here   it  is   quite  difficult  to   recognise   the  line   of  circular 


MODIFICATIONS   OF   CIRCULAR    ENTERORRAPHY.         383 

junction,  this  presenting  a  marked  contrast  with  the  ridge  seen  at  the 
Bite  of  the  Longitudinal  incision  which  had  been  closed  by  Lembert's 
Butures. 

Of  the  different  methods  of  producing  lateral  anastomosis,  Mr. 
Ballance  and  Mr.  Edmunds  consider  Halsted's  (Figs.  155  to  157)  to 
be  superior  to  all  in  which  plates,  bobbins,  and  other  mechanical  aids 
are  used.  The  above-mentioned  authorities  emphasise  one  objection 
which  applies  to  all  of  the  above — viz.,  that  the  surgeon  may  very 
likely,  in  cases  of  emergency,  not  he  provided  with  the  size  he  requires. 
As  to  the  claim  that  such  devices  shorten  the  time  of  operation,  Messrs. 
Ballance  and  Edmunds  reply  :  (1)  That  if,  as  in  Senn's  method  of 
anastomosis,  sutures  have  to  be  placed  around  the  plates,  the  time 
taken  is  not  much  shortened.  (2)  Such  a  method  as  Halsted's  lateral 
anastomosis  does  not  take  long  if  proper  attention  is  paid  to  the 
following  essentials:  (a)  A  plentiful  supply  of  round  needles  ready 
threaded  with  silk  sufficiently  thick  not  to  cut  the  intestinal  coats. 
(/3)  Using  the  needles  as  splints.  Thus,  if,  just  as  one  thread  is 
coming  to  an  end,  the  needle  which  carries  it  be  left  in  situ  transfixing 
the  cut  edges,  this  will  keep  the  parts  together  and  greatly  facilitate 
the  introduction  of  the  next  suture. 

It  is  becoming  increasingly  clear,  I  think,  that,  in  the  hands  of  an 
operating  surgeon  who  has  taken  care  to  acquire  skill  by  practice,  the 
chief  objections  to  enterorraphy  will  he  very  greatly  reduced — viz.,  the 
time  taken,  the  number  of  sutures  needed,  the  risk  of  yielding  of  sutures, 
of  leakage  at  the  junction  of  mesentery  and  intestine,  and  of  stenosis 
from  contraction  of  the  cicatrix,  especially  if  the  inversion  has  been 
needlessly  free. 

Where  the  surgeon,  from  any  want  of  faith  in  his  skill,  or  from  the 
condition  of  the  patient  requiring  that  the  operation  should  be  com- 
pleted speedily,  prefers  to  rely  upon  one  of  the  devices  intended  to  aid 
or  to  replace  circular  enterorraphy,  he  will  be  wisest  in  making  use  of 
Murphy's  button,  or  Mayo  Bobson's  bobbin,  or  Stanmore  Bishop's 
modification,  which  I  consider  to  be  a  distinct  improvement.  Of  these 
Murphy's  button  is  highly  to  be  recommended  on  account  of  the 
rapidity  with  which  the  operation  can  be  completed.  For  although 
there  are  undoubted  objections  to  the  use  of  the  button,  as  above 
described,  careful  adjustment  in  well-nourished  intestine,  and  a  wise 
selection  in  choosing  the  size  of  button  to  be  used,  will  avoid  most  of 
them.  Moreover,  it  must  be  remembered  that  the  accidents  that  have 
happened  are  comparatively  rare,  and  the  results,  as  far  as  can  be 
judged,  are  on  the  whole  satisfactory.  Comparison  between  Murphy's 
button  and  other  methods  of  resection  in  the  series  of  226  cases  of 
resection  of  intestine  for  gangrenous  hernia  collected  by  Gibson  (Ann. 
of  Surg.,  November,  1900)  is  on  the  whole  to  the  advantage  of  the  Murphy 
button,  for  in  the  63  cases  in  which  Murphy's  button  was  used  there 
were  14  deaths,  i.e.,  a  mortality  of  22  per  cent.,  while  in  the  remaining 
163  cases  in  which  various  other  methods  were  made  use  of  there  were 
44  deaths,  or  a  mortality  of  27  per  cent. 

Ferguson  {Ann.  of  Surg.,  1901,  vol.  xxxiv.)  states  that  in  115 
anastomoses  by  means  of  the  button,  and  performed  by  graduated  students, 
on  dogs  the  mortality  was  only  2  per  cent.,  whereas  in  300  operations 
by  Council's  method  the  mortality  was  3  per  cent.      In  50  operations 


384  OPERATIONS  ON  THE  ABDOMEN. 

by  the  Czerny-Lembert  method  the  mortality  reached  22  per  cent.,  and 
in  50  operations  after  Maunsell's  manner  25  per  cent,  of  the  dogs  died. 

Moreover,  Sir  F.  Treves  (Brit.  Med.  Journ.,  Aug.  28,  1898)  con- 
siders that  the  Murphy  button  is  the  best  means  of  uniting  divided 
intestine,  having  employed  it  in  50  cases  with  satisfactory  results. 

Mayo  Robson's  bobbin,  by  giving  support,  facilitates  the  suturing  at 
the  time  and  supplies  some  of  the  conditions  which  are  at  the  root  of 
Senn's  excellent  principle — viz.,  the  giving  support  to  the  ends  of  the 
intestine  by  a  body  which  will  be  safely  absorbed — while  its  ready 
applicability  to  a  very  large  range  of  different  operations  puts  it,  in  my 
opinion,  on  an  equal  footing  with  Murphy's  button.  Moreover,  the 
part  it  is  intended  to  play,  and  the  material  of  which  it  is  made,  render 
it  far  safer  than  that  most  ingenious  device. 

The  same  absence  of  any  threads  to  tie,  and  its  wider  applicability, 
make  Mr.  Robson's  bobbin  superior  to  Mr.  Paul's  decalcified  bone 
tube,  though  several  successful  cases  prove  the  efficienc}'-  of  this 
device. 

The  choice  may  be  said,  therefore,  to  lie  between  direct  suture, 
Murphy's  button,  and  decalcified  bone  bobbin.  For  the  great  majority 
of  cases  I  prefer  to  use  deep  and  superficial  sutures,  or  Council's 
suture.  Which  of  these  methods  will  be  finally  judged  to  be  the  best 
is  still  uncertain. 


RESECTION  OF  INTESTINE.   ENTERECTOMY. 
COLECTOMY. 

Indications  for  Resection  Operations. — The  chief  of  these  are  : 
(1)  New  growths.*  (2)  Gangrene  after  strangulation  in  hernia  or 
intestinal  obstruction.  (3)  Injuries,  gunshot  or  otherwise.  (4)  Some 
cases  of  irreducible  intussusception.  (5)  Some  cases  of  artificial  anus 
where  the  canal  of  the  intestine  cannot  be  otherwise  restored. 

I  propose  to  say  a  few  words  about  the  first  two,  the  most  frequent  of 
the  above  indications. 

The  subject  of  resection  for  gunshot  and  other  injuries  is  fully  dealt 
with  in  the  next  chapter. 

(i.)  Indications  for  Resection  in  New  Growths. — In  deciding 
between  resection  and  one  of  the  forms  of  anastomosis  without  resection, 
or  between  resection  and  artificial  anus,  the  surgeon  should  pay  parti- 
cular attention  to  the  following  points,  both  local  and  general.  The 
more  they  are  present,  the  more  favourable  is  the  case.  Small  size, 
definite  outline,  especially  if  the  growth  approaches  the  annular  form, 
free  mobility  as  pointing  to  absence  of  adhesions,  entire  absence  of 
that  tenderness  which  points  to  peritonitis,  or  even  to  that  breaking 
down  and  suppuration  which  may  accompany  new  growths  when  they 
ulcerate  and  become  septic,  a  situation  in  which  the  growth  can  be 
easily  got  at  and  isolated,  e.g.,  when  it  attacks  a  portion  of  intestine 


*  These  are  nearly  always  carcinomatous,  but  Corner  and  Fairbank  have  related  a 
fatal  case  of  a  secondary  resection  of  a  sarcoma  of  the  colon,  which  had  produced  intus- 
susception, in  a  boy  of  nine  years  of  age.  The  growth  was  first  noticed  during  the 
reduction  of  the  intussusception  about  two  months  earlier.  Only  11  cases  of  sarcoma  of 
the  colon  are  recorded  (Pract.,  June,  1902). 


RESECTION    OF    INTESTINE,    ETC.  385 

with  a  long  mesentery,  and  not  a  fixed  part  such  as  the  splenic  or 
hepatic  flexure.*  These  are  the  chief  local  points.  Most  of  these; 
patients  die  from  the  local  effects  of  their  growth  and  not  from  dissemina- 
tion, therefore  it  is  very  important  to  diagnose  and  operate  for  tins 
condition  while  the  growth  is  still  removable,  and  especially  before 
the  intestines  become  distended  and  damaged  from  increasing  obstruc- 
tion. When  a  patient  approaching  or  past  middle  age  complains  of 
constipation,  perhaps  alternating  with  occasional  attacks  of  diarrhoea, 
flatulent  dyspepsia,  griping  pains,  wasting  and  anaemia,  a  growth  of 
the  colon  should  be  suspected,  and  the  whole  course  of  this  bowel 
examined  carefully.  In  this  way  a  growth  may  often  be  discovered 
before  distension  develops.  Kectal  and  bimanual  examinations  of  the 
pelvis  and  of  both  loins  may  enable  the  surgeon  to  feel  a  tumour. 
Visible  peristalsis  is  a  very  valuable  sign,  and  gurgling  at  one  spot  may 
sometimes  terminate  a  griping  attack,  and  indicate  the  probable  site  of 
the  disease.  The  passing  of  blood  and  slime  generally  indicates  that  the 
growth  is  below  the  transverse  colon. 

Vomiting  may  not  occur  until  quite  late,  and  may  then  herald  the 
approach  of  the  complete  obstruction  that  is  too  often  allowed  to 
occur.  In  cases  of  doubt  or  of  strong  suspicion,  an  early  exploration  is 
strongly  advised,  for  with  early  removal  of  the  growth  the  prognosis 
is  good. 

Amongst  the  general  points  that  must  weigh  with  the  operator  are 
the  strength  and  nutrition  of  the  patients,  their  fitness  to  bear  a  severe 
operation  and  to  supply  the  needful  plastic  repair. 

Another  point  having  a  most  important  bearing  upon  the  advisability 
of  performing  resection  for  malignant  disease  is  whether  this  is  compli- 
cated by  obstruction,  tympanites,  &c.  If  there  is  one  point  which 
published  (and  still  more  the  unpublished!)  cases  prove,  it  is  that  the 
occasion  in  which  it  is  right  to  submit  a  patient  the  subject  of  intestinal 
obstruction  to  such  a  prolonged  operation  as  resection  and  suture  or 
anastomosis  of  the  resected  parts  must  be  of  the  very  rarest.  |  This  is 
plain  from  the  usual  state  of  the  patient  in  these  cases,  and  the  condi- 
tions within  the  abdomen  with  which  the  operator  has  to  deal  Is  a 
patient,  usually  past  middle  life,  whose  strength  and  powers  have  been 
sapped  for  days  or  weeks  by  the  nausea,  inability  to  take  food,  vomiting, 
distension,  and  all  the  distress  which  forms  part  of  a  miserere  of  the 
later  stages  of  chronic  intestinal  obstruction,  in  a  fit  state  to  go  through 

*  In  the  tables  of  Weir  (New  York  Med.  Jonrn.,  Feb.  13,  1886  ;  Butlin,  Oper.  Surg,  of 
Malig.  Dis.,  p.  231),  of  the  37  cases  collected  in  which  resection  of  cancerous  bowel 
was  performed,  32  were  of  the  large  intestine.  The  parts  involved  were — caecum,  7  ; 
ascending  colon,  4 ;  transverse  colon,  3  ;  descending  colon,  7  ;  sigmoid  flexure,  9 ; 
"  colon,"  2.  Malignant  disease  is  so  frequent  in  two  regions,  the  ileo-cascal  apd  the  left 
iliac  fossa,  that  when  there  is  any  reason  to  suspect  it  an  early  exploratory  incision 
should  always  be  made. 

t  Quite  as  instructive  in  their  way.     "  Nee  silet  mors." 

X  Dr.  Ricketts  (Ann.  of  Surg.,  vol.  i.  1894,  p.  472)  relates  a  case  which  was  most 
favourable  for  resection.  The  growth,  only  of  the  size  of  a  hickory  nut,  was  easily 
found,  drawn  out,  and  resected.  The  ends  were  united  by  a  Murphy's  button.  The 
ileum  beiug  enormously  distended  with  fa?cal  fluid,  owing  to  the  patient  having 
deferred  operation  till  the  last,  about  a  gallon  was  withdrawn  by  an  incision,  which 
was  closed  by  Lembert's  suture.     The  patient  sank  ten  hours  later. 

S. — VOL.    II.  25 


386  OPERATIONS  ON  THE  ABDOMEN. 

a  prolonged  operation,  and  to  supply  after  it  the  plastic  repair  which  is 
needful  for  success  ?  There  can  be  but  one  answer  here.  And  it  is  the 
same  when  we  examine  those  local  conditions  which  will  have  to  be  faced 
by  the  operator.  The  distension  of  the  intestines,  and  the  difficulty 
of  keeping  them  within  the  belly,  prolong  the  operation,  add  to  the 
shock  in  an  exhausted  patient,  and,  by  rendering  asepsis  most  difficult, 
diminish  his  chances  still  further.  Another  point,  viz.,  the  condition 
of  the  intestine  above  and  below  the  obstruction,  is  a  strong  argument 
against  resection  and  union  of  the  intestine  when  obstruction  is  present. 
Above,  the  intestine  will  be  distended,  congested,  softened,  and  septic ; 
below,  empty  and  shrunken.  The  difference  in  the  size  of  the  two 
sections  may  prove  a  serious  difficulty  in  their  union,  but  a  graver 
objection  to  uniting  them  now  is  the  fact  that  for  the  present  both  are 
paralysed  ;  and  though  this  can  be  met,  in  a  measure,  by  emptying 
the  contents  of  the  upper  bowel  when  this  is  cut  through  above  the 
growth,  yet  everyone  familiar  with  these  cases  knows  perfectly  well 
that  if  the  obstruction  be  low  down  it  is  extremely  difficult  to  empty 
the  bowel  above  sufficiently  in  the  short  time  available.  Much  of  its 
contents  are  left  behind  ;  the  condition  of  obstruction  largely  continues, 
with  its  result — a  continuance  of  toxic  absorption ;  and  if  the  contents 
of  the  intestine  are  passed  on  from  above,  too  often  they  find  the 
junction  of  the  resected  parts,  made  in  softened,  inflamed  tissues,  unfit 
to  bear  the  strain.  Where  obstruction  is  present,  resection  should  be 
deferred  until  one  of  the  following  steps  has  been  adopted.  Colotomy 
niay  be  performed  in  the  csecuni  or  some  part  of  the  colon,  to  empty 
the  intestine  and  restore  its  tone,  while  at  the  same  time  the  patient's 
strength  is  restored,  and  the  surgeon  chooses  his  own  time  for  the 
performance  of  what  is  a  very  severe  operation.  Dr.  Elliot  {Ann.  of 
Surg.,  1905,  vol.  xlii.p.688)  states  that  the  mortality  of  primary  resection 
and  immediate  suture  in  these  cases  is  at  least  50  per  cent,  even  in  the 
hands  of  the  best  surgeons,  and  in  some  hospitals  it  is  as  high  as  85 
per  cent.  Peritonitis  is  the  chief  cause  of  death,  and  this  is  nearly  always 
due  to  the  fact  that  the  most  perfectly  placed  sutures  or  mechanical 
devices  do  not  hold.  Another  cause  of  death  is  shock  partly  due  to  an 
unnecessarily  long  operation.  Dr.  Bell  Walker  analysed  the  records  of 
enterectomies  performed  at  Guy's  Hospital  from  1900 — 1905  and  found 
that  only  two  recoveries  had  followed  resection  and  immediate  enteror- 
rhaphv  undertaken  during  actual  intestinal  obstruction ;  and  in 
neither  of  these  patients  was  the  obstruction  due  to  growth.  Another 
way  of  performing  resection  in  two  stages  is  that  advocated  by  Mr.  F. 
T.  Paul,*  whose  name  will  frequently  occur  in  these  pages,  as  an 
authority  in  abdominal  surgery.  The  following  are  the  chief  steps  of 
this  operation.  1.  Explore  first  in  the  middle  line  unless  the  site  of 
the  obstruction  is  known.  2.  Make  a  sufficiently  free  incision  over 
the  site  of  the  obstruction.  3.  Having  cleared  away  any  adhesions,  tie 
the  mesentery,  and  divide  it  sufficiently  to  free  the  bowel  well  be}rond 
the  growth  on  each  side.  4.  Let  the  loop  of  bowel  containing  the 
growth  or  stricture  hang  out  of  the  abdomen,  and  sew  together  the 

*  "  Colectomy  "  {Brit.  Med.  Journ.,  vol.  i.  1895,  p.  1136).  A  paper  full  of  practical 
information,  but  especially  noteworthy  and  admirable,  nowadays,  from  its  convincing 
candour.    Failures  are  related  as  well  as  successes,  and  are  equally  instructive. 


RESECTION    OF   INTESTINE.    ETC. 


.}'s7 


mesentery  and  the  adjacent  sides  of  the  two  ends  (Fig.  135).  See  that 
the  stump  of  mesentery  lies  beneath  the  bowel,  where,  if  deemed  advis- 
able, it  can  be  drained  by  packing  cyanide  gauze  down  to  it.  5.  Liga- 
ture lightly  a  glass  intestinal  drainage-tube  I  Figs.  97  and  135)  into  the 
bowel  above  and  below  the  obstruction,  and  then  cut  away  the  affected 
part.  When  the  operation  is  thus  performed,  all  the  vessels  except 
those  in  the  primary  incision  are  tied  before  they  are  cut,  and  the  intra- 
peritoneal work  is  rendered  bloodless.  Elliot  (loc.  supra  cit.),  writing 
in   1905,  describes  and  re- 


FiG.  135. 


commends  a  very  similar 
method  to  the  one  described 
by  Paul  ten  years  earlier ; 
in  some  respects,  Elliot's 
method  is  an  improvement, 
thus  an  attempt  is  made 
"to  close  the  wound  about 
the  ends  of  the  intestine  as 
much  as  possible  "  before 
the  upper  distended  bowel  is 
clamped  and  the  tumour  is 
removed.  The  lower  end  of 
the  loop  below  the  obstruc- 
tion is  divided  between 
clamps  at  an  earlier  stage  to 
facilitate  the  suturing  of  the 
mesentery,  and  of  the  two 
limbs  of  the  loop  together. 
"  The  important  point  is  not 
to  open  the  upper  distended 
bowel  until  the  peritomeal 
cavity  is  closed."  No  tube 
is  used,  but  the  clamp 
forceps  may  be  left  on  for 
a  few  hours  unless  the 
symptoms  are  urgent.  This 
plan  is  not  so  good  as  that 
of  Paul  in  this  respect. 
6.  The  second  stage  of  the 
operation — that  of  destroy- 
ing the  spur  which,  as  will 
be  gathered  from  Fig.  135, 

is  formed  by  the  above  operation — is  undertaken  about  three  weeks 
later.  A  finger  being  introduced  into  the  bowel,  as  a  guide  to  each 
side  of  the  spur,  dressing-forceps  with  the  handles  fastened  together 
by  india-rubber  tubing  are  applied  to  the  spur,  one  blade  on  each  side. 
Paul's  enterotome,  which  can  be  gradually  tightened  by  means  of  a  screw, 
is  to  be  preferred  if  available.  These  will  come  away  within  a  week,  and 
some  days  later  the  rest  of  the  spur  is  destroyed  in  like  fashion,  the 
forceps  being  now  applied  as  far  as  the  finger  makes  out  the  spur  to 
reach.  As  soon  as  this  is  satisfactorily  accomplished  the  artificial  anus 
is  closed  by  separating  the  rosette  of  mucous  membrane  from  the  skin, 
turning  it  in,  and  bringing  the  freshened  edge  of  the  latter  over  it. 

25—2 


Colectomy  by  Paul's  method.  Drainage  of  the 
bowel,  and  preparation  of  it  for  subsequent  safe 
resection  of  the  bowel.     (Paul.) 


388 


OPERATIONS  ON  THE  ABDOMEN. 


Another  method  is  to  get  the  affected  coil  outside ;  if  this  he  not 
too  tied  down  by  adhesions,  keep  it  out  by  means  of  a  rod  passed 
beneath  it,  a  Paul's  tube  being  then  tied  into  the  upper  end  to  drain 
it.  Some  days  later,  when  the  patient's  condition  admits  of  it,  the 
growth  is  resected,  and  the  two  ends  united.  Mr.  Lane  adopted  this 
plan  successfully  in  a  very  interesting  case  of  growth  of  the  lower 
part  of  the  ileum.  A  knitting-needle  covered  with  india-rubber 
tubing  was  employed  here  to  keep  the  bowel  outside  (Clin.  Soc.  Trans., 
vol  xxvi.  p.  40). 

Hochenegg  leaves  the  loop  outside  the  abdomen  for  about  twelve 
days  and  then  resects  it ;  there  is  no  advantage  in  waiting  so  long. 


Fig.  136. 
1 


Fig.  137. 


Fig.  138. 


Mr.  Watson 
Cheyne's    fine 

dissector. 
(Down's  Cata- 
logue, 1894.) 


Doyen's  clamps. 


Carwardine's  clamp  forceps.  The 
two  pairs  lock,  and  hold  the  two 
ends  of  intestine  close  together  for 
suturing.     (Down's  Catalogue.) 


and 


Littlewood  successfully  employed  this  method  in  two  cases, 
removed  the  growth  without  an  anaesthetic  (loc.  infra  tit.). 
The  chief  disadvantages  of  the  method  are  the  following : — 
(a)  The  prolapsed  loop  containing  the  growth  is  apt  to  become  very 
congested  and  swollen,  and  (b)  unless  the  mesenteric  glands  have 
already  been  removed  they  may  become  infected ;  (c)  the  difficulty 
in  these  cases  is  to  get  the  loop  outside,  and  to  allow  this  some  of  the 
mesentery  may  need  ligaturing  and  severing;  once  the  growth  is 
delivered,  its  removal,  conducted  outside  the  abdomen,  does  not 
materially  increase  the  time  of  the  operation  and  the  degree  of  shock. 
For  these  reasons  I  prefer  to  remove  the  growth  at  once,  with  proper 
precautions  to  prevent  soiling  of  the  peritonaeum,  and  with  provision 
for  immediate  drainage  by  means  of  enterostomy  tubes. 

Operation. — The  first  question  which  arises  is  as  to  the  best  incision. 
If  the  surgeon  is  uncertain  as  to  the  exact  site  of  the  growth,  he  may 


RESECTION    OF   INTESTINE,    ETC  389 

make  a  median  incision  and  clear  the  matter  up  ;  otherwise  the  incision 
should  he  made  over  the  growth  itself,  either  obliquely,  as  in  an  incision 
for  appendicitis  or  for  left-sided  inguinal  colotomy,  or  vertically,  or  in 
one  linea  semilunaris.  The  variety  of  the  incision  is  immaterial  as 
long  as  the  growth  and  the  intestine  entering  and  leaving  it  is 
thoroughly  exposed.  That  the  median  incision  is  not  hest  suited  for 
this  is  shown  by  the  number  of  cases  recorded  in  which,  after  the 
operator  had  begun  by  an  incision  in  the  linea  alba,  he  abandoned  it, 
as  inadequate,  for  one  over  the  growth.  The  growth,  when  reached, 
may  be  covered  by  adherent  omentum,  or  resemble  an  intussusception, 
appearing  as  a  thick  rounded,  firm,  sausnge-like  swelling.  When  the 
growth  is  fully  exposed  the  surgeon  settles  whether  to  attempt  resection 
or  to  perform  a  lateral  anastomosis  (p.  402).  Resection  being  decided 
upon,  the  field  of  operation  is  carefully  shut  off  from  the  general 
peritoneal  sac  by  sterile  gauze.  The  amount  of  bowel  to  be  resected 
will  depend  chiefly  upon  three  things  (a)  the  size  of  the  growth :  at 
least  one  and  a  half  inches  of  apparently  healthy  bowel  at  each  end 
should  be  removed  with  the  growth  to  make  certain  of  cutting  through 
healthy  tissues,  (b)  The  position  and  degree  of  fixation  of  the  growth  : 
for  instance,  the  splenic  flexure  is  so  fixed  that  it  cannot  be  brought 
down  and  joined  to  the  lower  end  after  excision  of  the  descending  colon, 
therefore  it  is  wise  to  excise  it  and  to  use  the  more  movable  transverse 
colon  (Pollard,  loc.  infra  cit.).  Again  the  caecum  may  have  to  be 
removed  for  the  same  and  other  reasons,  as  in  my  case  quoted  below\ 
The  ends  must  meet  without  tension,  (c)  Due  consideration  should 
also  be  given  to  the  blood  supply.  I  shall  first  describe  a  comparative!}' 
simple  case — e.g.,  resection  of  a  limited  growth  of  the  small  intestine 
or  sigmoid,  and,  later,  the  more  difficult  removal  of  the  ileo-caecal  coil. 
Any  adhesions  present  must  next  be  divided  with  a  blunt-pointed 
scissors  ora  dissecting  tool  (Fig.  136).  Any  bleeding  vessels  should  be 
clamped  and  tied  at  once,  or  tied  before  the}'  are  divided  if  possible. 
The  difficulty  met  with  here  varies  extremely.  The  adhesions 
may  be  so  dense  as  to  render  further  operation  impossible.  In  such 
a  case  short-circuiting  should  be  performed.  Omental  adhesions  are 
not  uncommon — i.e.,  to  the  parietes,  over  the  growth  or  adhesions 
between  the  omentum,  and  the  small  and  large  intestine  contiguous 
to  the  growth.  The  loop  having  been  freed  is  brought  outside  the 
wound,  placed  upon  gauze,  and  emptied  by  gentle  pressure  with  the 
fingers  in  both  directions.  This  effected,  clamps  are  applied  well 
above  and  below  the  spots  where  it  is  decided  to  divide  the  intestine. 
A  host  of  such  instruments  have  been  devised.  The  best  are  those  of 
Doyen  and  Carwardine.  These  will  be  found  extremely  useful  on 
account  of  the  handles,  by  means  of  which  the  steps  of  the  opera- 
tion are  greatly  facilitated.  Carwardine's  clamps  can  be  locked 
so  as  to  automatically  hold  the  ends  together  during  the  insertion  of 
sutures  (Fig.  138). 

Several  other  clamps  act  by  perforation  of  the  mesentery.  A  very 
simple  method  is  that  of  Neuber,  in  which  a  narrow  elastic  band  or 
rubber  tubing  is  passed  through  a  small  opening  made  in  the 
mesentery,  close  to  the  intestine,  and  tied  or  clamped  around  the  gut. 
Others  have  used  cords  of  gauze.  Fig.  140  shows  a  clamp  devised  on 
the  same  principle  by  Mr.  W.  A.  Lane.     In  using  any  clamp  which 


390 


OPERATIONS  ON  THE  ABDOMEN. 


perforates  the  mesentery,  great  care  must  be  taken  not  to  injure  any 
vessel.  This  is  easily  managed  in  the  case  of  un distended  intestine, 
but  when  obstruction  is  present  and  all  the  small  vessels  enlarged, 
very  troublesome  bleeding  may  follow  perforation  of  the  mesentery. 

Whatever  form  of  clamp  is  used,  if  it  has  been  long  in  situ  or  applied 
too  tightly  it  may  be  well  to  shift  it,  and  to  cut  away  the  ends  of  the 
intestine  which  have  been  submitted  to  pressure,  for  fear  that  their 
nutrition  has  suffered  dangerously. 


Fig.  139. 


Line  of  section 
of  mesocolon 


Enlarged  gland 
in  mesocolon 


Sutures  inserted 
in  mesocolon 


Forceps  clampine 

bowel   and  mesocolon 

obliquely 

Resection  of  the  intestine  for  growth.  Note  that  the  sheathed  clamps  are  placed 
obliquely,  and  that  the  mesentery  is  tied  before  it  is  divided.  Shorter  and  unsheathed 
clamps  are  also  applied  between  those  shown  in  the  figure  and  the  growth  to  prevent  any 
leakage  from  this  part. 

Where  no  clamps  are  obtainable  an  assistant's  hands  must  be  made 
use  of.  But  handled  clamps  are  much  to  be  preferred  ;  hands  are 
more  in  the  way,  and,  however  willing,  are  liable  to  make  more  varying 
pressure,  and  to  relax  long  before  a  tedious  operation  is  completed. 

If  the  intestine  is  at  all  distended,*  it  is  emptied  in  the  manner 
advised  at  footnote,  p.  397.  The  diseased  mass  is  now  isolated  by  two 
more  clamps  placed  between  the  first  two  and  the  growth,  which  is 


*  After  emptying  the  intestine  there  may  still  remain  much  difference  between  the 
ends  when  resected.  Both  ends  must  then  be  closed  and  inverted,  and  a  lateral  anas- 
tomosis made. 


RESECTION    OF   INTESTINE,    ETC.  391 

resected  with  blunt-pointed  scissors,  the  gut  being  cut  across  nearly 
at  right  angles  to  its  long  axis  an  inch  and  a  half  beyond  the 
growth.  More  of  the  bowel  is  removed  at  the  free  than  at  the 
mesenteric  border,  so  that  the  ends  that  remain  may  be  well-nourished. 
This  should  leave  about  half  an  inch  of  gut  beyond  each  sheathed 
clamp,  in  order  to  allow  of  easy  introduction  of  the  first  row  of  sutures. 
About  two  inches  should  be  left  projecting  if  a  Murphy's  button  or  a 
bobbin  is  to  be  used.  The  ends  are  carefully  cleansed.  In  the  present 
instance,  resection  of  intestine  for  growth,  the  incisions  should  be 
carried  onwards  through  the  mesentery  so  as  to  remove  a  triangular 
piece  with  the  base  below  at  the  intestine.  By  this  means  it  is 
probable  that  any  implicated  lymphatics  will  be  removed  as  well. 
The  cut  vessels  in  the  mesentery  are  either  clamped  and  tied  with 
catgut,  or,  where  a  large  piece  has  to  be  removed,  they  can  be 
secured  before,  and  hemorrhage  avoided,  by  means  of  an  aneurysm- 
needle  carrying  catgut  (Fig.  139). 

The  soiled  gauze  which  has  shut  off  the  field  of  operation  is  next 
replaced  by  fresh,  and   the    surgeon    decides   whether   to    unite    the 

Fig.  140. 


Lane's  intestinal  clamp.     (Down's  Catalogue,  1894.) 

intestine  end  to  end  by  direct  suture,  by  Murphy's  button,  or  Kobson's 
bobbin,  or  to  perform  lateral  anastomosis  of  the  two  parts,  which  may 
be  of  unequal  size. 

With  regard  to  the  details  of  the  steps  adopted  in  the  more  difficult 
operation  of  resection  of  the  ileo-csecal  coil,  I  shall  quote  from  a  very 
helpful  report  of  a  case  by  Mr.  Lowson,  of  Hull  (Lancet,  vol.  i.  1893, 
p.  618)  : 

The  abdomen  having  been  opened  by  an  incision  in  the  right  linea  semilunaris,  the 
omentum  was  found  adherent  to  the  tumour  anteriorly,  and  detached  after  ligature. 
"  Pushing  the  colon  inwards,"  I  now  entered  the  scissors  above  the  level  of  the  tumour, 
through  the  peritonaeum  lining  the  posterior  wall  of  the  abdomen,  to  the  outer  side  of 
the  great  bowel,  and  ran  it  down  to  a  point  opposite  the  lower  end  of  the  cascum.  The 
bowel  could  now  be  easily  separated  from  its  bed.  It  still  remained  to  divide  the 
peritonajum  on  the  inner  side  where  the  colic  vessels  spread  out,  fan-like,  to  supply  the 
colon.  This  was  done  by  tying  the  serous  membrane  with  the  vessels  in  five  or  six 
successive  pieces,  and  dividing  between  the  ligatures  and  colon.  The  line  of  this 
incision  inclined  downwards  and  inwards,  meeting  the  ileum  as  it  crossed  to  join 
the  colon  five  or  six  inches  from  the  ileo-cascal  valve.  Several  diseased  glands  were 
included  in  this  triangle.  The  ileum  was  separated  from  the  mesentery  in  the  same 
way,  and  now  the  greater  part  of  the  ascending  colon,  with  the  caecum  and  four  or  five 
inches  of  the  ileum,  were  free  along  with  the  tumour.  The  time  had  now  arrived  for 
dividing  the  bowel.  Two  long  Makins's  clamps  were  applied  to  the  colon  above  the 
tumour,  and  between  these  the  bowel  was  divided  as  nearly  at  right  angles  as  possible. 
The  ileum  having  been  divided,  and  the  diseased  portions   removed,  the   ends   of   the 


392  OPERATIONS  ON  THE  ABDOMEN. 

intestine  were  closed  by  fine  continuous  sutures  and  turned  in  by  Lembert's  sutures 
Lateral  anastomosis  was  performed  by  means  of  Senn's  plates.  Mr.  Lowson  draws 
attention  to  one  detail,  which,  as  he  says,  "cannot  be  neglected  without  fatal  extrava- 
sation— i.e.,  to  be  especially  particular  to  bring  the  serous  surfaces  accurately  in 
apposition  at  the  point  where  the  mesentery  joins  the  intestine,  and  where  the  serous 
coat  of  the  mesentery  is  deficient  behind."  The  patienc,  aged  33,  made  a  good  recovery, 
and  thirteen  months  later  there  was  no  perceptible  recurrence. 

Tn  a  recent  case  of  carcinoma  of  the  ascending  colon  and  hepatic  flexure,  one  of  us  (R.  P.  R.) 
found  considerable  difficulty  in  bringing  the  growth  out  of  the  wound,  but  this  was  accom- 
plished in  the  manner  described  above  by  Mr.  Lowson.  Bleeding  was  difficult  to  stop  in 
the  depth  of  the  wound  near  the  head  of  the  pancreas,  to  which  and  to  the  duodenum  the 
growth  was  slightly  adherent,  and  the  ureter  was  exposed  and  avoided.  It  was  found 
to  be  impossible  to  sever  the  colon  well  away  from  the  growth  and  yet  to  leave  enough 
of  the  ascending  colon  to  join  to  the  transverse  colon,  without  trespassing  upon  the  region 
of  the  ileo-cascai  valve.  The  cascum  and  about  two  inches  of  the  ileum  were  therefore 
removed  with  the  growth,  and  an  end  to  end  union  made  between  the  ileum  and  the 
transverse  colon,  by  means  of  two  layers  of  sutures,  and  this  was  easily  accomplished 
because  the  two  ends  were  of  equal  calibre.  This  plan  was  preferred  to  lateral  anastomosis 
also  for  another  reason,  e.g.,  it  could  be  carried  out  more  speedily,  as  some  valuable  time 
would  be  consumed  in  closing  the  separate  ends.  The  man  recovered,  but  a  fascal  fistula 
formed  and  had  to  be  closed  later. 

In  a  case  of  excision  of  the  cascum  and  part  of  the  ileum  for  multiple  fistula?  due  to 
tuberculous  disease,  I  used  a  Murphy  button,  because  of  the  impossibility  of  bringing  a 
very  adherent  ascending  colon  into  the  wound,  and  the  child  was  already  collapsed.  She 
recovered  without  a  fistula  and  gained  weight  very  rapidly,  being  stout  and  well  when  I 
last  saw  her  two  years  after  the  operation. 

Mr.  Bilton  Pollard  (Lancet,  1904,  vol.  i.  p.  175)  records  seven  cases  of 
excision  of  carcinomatous  growth  of  the  colon ;  all  these  patients 
survived  the  operations,  and  one  was  alive  and  well  four  years  after- 
wards, another  after  two  and  a  half,  and  a  third  after  two  years  and  two 
months.  One  died  of  heart  disease  after  four  years.  The  others  were 
recent  cases  operated  upon  nine,  six,  and  two  months  hefore  puhlication. 
End  to  end  union  was  made  by  direct  suture,  two  rows  of  stitches  being 
used.  The  parietal  wound  was  drained  in  only  one  case — one  in  which 
a  portion  of  the  kidney  was  excised  due  to  invasion  of  growth.  Mr. 
Pollard's  patients  were  well  a  year  after  his  paper  was  written,  and  he 
had  performed  two  more  colectomies  successfully  during  the  year. 

Mr.  Littlewood  (Lancet,  May  30th,  1903)  publishes  14  cases  of 
resection  of  the  colon  for  columnar-celled  carcinoma  with  10  recoveries. 
End  to  end  union  was  made  by  means  of  Czerny-Lembert  sutures  of 
catgut  in  all  except  one,  which  in  lateral  anastomosis  was  used  instead, 
because  the  ends  could  not  be  brought  together,  the  ileum  was  joined 
to  the  sigmoid  colon ;  death  occurred  six  days  later.  "  Of  the  six 
successful  cases  of  primary  colectomy,  there  was  practically  no 
obstruction  at  the  time  of  the  operation."  In  one  case  there  was 
obstruction,  but  the  condition  of  the  intestine  seemed  to  he  so  good 
that  an  immediate  resection  was  undertaken,  but  the  stitches  tore 
out  and  death  occurred  from  peritonitis  on  the  sixth  day.  This  case 
illustrates  the  danger  of  primary  resection  and  suture  in  cases  of 
obstruction. 

Mr.  Mayo  Robson  (Lancet,  1904,  vol.  i.  p.  1553)  states  that  he  has  per- 
formed twenty-one  enterectomies  for  growth  in  private  practice  with  four 
deaths;  one  patient  was  well  ten  years  after  the  operation,  one  after  four 
and  a  half  years,  three  after  three  and  a  half  years,  two,  three  years, 


RESECTION    OF   INTESTINE,    ETC.  393 

and  one,  one  year,  without  a  sign  of  recurrence.  In  31  hospital  cases 
the  primary  mortality  was  18  per  cent. 

Mr.  Kobson  states  that  Professor  Morton,  employing  the  decalcified 
bone  bobbin,  lias  performed  seven  consecutive  colectomies,  without  a 
death.  Homer  Gage  (Host.  Med.  Sun/.  Jov/rn.,  Sept.  10,  1903)  in 
iu  a  collection  of  56  eases  by  famous  operators  found  that  13,  01*23  per 
cent.,  had  survived  the  three  year  limit  without  an}'  sign  of  recurrence. 
These  results  are  very  good  and  they  serve  to  indicate  that  early 
resection  of  carcinoma  of  the  colon  is  attended  with  considerahle  success. 
The  figures  are  too  favourable,  however,  for  unsuccessful  results  are  not 
published  nearly  often  enough. 

(ii.)  Eesection  of  Intestine  for  Gangrenous  Hernia.* — This,  the 
second  most  frequent  indication  for  resection,  must  be  treated  separately. 
The  operation  has  now  to  be  undertaken  under  different  conditions 
from  that  under  which  removal  of  a  new  growth  is  performed.  We 
have  seen  (p.  385)  that  then  it  is  always  best  to  defer  resection  of  the 
intestine,  if  possible,  until  obstruction  has  passed  away  under  medical 
treatment,  or  has  been  met  by  a  colotomy,  the  surgeon  choosing  his 
time  when  the  patient's  general  condition  of  strength  and  nutrition,  and 
the  local  state  of  the  bowel,  are  alike  rendered  as  favourable  as  ma)T  be 
for  meeting  the  calls  of  a  severe  plastic  operation.  In  resection  for 
gangrenous  hernia,  the  conditions  both  of  the  patient  and  the  intestine 
to  be  operated  on  are  very  different.  Before  describing  the  actual 
operation  I  would  say  that  no  absolute  rules  can  be  laid  down  here. 
Relief  of  a  strangulated  hernia  is  one  of  those  operations  of  emergency, 
sometimes  admitting  of  no  delay,  which  any  general  practitioner  must 
undertake,  often  under  very  unfavourable  surroundings.  It  would  be 
most  unfair  to  expect  that  such  a  man,  when  face  to  face  with  a 
gangrenous  hernia,  should  meet  it  in  the  same  way  as  a  hospital 
surgeon,  able  to  command  the  very  best  surroundings,  abundant  help, 
and  himself  experienced  in  intestinal  surgery.  As  I  have  said  at  p.  49, 
when  the  condition  of  the  patient,  the  experience  of  the  operator,  and 
his  surroundings  admit  of  his  taking  this  step,  resection  of  the 
gangrenous  intestine  should  always  be  performed.  Where  the  above 
conditions  are  absent,  the  operator  must  rest  content  with  enlarging  the 
wound,!  drawing  all  the  gangrenous  intestine  well  outside  the  peri- 
toneal sac,  opening  and  draining  it  thoroughly  by  one  of  the  means 
given  at  p.  346.  This  will  avoid  the  terrible  risks  of  a  continuance  of 
paralysis  of  the  bowel,  stercoraceous  vomiting,  exhaustion,  or  toxcemia. 
The  loop  must  be  kept  outside  by  a  sterilised  bougie  or  glass  rod,  as 
in  inguinal  colotomy  (p.  128),  aided  by  a  few  sutures.  Any  gangrenous 
omentum  must  be  removed,  and  the  sac  cleansed  as  far  as  possible. 

*  The  following  are  some  of  the  most  useful  papers  on  this  subject : — Lockwood 
(Med.-Ckir.  Trans.,  vols,  lxxiv.  and  lxxvii.)  ;  W.  A.  Lane  {Clin.  Soc.  Trans.,  vol.  xxiv. 
p.  102)  ;  McCosh — three  cases  treated  successfully  by  circular  enterorraphy  {Ann.  of 
Surg.,  vol.  i.  1894,  p.  647)  ;  Ransohoff  {ibid.,  vol.  i.  1892)  ;  Mickulicz  {Berl.  Klin.  Woch., 
Nov.  10,  1892)  ;  Riedel  {Dent.  Med.  Woch.,  1883,  No.  45)  ;  Eeichel  {Dent.  Med.  Woch., 
1883,  No.  45);  Zeidler  {Cent.  f.  Chir.,  Jan.  16,  1893,  p.  62) ;  Caird  {Edin.  Med.  Journ., 
1895,  p.  312  ;  Gibson  {Ann.  of  Surg.,  Oct.  and  Nov.  1900);  Barker  {Lancet,  1903,  vol.  i. 

P-  1579)- 

f  In  a  very  few  cases,  where  the  surroundings  are  even  more  unfavourable,  the  operator 
may  have  to  be  content  with  simply  opening  the  bowel  and  doing  no  more  (p.  49). 


394  OPERATIONS  ON  THE  ABDOMEN. 

Gibson  (loc.  cit.)  gives  the  mortality  of  primary  resection  and  end  to 
end  union  as  26  per  cent,  and  that  of  artificial  anus  formation  as  53 
per  cent.,  but  these  figures  must  not  be  accepted  too  readily,  for  the 
most  severe  cases  are  often  considered  to  be  unsuitable  for  resection,  and 
artificial  anus  is  made  as  a  last  resort  in  such  cases. 

Operation. — The  intestine  being  found  to  be  gangrenous,  the  extent 
of  this  must  be  first  made  out.  It  is  possible  that  in  a  few  cases  the 
mischief  may  be  so  circumscribed  as  to  involve  only  part  of  the  circum- 
ference of  the  bowel.  Here  the  resection  of  a  very  small  portion  of 
bowel  is  required ;  while  in  some  it  may  prove  sufficient  merely  to 
invert  and  suture  the  margin  of  the  aperture,  and  it  is  possible  to 
accomplish  this  through  the  original  wound.  Successful  cases  of 
partial  resection  are  recorded  by  Sachs  (Deut.  Zeit.  f.  Chir.,  Bd.  xxxii. 
S.  93)  ;  Barette  (These  cle  Paris,  1883,  "  De  l'lntervention  Chirurgicale 
dans  les  Hernies  ") ;  Lindner  (Berl.  Klin.  Woch.,  1891,  p.  277).  One 
or  two  cases  have  also  been  recorded  in  America,  but  such  circumscribed 
mischief  is  very  rarely  met  with,  and,  where  such  limited  resection  is 
practised,  care  must  be  taken  to  place  the  sutures  in  healthy  tissues. 
Five  cases  of  partial  gangrene  of  the  intestine  treated  by  inversion 
of  the  gangrenous  or  ruptured  portion  are  very  briefly  given  in  an 
instructive  but  very  short  paper  by  Mr.  Caird  (Eclin.  Med.  Joiim.,  1895, 
p.  312): 

All  five  were  cases  of  hernia.  There  was  a  "  perforation  "  of  the  intestine  in  one, 
and  a  "  rupture  "  in  two.  Of  the  five  cases,  three  recovered.  Of  the  two  which  died, 
one  was  an  infant  aged  18  months.  The  necropsy  showed  firm  union  of  the  intestine 
without  peritonitis.  "  The  intestine  was  beset  with  typhoid  ulcers  of  ten  or  fourteen 
days'  duration." 

The  following  is  Mr.  Caird's  advice  as  to  the  treatment  of  gangrenous 
intestine  by  inversion,  and  the  cases  suitable  to  this  method  :  "  If  we 
meet  with  the  typical  elliptical  necrosis  of  the  bowel  which  runs  longi- 
tudinally opposite  the  mesenteric  attachment,  we  may,  with  Lembert's 
sutures,  stitch  the  sound  tissues  over  the  unhealthy,  thus  inverting  the 
gangrenous  area  into  the  lumen.  This  practice,  which  obviates  the 
necessity  of  cutting  any  part  of  the  bowel  away,  and  requires  no  special 
dexterity,  is  in  all  probability  not  applicable  with  safety  where  more 
than  one-third  of  the  circumference  is  destroyed.  The  fear  of  stricture 
ensuing  rather  determines  us  to  resect  in  such  cases.  .  .  .  The 
method  of  inversion,  although  easy,  cannot  be  modified  to  meet  the 
exigencies  of  every  case.  It  does  not  lend  itself  to  those  instances  in 
which  the  gut  is  almost  completely  divided  by  the  tight  grasp  of  a 
narrow  femoral  ring.  The  vitality  of  the  proximal  end  has  then  been 
too  severely  tried  to  admit  of  such  an  experiment.  We  should  require 
to  invaginate  a  few  inches  of  the  damaged  gut  before  we  came  upon 
healthy  tissue  to  suture  ;  and  since  it  is  impracticable  to  reproduce  the 
successful  natural  cure  occasionally  seen  in  cases  of  intussusception, 
we  are  driven  to  resect."  If  inversion  be  made  use  of,  the  greatest 
care  must  be  taken,  as  in  partial  or  complete  resection,  to  ensure  that 
the  sutures  lie  in  healthy  tissues. 

Mr.  Makins  {Clin.  Soc.  Trans.,  vol.  xxxvi.  p.  183)  also  draws 
attention  to  the  value  of  inversion  in  some  cases;  he  records  two 
successful  operations,  in  one  of  which  an  area  three-quarters  of  an  inch 
in  diameter  was  inverted. 


UKSKCTION    OK    INTKSTINE,    ETC. 


395 


Far  commoner  conditions  are  :  (i)  Where  a  whole  loop  or  knuckle  is 
gangrenous  ;  (2)  while  the  loop  may  appear  fairly  healthy,  at  its  neck 

(where  the  pressure  has  been  exerted),  one  or  two  pressure-furrows  or 
lines  of  ulceration  are  present,  and  the  greatest  care  must  he  taken  in 
drawing  this  part  of  the  howel  down,  or  its  contents  may  escape  into 
the  peritomeal  sac.  (3)  The  gangrene  extends  over  tin.'  convexity  of 
the  loop.  In  these  last  three,  free  resection  passing  through  healthy 
tissues  will  he  required. 

The  first  question  that  arises  when  resection  is  determined  upon  is 
whether  we  should  carry  it  out  through  the  original  wound  enlarged, 
or  through  a  second  in  the  abdominal  wall.  The  answer  to  this  must 
depend  mainly  upon  the  variety  of  the  hernia  and  the  means  adopted 


Fig.  141. 


Fig.  142. 


Two  different  ways  of  dealing  with  the  mesen- 
tery in  resection  of  the  intestine  are  here  shown. 
In  one  the  bowel  is  detached  from  the  mesentery 
a  little  above  their  junction,  all  bleeding  points 
being  carefully  tied,  or  the  two  folds  of  the 
mesentery  united  with  a  fine  continuous  suture. 
The  dotted  outline  of  the  wedge  shows  the  other 
mode  of  dealing  with  the  mesentery.  Drain- 
age-tubes are  used  as  clamps.  (Esmarch  and 
Kowalzig.) 


Here  the  resected  ends  are 
shown  sutured,  and  the  edges  of 
the  redundant  fold  of  mesentery 
which  is  present  where  no  wedge 
is  removed  are  being  united  with 
a  continuous  suture.  Note  that 
here  and  in  Fig.  145  the  union  of 
the  bowel  and  the  mesentery  is 
continuous  across  the  triangular 
interval  at  the  junction  of  the 
two.     (Esmarch  and  Kowalzig.) 


for  uniting  the  resected  ends.  Where  union  by  suturing  is  adopted, 
especially  in  umbilical  or  inguinal  hernia,  it  will  be  sufficient  to  enlarge 
the  wound  if  necessary  either  to  allow  an  exclusive  resection  to  be 
carried  out,  or  to  facilitate  the  reduction  of  the  sutured  intestine  and 
the  bulky  mesenteiy. 

In  femoral  hernia  it  is  wise  to  make  a  fresh  incision  through  the 
lower  part  of  the  corresponding  rectus  sheath,*  unless  the  amount 
of  bowrel  to  be  removed  is  very  small.     This  is  better  than  to  have  to 


*  Mr  W.  A.  Lane  made  use  of  a  median  incision  in  two  cases  in  which  he  resected 
gangrenous  hernia,  and  united  the  intestine  by  means  of  Senn's  plates  and  lateral 
anastomosis.  One  patient  made  a  good  recovery  ;  the  other,  whose  condition  was  very 
grave  at  the  time  of  operation,  died  on  the  fifth  day,  and  the  necropsy  showed  a 
perforated  gangrenous  patch  on  the  upper  piece  of  the  intestine  [film,  Soc.  Trans., 
vol.  xxiv.  p.  182). 


396  OPERATIONS  ON  THE  ABDOMEN. 

divide  Poupart's  ligament,  in  order  to  get  a  proper  view  of  the  damaged 
bowel  above  the  obstruction.  This  ligament  will  have  to  be  divided  if 
the  resection  is  completed  below  the  femoral  canal,  otherwise  it  will 
not  be  possible  to  reduce  the  sutured  bowel  and  the  mass  of  mesentery 
without  exerting  undue  force.  Barker  (Lancet,  1903,  vol.  i.  p.  1579) 
was  compelled  to  sever  Poupart's  ligament  on  this  account  after  the 
resection  of  eighteen  inches  of  small  intestine  ;  a  large  hernia  developed 
at  the  site  of  the  operation  and  had  to  be  treated  by  another  operation 
two  and  a  half  years  later  (Clin.  Soc.  Trans.,  1905,  p.  136). 

A  hernia  is  not  likely  to  form  at  the  abdominal  wound  which  should 
be  valvular,  and  should  be  sutured  with  due  care.  The  adoption  of 
this  second  incision  will,  of  course,  involve  a  risk  of  carrying  infection 
into  the  peritonaeal  sac  and  the  abdominal  wound,  and  every  pre- 
caution must  be  taken  to  lessen  this  danger,  which  has  been 
exaggerated. 

Any  gangrenous  or  septic  omentum  having  been  tied  off  and  removed, 
the  sac  and  damaged  intestine  are  carefully  cleansed  with  perchloride 
of  mercury  solution  (1  in  5000),  any  opening  in  the  bowel  being 
temporarily  but  firmly  closed.  If  this  is  not  possible  the  mesentery 
should  be  tied,  and  the  gangrenous  loop  excised,  the  divided  ends  being 
cleansed,  tied  and  covered  with  antiseptic  gauze,  and  drawn  upwards 
and  out  through  the  abdominal  wound. 

The  second  question  concerns  the  length  of  bowel  to  be  resected. — Care 
should  be  taken  to  remove  too  much  rather  than  too  little,  for  we  find 
in  many  of  the  fatal  cases  reported  that  the  cause  of  death  was 
attributed  to  gangrene  spreading  upwards  above  the  seat  of  suture;  on 
the  other  hand,  we  find  that  recovery  has  followed  when  large  portions 
of  the  intestine  have  been  removed.  Thus,  Ramdohr  excised  two  feet ; 
Rydyggier  had  a  case  in  which  54  centimetres  were  sacrificed  ;  Rushton 
Parker  cut  out  twelve  inches  ;  Walter  also  removed  two  feet  four  inches  ; 
and,  lastly,  Kocher  had  a  patient  who  left  the  hospital  perfectly  well 
on  the  eighteenth  da}T,  after  having  had  about  five  and  a  quarter  feet 
of  intestine  removed.  All  these  patients  recovered  (Kendal  Franks, 
Lancet,  vol.  i.  1893,  p.   1387). 

Barker  (Lancet,  1903,  vol.  i.  p.  1579)  has  successfully  resected  over 
six  feet  of  small  intestine  for  gangrene  of  a  loop  due  to  femoral  hernia 
in  a  woman  of  63  years.  Peck  (Ann.  of  Surg.,  1903,  vol.  xxxviii. 
p.  451)  removed  eight  and  a  half  feet  of  gangrenous  small  intestine 
without  any  subsequent  loss  of  nutrition  during  the  succeeding  two 
years  ;  at  the  end  of  this  time  an  operation  was  performed  for  the  relief 
of  a  ventral  hernia,  and  the  bowel  was  examined  and  found  to  be  normal 
in  appearance,  no  sign  of  the  line  of  union  being  seen.  Kocher  quotes 
Monari  to  the  effect  that  up  to  seven-eighths  of  the  intestine  of  animals 
may  be  removed  without  harm,  and  Roux  has  recorded  the  case  of  a 
patient  who  survived  with  only  five  feet  of  small  intestine  and  half 
the  length  of  his  large  intestine  (Kocher,  Oper.  Surg.,  p.  260). 

In  any  variety  of  strangulated  hernia,  the  intestine  above  the 
obstruction  must  be  examined,  and  the  site  for  the  upper  line  of  section 
should  be  chosen  with  great  care.  The  lower  section  ma}r  be  within 
two  inches  of  the  lower  constriction. 

No  paralysed,  congested,  or  greatly  distended  bowel  should  be  left 
behind;  failure   to   remove  enough  may  lead  to  death  from  toxaemia, 


RESECTION    OF   INTESTINE,    ETC.  397 

paralytic  distension,  enteritis,  or  peritonitis,  the  latter  being  due 
either  to  sloughing  of  the  upper  end  at  the  line  of  suture,  or  to  infection 
of  the  peritonaeum  through  the  wall  of  the  damaged  intestine,  without 
any  visihle  perforation.  Mr.  Barker  (Lancet,  1903,  vol.  i.  p.  1579)  nft8 
Btrongly  advocated  more  extensive  resections  in  all  cases  which  need 
resection  at  all.  Sound  tissues  may  thus  he  obtained  for  suture, 
paralysed  intestine  in  a  condition  of  infective  cellulitis  may  he  removed, 
together  with  pints  of  poisonous  contents,  which  would  otherwise 
become  absorbed  to  some  extent  with  lethal  effects. 

Clairemont  and  Banzi  {Ann.  of  Surg.,  1903,  vol.  xxxviii.  p.  914) 
have  shown  how  poisonous  these  retained  products  are,  and  others 
have  proved  how  virulent  the  bacillus  coli  becomes  in  cases  of  intestinal 
obstruction. 

It  is  important  to  examine  the  mesentery  to  find  out  the  condition  of 
its  blood  vessels,  the  presence  of  pulsation  and  the  absence  of  cedema 
or  extravasation  of  blood  being  essential  at  the  line  of  section. 

Barker  points  out  that  an  extensive  resection  takes  very  little  more 
time  than  a  small  one,  and  that  there  is  hardly  any  difference  in  the 
amount  of  shock  induced ;  that  nutrition  is  not  impaired  in  resections 
up  to  six  feet  Barker  and  others  have  shown  (vide  supra). 

Since  adopting  wider  resections  Mr.  Barker  has  performed  seven  of 
these  operations  with  only  two  deaths,  and  one  of  these  was  due  to 
obstruction  from  an  old  fibrous  band  which  pressed  upon  the  intestine, 
after  its  return.  The  other  was  due  to  peritonitis  probably  due  to 
infection  from  the  sac  which  was  not  drained  through  the  groin. 

The  rule  must  be,  therefore,  to  remove  every  atom  of  suspicious 
bowel,  and  to  cut  through  and  place  the  sutures  in  healthy  tissues.* 
It  would  seem  from  published  cases  that  the  mesentery  may  with  equal 
success  be  treated  as  in  Fig.  139,  by  excision  of  a  wedge,  or  as  in 
Figs.  141,  144.  In  this  latter  case  the  mesentery  is  divided  as  close  to 
the  bowel  as  possible.  As,  however,  more  time  is  occupied  by  the 
removal  of  a  wedge,  since  many  more  vessels  have  to  be  tied,  and  as 
there  is  no  corresponding  advantage  gained  by  so  doing,  the  simpler 
plan  of  uniting  the  cut  edges  as  in  Figs.  142  and  144  is  to  be  preferred. 

The  intestine  to  be  removed  is  drawn  well  out  of  the  wound,  and  its 
base  surrounded  with  gauze  packing  to  protect  the  peritonaeum.  The 
two  ends  of  the  loop  are  placed  together  and  clamped  with  a  single  pair 
of  Doyen's  long  clamp  forceps,  as  advised  by  Mr.  Barker  (loc.  supra  cit.) 

*  Lockwood  gives  the  useful  hint  to  cut  through  the  collapsed  distal  end  first,  as  the 
gangrenous  portion  and  the  distended  end  may  then  be  drawn  further  from  the  wound, 
and  used  as  a  spout  to  carry  off  the  fascal  accumulation  (Med.-Chir.  Tram.,  vol.  lxxiv. 
p.  213).  Caird  (13dm.  Med.  Jonrn.,  vol.  ii.  1895,  p.  314)  advises  thus  on  this  point : 
The  peritonaeum  being  well  shut  off,  "  just  beyond  the  distal  end  of  the  gangrenous 
mass  a  couple  of  long-bladed  pressure-forceps  should  be  applied  side  by  side,  and  the 
gut  completely  divided  between  them.  The  mesentery  should  now  be  severed  along  its 
attachment  to  the  portion  of  gut  we  wish  to  remove,  and  this  enables  us  to  hold  the 
free  extremity  over  a  vessel,  when,  on  removing  the  forceps,  the  contents  escape  and 
the  congestion  abates.  Having  thus  relieved  the  congestion  and  emptied  the  gut,  we 
may  now  reapply  the  forceps  on  the  central  healthy  gut,  and  cut  away  the  intervening 
damaged  portion."  Mr.  Caird  considers  that  if  the  pressure-forceps  have  inflicted  any 
permanent  damage  on  the  cut  margin  of  the  gut  that  edge  becomes  inverted,  thanks  to 
the  Lembert's  sutures  (ride  infra). 


398 


OPERATIONS  ON  THE  ABDOMEN. 


and  shown  in  the  figures.  Traction  is  then  made  upon  the  middle  of  the 
loop  to  get  the  mesentery  taut  and  free  of  folds,  and  the  two  layers  are 
clamped  together  with  another  pair  of  long  clamps,  whose  points 
should  reach  that  of  the  first  pair  if  possible.  If  the  resection  is  very 
extensive,  a  third  pair  of  clamps  may  be  applied  to  the  remainder  of 
the  wide  mesentery,  by  thrusting  one  of  its  blades  through  both  layers 
near  the  tip  of  the  second  pair.  The  mesentery  is  divided  between 
the  clamps  and  the  intestine,  and  the  proximal  end  of  the  loop  is 
liberated  from  the  first  clamp,  which  should  still  hold  the  distal  end 
and  both  mesenteries.  A  fresh  clamp  is  placed  near  the  distal  end  of  the 
loop,  which  is  then  divided  between  the  two  clamps,  and  brought  away 
from  the  wound  and  liberated  over  a  basin  at  the  side  of  the  table. 
While  the  contents  of  the  intestine  are  being  drained  away  as  far  as 
possible,  the  two  layers  of  the  mesentery  are  sewn  together  with  mattress 
sutures  of  silk,  each  suture  securing  about  two-thirds  of  an  inch  of  the  two 


Fig.  143. 


Forceps  clamping; 
both  ends  of 
the: 


Line  of 

of   mesentery 


Forceps  clamping 
the  mesentery 


Resection  of  gangrenous  intestine  ;  The  blades  of  the  forceps  clamping  the 
intestine  should  be  sheathed  with  rubber.  The  folded  loop  here  represented  is 
for  convenience  of  drawing  only  a  short  one.     (After  Barker,  Lancet,  vol.  i.  1903.) 

membranes.  The  intestinal  ends  if  unequal  in  calibre  are  placed  and 
clamped  together  obliquely,  so  that  more  may  be  removed  from  the 
convex  border  of  the  smaller  one,  in  order  to  equalise  the  sections  to 
facilitate  the  suturing.  The  projecting  pieces  are  then  shaved  off, 
close  to  the  clamp  forceps,  and  another  clamp  is  applied  to  both  tubes 
parallel  with  the  first  but  nearer  the  body.  The  first  is  then  removed, 
leaving  one-third  of  an  inch  of  each  extremity  projecting  beyond  the 
second  clamp.  The  ends  are  joined  together  b}^  a  continuous  catgut 
suture  which  pierces  all  the  coats,  and  inverts  the  edges,  all  knots 
being  tied  so  that  they  be  within  the  bowel.  If  another  layer  is  con- 
sidered necessary  the  clamp  should  be  moved  further  away  to  allow 
inversion  to  be  produced  by  means  of  a  continuous  Lembert  or  Cush- 
ing  suture ;  an  omental  graft  may  be  applied  in  some  cases.  Mr. 
Barker's  method  of  resection  of  gangrenous  bowel  is  a  good  and  speedy 
one  ;  and  in  these  cases  time  is  of  immense  importance.  It  must  not 
be  forgotten,  however,  that  careful  and  accurate  sewing  is  of  even 
greater  importance  {vide,  Figs.  143,  144,  and  145). 

Murphy's  button  or  bone  bobbin  may  be  preferred  by  some  surgeons 


RESECTION    OF   INTESTINE,    ETC. 


399 


on  account  of  the  ease  and  rapidity  of  introduction,  but  I  prefer  to 
trust  to  direct  suture,  believing  that  this  method  is  the  best  if  well 
carried  out,  and  with  practice  it  can  be  performed  in  from  10 — 15 
minutes  ;  it  needs  more  care  than  a  button,  however,  and  it  is  certain 
that  the  button  has  given  very  good  results  in  the  past.  Gibson  (Ann* 
of  Surg.,  1900)  found  the  mortality  of  resection  and  primary  reunion 
b\  suture  to  be  38  per  cent.,  and  that  of  the  same  procedure  with  the 
aid  of  the  Murphy  button  to  be  only  30  per  cent.,  but  these  figures  refer 
to  the  ten  years  ending  in  1898,  and  since  then  the  technique  of  direct 
suture  has  improved  greatly.  Circular  enterorraphy  is  safer  and  more 
satisfactory  in  every  way  than  lateral  anastomosis. 


Fig.  144. 


Forceps  clamping 
Jistal  enJ 
ae  loop 


the  distal  end 
of  the  " 


Open  end  of  the  loop,  of 
intestine  moved  ■vrell 
away  from  the  wounn 

Resection  of  gangrenous  intestine ;    the  folded  mesentery  is  tied  while  the 
intestine  is  draining.     (After  Barker.) 

As  the  sac  will  almost  certainly  have  been  septic,  drainage  should 
be  employed. 

The  question  of  the  advisability  of  attempting  a  radical  cure  now 
arises.  Very  often  this  will  be  forbidden  by  the  general  condition  of 
the  patient.  Whenever  there  is  any  risk  of  septic  infection,  or  any 
doubt  as  to  the  efficiency  of  the  suture,  the  wound  must  be  kept  open. 
Mikulicz,  if  I  understand  him  rightly  (loc.  siqwa  cit),  leaves  these 
cases  open. 

If  any  extravasation  have  taken  place  into  the  peritonseal  sac,  this 
must   be  cleansed,    and   drainage   employed    as    advised    at    pp.    326, 

339- 

It  may  be  convenient  to  briefly  recapitulate  here  the  chief  courses 
open  in  the  treatment  of  gangrenous  hernia.     (1)  Leaving  things  alone 


400 


OPERATIONS  OX  THE  ABDOMEN. 


(p.  49)  ;  a  course  only  to  be  adopted  when  the  condition  of  the  patient 
and  the  surroundings  of  the  surgeon  do  not  admit  of  more  being  done. 
(2)  Primary  resection  either  of  a  portion  of  a  coil,  as  in  a  gunshot 
wound,  or  more  usually  of  the  whole  loop.  (3)  Intermediate  resection 
(Riedel,  Deut.  Med.  Woch.,  1883,  No.  45).  Resection  is  performed, 
an  artificial  anus  established,  and  after  twenty-four  or  forty-eight 
hours  the  edges  of  the  intestine  are  vivified  and  united  by  suture. 
(4)  Enterostomy,  or  the  making  of  an  artificial  anus  and  the  closure 
of  this  at  a  subsequent  date.  In  cases  where  the  collapse  of  a  patient 
demands  prompt  termination   of  the   operation,    the   surgeon    should 


Fig.  145. 


Forceps  damping 
both  ends 


First  or  deep  suture 
being   introduced 


TaiL  thread  of  deep  suture 

Resection  of  gangrenous  intestine.  The  loop  has  been  removed  and  the 
healthy  ends  are  being  joined  together  ;  the  continuous  deep  suture  is  being  intro- 
duced. Note  that  the  distal  end  is  clamped  obliquely  so  as  to  make  the  section 
equal  to  the  dilated  proximal  end.     (After  Barker.) 


insert  two  Paul's  tubes  in  the  ends  of  the  intestine,  keeping  these  well 
outside  (Fig.  135).  The  artificial  anus  must  be  closed  later  on  (p.  414). 
In  any  case  in  which  I  was  not  satisfied  as  to  the  completeness  and 
efficacy  of  the  sutures,  I  should  prefer  to  place  the  sutured  bowel  just 
within  the  abdomen,  and  leave  a  temporary  drain  reaching  down  near 
to  the  line  of  suture.  Packing  around  the  coil  interferes  with  natural 
reinforcement  from  adhesion  to  neighbouring  coils.  In  twenty-four  or 
thirty-six  hours  it  will  be  safe  to  remove  the  gauze  drain  and  to  close 
the  wound  by  means  of  provisional  sutures  inserted  at  the  time  of  the 
operation.     Or  the  following  precaution  may  be  adopted. 

Omental  Grafting  (Figs.  146,  147,  and  148). — This  is  one  of  those 
details  in  intestinal  surgery  which  we  owe  to  Senn.  To  strengthen  a 
weak  spot  or  line  of  union  a  strip  of  omentum  is  torn,  not  cut,  from  the 


RESECTION    OF   INTESTINE,    ETC. 


401 


free  end  of  the  omentum,  laid  over  the  spot  which  it  is  intended  to 
strengthen,  and  secured  willi  a  lew  sutures.  The  contiguous  surfaces 
may  first  be  lightly  scarified,  short  of  causing  bleeding.  Another 
method,  that  of  leaving  the  graft  attached  by  one  end,  should  not  be 

Fig.  146. 


Ileo-ileostomy,  with  Senn's  plates,  completed.  An  omental  graft  has  been 
placed  over  the  line  of  union.  From  a  specimen  removed  from  a  dog  some  time 
after  recovery.    (Jessett.) 

adopted,    as   this  may,  later,  bring  about  ill  results  in  the  form  of 
intestinal  obstruction. 

In  the  after-treatment  of  resection  cases  collapse  must  be  vigorously 
combated,  feeding  by  the  bowel  trusted  to  for  thirty-six  or  forty-eight 
hours,  and  as  little  morphine  or  opium  given  as  possible,  for  fear  of 


Fig.  147. 


Ileo-colostomy.  The  line  of  implantation  of  the  small  into  the  large  intestine 
has  been  covered  with  an  omental  graft.  From  a  specimen  removed  from  a  dog 
some  time  after  recovery.     (Jessett.) 

"conducing  to  further,  and  perhaps  fatal,  intestinal  paralysis"  (Lock- 
wood).  Flatus  will  probably  be  passed  in  forty-eight  hours,  and  the 
bowels  act  between  the  fourth  and  six  days. 

Treatment  of  Intestine  which  is  Dangerous  though  not  actually- 
Gangrenous. — Before  leaving  the  subject  of  grangrenous  intestine  in 
hernia,  and  its  treatment,  there  is  one  remaining  allied  class  of  hernia 
often  very  fatal,  for  which  modern  surgery  may  do  much,  viz.,  that  in 
which  the  condition  of  the  bowel  is  such  that,  though  gangrene  is  not 

s. — vol.  11.  26 


402 


OPERATIONS  ON  THE  ABDOMEN. 


Fig. 


yet  present,  this  may  set  in  if  the  bowel  be  returned  into  the  abdomen. 
In  Ransohoff's  words  (loc.  supra  cit. ;  Ann  of  Surg.,  vol.  ii.  1892, 
p.  349),  "  Such  a  knuckle  is  a  menace.  Bowel  that  is  not  at  all 
doubtful  in  appearance  will  at  times  repay  the  trust  placed  in  it  by 
a  perforation.  Among  ninety-six  deaths  after  herniotomy  it  was,  in 
twenty-six  cases,  the  result  of  returning  intes- 
tine which  subsequently  perforated.  To  return 
doubtful  intestine  is  necessarily  jeopardising  life. 
To  treat  such  intestine  as  radically  as  bowel 
already  gangrenous  is  an  extreme  measure  not 
to  be  advocated.  Fortunatehy  the  intestine  can 
be  retained  in  the  wound  for  a  number  of  days 
in  gauze  packing  or  by  sutures.  When  its 
viability  has  been  established  it  is  an  easy 
matter  to  return  it  into  the  abdomen."  Graefe 
has  reported  {Dent.  Zeit.  j.  Chir.,  Bd.  xxxiv. 
S.  82)  a  successful  case  in  which  the  intestine 
was  so  retained  for  five  days  before  it  was 
replaced. 

While  I  entirely  agree  with  Dr.  Ransohoff  in 
the  principle  of  the  above,  I  think  he  represents 
the  returning  of  such  intestine  as  unduly  easy. 
Even  after  twenty-four  or  thirty-six  hours,  the 
earliest  date  at  which  it  will  be  safe  to  return 
it,  the  intestine  will  be  found  adherent  to  the 
gauze  and  to  bleed  easily.  Cases  in  which  this 
difficulty  arises  should  be  quite  rare  at  the 
present  day,  now  that  the  principles  that  govern 
are  better  known.  In  any  case  of  doubt,  or 
when  the  surroundings  or  the  condition  of  the  patient  do  not  allow 
a  resection  I  should  always  empty  the  distended  intestine  as  far  as 
possible  by  means  of  a  temporary  enterostomy,  a  small  tube  being  fixed 
at  the  convexity  of  the  bowel,  for  this  is  the  first  essential  step  towards 
saving  the  patient's  life.  A  few  days  later  the  fistula  can  be  closed  by 
inversion  if  the  patient  survives. 


An  omental  graft  secured 
in  place  over  the  line  of  an 
enterorraphy.  I,  Intestine. 
M,  Mesentery.  0,  Graft. 
S,  Suture  fixing  graft. 
(Walsham.) 

successful   resection 


INTESTINAL    ANASTOMOSIS.      SHORT-CIRCUITING. 
LATERAL    ANASTOMOSIS.     "UNILATERAL  AND    BILATERAL 

EXCLUSION. 


The  first  two  of  the  above-given  terms  have  been  often  needlessly 
used  for  the  same  thing — viz.,  the  establishment  of  a  permanent 
fistulous  opening  between  the  bowel  above  and  the  bowel  below  some 
point  of  obstruction,  usually  a  growth  which  cannot  be  removed. 

By  Lateral  Anastomosis  is  meant  the  making  of  a  fistulous  opening 
between  two  parts  of  resected  intestines,  the  two  ends  being  first 
securely  closed. 

However  end-to-end  junction  of  resected  intestine  may  ultimately  be 
performed,  it  is  certain  that  the  above  operations  have  a  great  future 
before   them.     The  principle   of  them   all,   and  the  making  them   of 


INTESTINAL    ANASTOMOSIS,    ETC.  403 

practical  utility,  we  owe  to  the  labours  and  experiments  of  Prof.  Benn, 
and  their  elaboration  is  due  largely  to  the  work  of  Maisoneuve,  Hart- 
man,  Mikulicz,  Salzer,  Monprofit,  Lane  and  others. 

Indications. — Intestinal  anastomosis  or  short-circuiting  are  torepla 
resection  where  the  genera]  and  local  conditions  forbid  the  severer  step 
in  Buch  cases  as— (a)  Growth;  for  cases  suitable  for  resection  see 
p.  384.  (M  Contraction,  cicatricial  and  not  malignant  in  character, 
(c)  Matting  of  intestines  by  old  mischief,  perhaps  dating  to  tubercular 
peritonitis,  or  inflammation  about  a  caseous  mes<  uteric gland,  (d)  An 
intussusception  which  is  irreducible  but  not  gangrenous.  It  has  also 
been  employed  or  the  treatment  ot  constipation  and  also  for  colitis  and 
for  some  cases  of  volvulus. 

Mayo  Kobson  (Lancet,  Sept.  27,  1902)  has  recorded  some  interest- 
ing and  successful  cases  of  enterectomy  and  short  circuiting  for 
tuberculosis  of  the  intestine. 

Advantages. — Prof.  Senn  claims  the  following,  and  with  regard  to 
the  principle  of  intestinal  anastomosis  all  will  agree  with  him.  As 
regards  the  details  as  to  which  method  is  the  best,  time  alone  will 
show.  (1)  That  the  operation  can  be  rapidly  performed  with  a  great 
saving  of  time.  (2)  That  the  junction  of  the  intestinal  surfaces  around 
the  anastomosis  is  a  safe  one.  (3)  That  the  operation  is  independent 
of  any  difference  in  the  size  of  the  bowel  above  and  below  the  obstruc- 
tion. (4)  That  the  principle  is  of  very  wide  application.  To  these 
may  be  added :  (5)  That  the  opening  may  be  made  of  any  size  that  may 
be  desired ;  (6)  That  there  may  not  be  any  need  to  interfere  with  the 
mesentery. 

But  according  to  the  experiments  of  Chlumsky  side-to-side  union  is 
not  so  firm  as  that  of  end-to-end,  and  contraction  of  the  orifice  is  more 
likely  to  follow  it. 

I.  Anastomosis  by  Sutures  alone  (Figs.  149-153).— Most 
surgeons  are  abandoning  artificial  aids  in  anastomosis  and  preferring  to 
trust  to  sutures  alone,  just  as  in  end-to-end  union  they  have  returned 
to  circular  enterorraphy.  The  method  of  Abbe,  which  has  given  good 
results,  is  as  follows  :  After  resection  of  the  intestine  and  closure  of  the 
two  ends,  the  two  segments  of  intestine  are  laid  parallel  with  each  other, 
and  two  rows  of  continuous  Lembert's  sutures  are  applied  a  quarter  of 
an  inch  apart  and  an  inch  longer  than  the  incision  which  it  is  proposed 
to  make  (Fig.  149).  Each  piece  of  silk  (twenty-four  inches  long)  is  left 
at  the  end  of  its  row,  being  still  threaded.  The  bowel  is  then  opened 
for  four  inches,  a  quarter  of  an  inch  from  the  sutures,  both  rows  being 
to  one  side  of  the  cut.  Any  vessels  that  bleed  are  treated  by  forci- 
pressure.  The  opposite  segment  of  bowel  is  then  opened  in  the  same 
way.  The  two  adjacent  cut  edges  are  now  united  by  a  suture  which 
traverses  both  the  mucous  and  serous  wall  (Fig.  150),  and  so  secures 
any  bleeding  points,  the  forceps  being  taken  off  as  they  are  reached. 
The  two  free  cut  edges  are  secured  with  a  similar  "  whipping  "stitch, 
after  which  the  serous  surfaces  on  the  opposite  side  of  the  opening  are 
approximated  and  secured  by  continuous  Lembert's  sutures,  the  first 
threads  securing  this  purpose'.  It  is  claimed  that  this  method  requires 
little,  if  any,  longer  time  than  that  with  mechanical  supports  of  any 
kind,  and  that  it  is  free  from  many  of  their  disadvantages,  viz.,  the 
need  of  special  apparatus,  foreign  bodies  which  have  to  come  away, 

26 — 2 


404 


OPERATIONS  ON  THE  ABDOMEN. 


contraction  of  the  opening,  which  is  here  so  very  free,  and  the  prolapse 
of  the  mucous  membrane  through  the  opening. 

Abbe's  method  is  not  an  ideal  one  because  the  edges  of  the  whole 
circumference  of  the  orifice  are  not  secured  together  by  means  of  a 
stitch  which  pierces  the  whole  thickness  of  the  intestinal  walls,  which 
is  a  desideratum  in  all  forms  of  intestinal  union.  Moreover  the 
method  of  catching  the  vessels  with  forceps  is  not  so  good,  simple  and 
easy  as  by  clamp  forceps  in  the  following  adaptation  of  Moynihan's 
method  of  gastrojejunostomy. 

II- — The  two  chosen  loops  or  inverted  ends  are  brought  well  out  of 
the  abdominal  cavity  and  the  latter  protected  by  gauze  packing.  A 
suitable  length  and  width  of  the  antemesenteric  part  of  each  bowel  is 
emptied  with  the  fingers  and  clamped  with  Doyen's  pliable  curved 
forceps  sheathed  with  rubber.  The  rest  of  the  prolapsed  loops  having 
been  returned  or  covered  with  gauze  and  a  sterile  swab  placed  between 
them,  the  forceps  are  approximated  and  a  continuous  silk  suture  is 
inserted  to  join  the  touching  edges  of  the  clamped  portions  of  bowel  for 


Fig.  149. 


Fig.  150. 


Abbe's  method  of  anastomosis  by  sutures 
only.  To  show  the  suturing  of  the  intes- 
tine before  the  incision  is  made.  (American 
Text-book  of  Surgery.) 


To  show  the  four- inch  openings  and  the 
sewing  of  the  edges.  (American  Text-booh 
of  Surgery) 


a  distance  of  three  inches.  Longitudinal  incisions  two  and  a  half  inches 
long  are  then  made  through  the  serous  and  muscular  coats  of  the  exposed 
pieces  of  intestine,  and  the  elliptical  pieces  of  mucous  membrane 
which  protrude  are  removed  with  scissors.  The  mucous  membrane  is 
thoroughly  cleansed  with  solution  of  lysol,  and  a  continuous  catgut 
suture  is  used  to  unite  the  edges.  The  needle  must  pierce  all  the  coats, 
and  the  insertions  should  be  only  about  one-eighth  of  an  inch  apart,  so 
that  the  thread  may  prevent  an}7  bleeding,  as  well  as  secure  the  edges 
firmly  together.  The  knot  should  be  upon  the  mucous  surface  so  as  to 
prevent  infection  at  this  otherwise  likely  spot  (vide  p.  359).  The  clamps 
are  then  removed,  and  the  continuous  sero-muscular  stitch  is  again 
taken  up  to  complete  the  circle  of  peritonseal  apposition  around  the 
aperture.  The  width  of  this  apposition  should  be  about  one  quarter  of 
an  inch. 

III. — Dr.  Halsted  has  described  another  method  of  intestinal  anas- 
tomosis by  suture  only  (Bulletins  Johns  Hopkins  Hospital,  vol.  ii.  No.  10). 
He  prefers  quilt  or  square  sutures  (Figs.  151  to  153)  because  one  row 
is  sufficient,  and  they  tear  out  less  easily  and  constrict  the  tissues  less 
than  do  the  Lembert's  sutures.  The  following  are  the  steps  of  this 
method.     The  two  selected  portions  of  intestine  having  been  placed 


INTESTINAL   ANASTOMOSIS,    ETC. 


405 


in  contact  along  their  mesenteric  borders,  six  s<|u:ive  sutures  are  put  in 
a  straight  row,  tied,  and  cut  short.  At  each  end  of  this,  the  posterior 
row  of  sutures,  and  nearer  the  free  border,  two  lateral  square  sutures 
are  applied  (Fig.  152),  tied,  and  cut  short.  Eight  or  nine  Bquare 
sutures  are  now  applied  so  as  to  draw  together  the  free  borders.  These 
sutures  are  not,  however,  tied,  but  drawn  aside  (Fig.  153),  so  as  to 
make  room  for  the  scissors  with  which  the  two  segments  of  intestine  are 
opened.     Finally,  the  sutures  of  the  anterior  row  are  tied  and  cut  short. 


Fig.  151. 


Fig.  152. 


Method  of  lateral  anastomosis   by  Halsted's  simple  suturing.     The  sutures  are  of   the 
square  kind.     Fig.  151,  first  stage  ;  Fig.  152,  second  stage.     (Jessett,  from  Halsted.) 


Fig.  153. 


Halsted's  operation,  third  and  fourth  stages.     (Jessett,  from  Halsted.) 

Mr.  Bidwell  (Brit.  Med.  Journ.,  vol.  i.  1902,  p.  322)  uses  this  method 
for  performing  ileo-sigmoidostomy  for  irremovable  growth  of  the  colon. 
He  does  not  use  any  intestinal  clamp,  but  ties  the  ileum  at  two  places 
by  means  of  thin  rubber  tubing  so  as  to  avoid  damaging  the  distended 
bowel  in  cases  of  obstruction,  but  properly  applied  clamps  are  better. 
Halsted's  stitch  is  very  good  as  regards  the  outer  coats,  but  I  prefer  to 
use  a  perforating  stitch  to  secure  the  edges,  and  to  supplement  this 
with  some  form  of  continuous  sero-muscular  suture  ;  the  aperture  is 
not  so  likely  to  contract  after  this  method  as  after  that  of  Halsted. 


406 


OPERATIONS  ON  THE  ABDOMEN. 


IV.  Anastomosis  with  Murphy's  Button  (Fig.  158). — The 
technique  here  differs  hut  little  from  that  already  given  for  end-to-end 
junction  by  this  method.  Similar  spots  in  the  ileum  and  caecum  having 
been  chosen,  a  needle  threaded  with  about  a  foot  of  silk  is  inserted  in 
the  long  axis  of  the  bowel  as  at  Fig.  154  ;  a  stitch  is  taken  through 
the  entire  wall  of  the  bowel,  one-third  the  length  of  the  incision  to  be 
made  ;  the  needle  is  again  inserted,  one-third  the  length  of  the  incision 
from  its  outlet,  in  a  line  with  the  first,  and  embracing  the  same  amount 
of  tissue.  A  loop,  three  inches  long,  is  held  here,  and  the  needle  is 
inserted  in  a  similar  manner,  making  two  stitches  parallel  to  the  first 
in  the  reverse  direction,  and  one-fourth  of  an  inch  from  it,  coming  out 
at  a  point  near  the  original  insertion  of  the  needle.  This  forms  the 
running  thread  (Fig.  154)  which,  when  tightened,  draws  the  incised 
edge  of  the  bowel  within  the  cup  of  the  button.  A  similar  running 
thread  is  inserted  in  like  fashion  in  the  colon.  Incisions  two-thirds 
the  length  of  the  diameter  of  the  button  to  be  used  are  then  made 
between  the  two  running  threads  (Fig.  154),  care  being  taken  not  to 


F1GJ154. 


This  shows  the  method  of  passing  the  puckering  thread  when  Murphy's  button 
is  used  in  lateral  intestinal  anastomosis,  gastroenterostomy,  &c. 


cut  these,  the  female  half  of  the  button  slipped  into  the  ileum  and  the 
male  into  the  colon,  the  running  thread  drawn  tight  and  tied  firmly 
round  the  central  cylinders.  While  this  is  done,  an  assistant  holds 
each  half  in  place,  and  care  is  taken  that  the  intestine  is  held  evenly 
all  round  the  cylinder  in  the  grip  of  the  ligature.  Th^  two  halves  of 
the  button,  next  held  in  the  fingers,  are  firmly  pressed  together  until 
the  serous  surfaces  are  in  accurate  contact  all  round  and  at  eveiw  point. 
A  few  reinforcing  mattress  sutures  may  be  inserted  if  considered 
necessary.  The  use  of  the  button  has  not  been  attended  with  great 
success  in  short  circuiting  for  obstruction  by  irremovable  growth  ;  it 
has  not  uncommonly  led  to  leakage  from  sloughing  (Bidwell,  loc.  cit.). 
Mayo  Robson's  bobbin  or  that  of  Stanmore  Bishop  may  be  used  more 
safely.  These  contrivances  are  especially  suitable  when  it  is  not 
possible  to  withdraw  the  intestine  from  the  abdomen  ;  but  they  are 
slippery  to  handle,  and  they  are  difficult  to  decalcify  evenly,  so  that 
some  parts  are  absorbed  before  others. 

V.  Anastomosis  with  the  Elastic  Ligature  of  McGrraw  (Amer. 
Med.,  Aug.  3,  1901)  (vide  Figs.  208  to  210,  p.  521). — The  two  loops 
are  brought  together  and  joined  by  means  of  a  continuous  Lembert  silk 
suture,  running  for  a  distance   of  three   inches  in  a  semilunar  curve, 


INTESTINAL   ANASTOMOSIS,    ETC.  407 

along  the  length  of  the  loops  and  one-third  of  an  inch  away  from  their 
free  borders. 

An  elastic  ligature  two  or  three  millimetres  in  diameter  and  threaded 
on  ;t  suitable  and  long  Btruight  needle  is  then  passed  twice  through 
the  walls  of  first  one  and  then  the  other  bowel  at  the  five  borders.  The 
ligature  must  not  run  transversely  hut  longitudinally  in  the  intestine, 
and  it  should  take  a  hite  of  from  one  and  a  half  to  two  inches  ;  it 
should  he  both  threaded  and  passed  while  upon  the  stretch,  so  that 
when  it  contracts  it  may  entirely  fill  the  perforations  in  the  intestine 
to  prevent  any  leakage.  The  needle  should  be  held  at  right  angles 
to  the  bowel  during  its  insertion,  so  that  it  may  pierce  the  mucosa, 
and  not  leave  any  bridges  uncompressed  by  the  ligature.  When  the 
ligature  is  tightened  and  twisted  into  a  single  knot,  the  latter  is  secured 
by  means  of  a  silk  ligature  tied  around  it.  The  ends  are  then  cut 
short,  and  the  circle  of  Lembert  suture  is  completed  around  the 
ligatures  (vide  Fig.  210,  p.  523).  Dudley  Tait  (Ann.  of  Surg.,  1906, 
vol.  xliii.  p.  190)  recommends  a  simpler  method.  The  ligature  is  held 
upon  the  stretch,  clamped  close  to  the  bowel,  and  then  tied  beneath  the 
clamp.  The  ends  can  be  cut  without  fear  of  the  knot  slipping.  It  is 
claimed  that  this  method  is  very  rapid  and  simple,  and  that  it  carries 
less  risk  of  sepsis  and  shock  than  any  other  plan,  also  that  it  can  be  as 
quickly  used  as  a  Murphy  button,  but  without  the  risks  of  leaving  a 
dangerous  foreign  bod}'  in  the  intestine. 

Dudley  Tait  has  shown  by  his  experiments  upon  animals  that  the 
stoma  which  is  made  by  the  elastic  ligature  is  large  and  clean  cut,  and 
that  subsequent  contraction  is  unlikely  even  when  an  alternative  passage 
remains  open.  If  the  ligature  break  or  be  not  tight  enough,  the 
anastomosis  fails  or  is  imperfect,  but  these  accidents  are  avoidable. 
It  is,  however,  utterly  unsuitable  for  cases  of  intestinal  obstruction 
which  require  immediate  drainage,  for  the  ligature  does  not  cut  out 
and  provide  an  opening  for  several  days ;  but*  McGraw  uses  the 
ligature  in  combination  with  resection,  the  limbs  of  the  loop  to  be 
excised  being  anastomosed,  and  the  anastomosis  returned  just  within 
the  abdomen.  The  loop  is  then  resected  and  the  ends  drained  until 
the  anastomosis  is  well  established. 

Meyer,f  Murphy, J  Oschner,§  and  other  American  surgeons,  speak 
highly  of  the  ligature  method,  especially  for  gastrojejunostomy. 
Oschner  has  performed  forty  gastrojejunostomies  without  any  ill  effects 
arising  from  the  use  of  the  ligature,  but  it  must  not  be  used  if  the 
pylorus  is  obstructed.  Personally  I  prefer  the  direct  suture  method 
to  any  other,  because  a  firm  union  and  a  free  opening  are  established 
at  once  and  nothing  is  left  to  chance  or  to  sloughing. 

INTESTINAL     EXCLUSION. 

Mere  anastomosis  may  not  be  enough  in  some  cases,  and  it  may  be 
desirable  to  go  further  and  "  exclude  "  a  portion  of  diseased  intestine, 


*  McGiaw  (Ann.  of  Surg.,  1904,  vol.  xl.  p.  688). 
f  J/cd.  Record,  Jan.  25,  1902. 
J  Bust.  Med.  and  Surg.  Journ.,  Jan.  28,  1904. 
§  Ann.  of  Surg.,  1904,  vol.  xxxix.,  p.  144. 


408 


OPERATIONS  ON  THE  ABDOMEN. 


so  that  the  feces  may  not  reach  and  irritate  that  part,  or  get  retained 
within  it.  Thus,  in  cases  of  colitis  or  tuberculous  disease  or  growth,  it 
is  desirable  to  give  the  diseased  part  as  complete  rest  as  possible,  and 
in  chronic  constipation,  anastomosis  alone  will  not  prevent  fsecal 
accumulation  in  the  csecum  and  colon.  Moreover,  it  is  not  only 
necessary  to  divert  the  stream  completely  for  these  reasons,  but  also  to 
prevent  the  contraction  of  the  new  orifice,  which  may  occur,  if  an 
alternative  course  is  left  open.* 

"Unilateral  exclusion  involves  complete  division  of  the  intestine  above 
the  disease,  with  anastomosis  or  implantation  of  the  proximal  end  into 
the  side  of  the  healthy  intestine  below ;  the  distal  extremity  may  be 
either  closed  or  drained  according  to  the  necessity ;  it  is  generally 


Fig.  155. 


Obstruction. 


Caecum 


Descending' 
colon 


Ileum 

Anastomosis 
Sigmoid 


Rectum 


Appendix. 
Ileo-sigmoidostomy.    Anastomosis  without  exclusion. 

closed.  For  example,  the  ileum  may  be  cut  across  near  the  ceecuni, 
and  the  upper  segment  joined  to  the  sigmoid  colon,  the  csecal  end  of 
the  ileum  being  inverted  or  drained  (Fig.  156). 

Operation. — Mr.  Arbuthnot  Lane's  method  of  performing  ileo- 
sigmoidostomy  is  described  here  as  an  example,  but  other  parts  may 
be  joined  in  a  similar  way  according  to  the  requirements  in  any  given 
case.  The  ileum  about  six  inches  from  the  csecum  is  clamped  with 
two  pairs  of  crushing  forceps,  which  are  placed  transversely  across  the 
intestine  at  a  distance  of  one  inch  from  each  other.  The  forceps  serve 
to  break  the  muscular  and  mucous  coats  which  retract,  but  the 
peritonseal  covering  and  fibrous  tissues  are  not  torn,  but  are  ligatured 
after  the  forceps  have  been  removed  and  have  left  a  deep  constriction. 
The  empty  piece  of  intestine  between  the  two  ligatures  is  then  excised 
and  its  mesentery  tied.  The  comparatively  small  stumps  are  inverted 
by  means  of  a  purse-string  sero-muscular  silk  suture.  Doyen  showed 
the  advantages  and  safety  of  this  rapid  and  simple  method  of  closing 
divided  bowel.  A  lateral  anastomosis  is  now  made  between  the 
proximal  segment  of  the  ileum  and  the   side  of  the  sigmoid  loop  of 

*  Summers  (Ann.  of  Srwg.,  1905,  p.  99). 


UNILATERAL    EXCLUSION. 


409 


colon,  botli  of  which  are  suitably  clamped  and  brought  outside  the 
abdomen,  so  that  the  peritonaeum  can  be  protected  with  gauze  tampons. 
Two  continuous  silk  sutures  are  used,  a  deep  <>ne  piercing  all  the  coats, 
and  the  other  only  including  and  inverting  the  serous  and  muscular 
coats. 

This  plan  has  been  recommended  for  the  treatment  of  certain  cases 
of  chronic  colitis,  but  for  it  to  be  efficient,  the  sigmoid  colon  at  and 
below  the  anastomosis  must  be  healthy,  which  may  not  be  the  case  in 
dysentery  and  other  forms  of  colitis.  Another  objection  is  that  faeces 
may  still  find  their  way  into  the  caecum  by  reverse  peristalsis  (Cannon, 
loc.  infra  cit.). 

Summers  (loc.  supra  cit.)  records  three  cases  treated  in  this  way, 
and  in  these  no  reflux  was  noticed,  but  this  may  have  been  at  least 

Fig.  156. 


Cascum 


centime; 
Colon      to 


astomosis 


J Rectum 


Appendix 


Unilateral  exclusion.     The  ileum  has  been  cut  across,  its  ends  inverted,  and 
the  proximal  part  anastomosed  to  the  sigmoid  colon. 


partly  due  to  the  Gibson  valvular  fistula  that  was  made  into  the  caecum 
in  two  of  these  cases. 

In  combination  with  appendicostomy  or  caecal  fistula  this  plan  may 
be  found  to  be  useful  in  some  cases,  for  the  colon  can  be  washed  out 
in  case  of  need  (pp.  138  and  140). 

Chronic  constipation  (Lancet,  vol.  ii.  1904,  p.  1695,  and  vol.  ii. 
1905,  p.  862). — Mr.  Arbuthnot  Lane  has  practised  this  operation  for 
chronic  constipation,  with  the  object  of  preventing  the  accumulation 
and  decomposition  of  fasces  in  the  caecum  and  colon.  A  mere  entero- 
anastomosis  does  not  prevent  the  faeces  from  reaching  the  caecum 
through  the  ileum,  and  moreover  the  new  orifice  may  close  in  the 
absence  of  obstruction  in  the  course  of  the  large  intestine.  Unfor- 
tunately regurgitation  may  still  take  place  after  unilateral  exclusion, 
the  antiperistaltic  waves  of  contraction  carrying  the  contents  of  the 
sigmoid  colon  backwards  into  the  caecum.     Cannon  (Amer.  Journ.  of 


4io  OPERATIONS  ON  THE  ABDOMEN. 

Physiology,  1902)  proved  by  means  of  the  X-rays  that  enemata  con- 
taining bismuth  were  taken  to  the  caecum  by  antiperistalsis,  and  clinical 
experience  has  shown  that  the  caecum  may  fill  with  faeces,  in  time, 
after  unilateral  exclusion.  Enemata  may  be  of  no  avail  then,  and 
purgatives  cannot  be  expected  to  act,  unless  a  satisfactory  drug  can  be 
discovered  for  exhibition  through  the  blood  stream.  The  result  is  that 
in  some  patients  the  greater  part  of  the  colon  has  been  resected  in 
order  to  relieve  the  patient  of  pain.  Appendicostomy,  or  Gibson's 
valvular  caecostomy  may  remove  the  necessity  of  this  heroic  treatment 
by  allowing  the  introduction  of  fluid  or  purgatives.  It  was  at  first 
expected  that  diarrhoea  might  be  troublesome  after  joining  the  ileum 
to  the  lower  sigmoid  or  rectum,  but  experiments  on  animals  and  clinical 
experience  have  shown  that  this  does  not  occur  except  as  a  very 
temporary  annoyance.  Within  a  few  weeks  the  bowels  may  be  acting 
once  or  twice  a  day  with  regularity ;  but  unfortunately  as  time  goes  on 
constipation  may  return,  and  this  is  true  to  a  lesser  degree  even  after 
resection  of  the  colon  in  some  cases.  Whether  time  and  results  will 
prove  these  operations  to  be  of  value  in  the  treatment  of  colitis  and 
constipation  is  an  open  question. 

My  friend  Dr.  Sheaf  has  kindly  allowed  me  to  read  his  thesis  upon 
this  subject,  and  he  concludes  that  ileo-sigmoidostomy  is  not  much 
good  for  women  with  chronic  constipation,  but  that  it  is  more  hopeful 
for  men.  Colectomy,  although  it  is  attended  with  severe  shock,  and  is 
more  dangerous,  affords  far  better  prospect  of  cure  or  of  marked  relief, 
most  of  the  patients  having  improved  greatly  in  their  general  health 
after  this  operation.  "  But  the  results  are,  on  the  whole,  disappointing, 
many  of  the  patients  being  of  such  poor  fibre  and  neurotic  temperament 
that  nothing  can  make  them  healthy  citizens.  The  disease  is  often 
the  result  of  careless  habits,  which  will  remain  after  the  operation." 

Personally  I  regard  less  drastic  measures  with  more  favour,  and 
believe  that  very  few  cases  of  constipation  are  not  amenable  to  treatment 
by  means  of  proper  dieting  habit,  muscular  exercises,  massage  of  the 
colon,  a  sufficiency  of  fluid,  and  such  drugs  as  belladonna,  aloes  and 
nux  vomica.  In  cases  of  real  mechanical  obstruction,  unilateral 
exclusion  is  a  recognised  surgical  proceeding.  Appendicostomy,  as 
suggested  by  Mr.  Keetley,  is  an  alternative  treatment  for  constipation, 
and  being  less  severe  and  dangerous  than  unilateral  exclusion  it  is 
certainly  worthy  of  trial  in  preference  to  ileo-sigmoidostomy,  which  may 
ultimately  lead  to  resection  of  the  colon.  Moreover,  appendicostomy 
provides  an  opening  which  does  not  leak,  and  yet  allows  the  introduction 
of  fluid  or  drugs  into  the  colon  in  order  to  secure  an  evacuation.  In 
Mr.  Keetley's  published  case,  this  plan  acted  admirably.  Cannon 
(loc.  cit.)  and  Goddard  (Lancet,  vol.  i.  1905,  p.  795)  have  shown  that 
absorption  of  fat,  carbohydrates  and  fluid  occur  to  an  appreciable 
extent  in  the  caecum  and  colon,  but  it  is  certain  that  these  functions 
can  be  replaced  by  the  small  intestine. 

Many  pathologists  of  large  experience  have  not  observed  the  adhesions 
that  Mr.  Lane  has  described  from  his  clinical  experience,  and  Dr.  A. 
Barrs  {Lancet,  vol.  ii.  1904,  p.  1888)  in  a  trenchant  criticism  of  opera- 
tive treatment  for  constipation  states  that,  "  looking  back  over  eleven 
years  of  post-mortem  work  in  a  large  general  hospital,  I  cannot  recall 
one  case  where  the  changes  described  by  Mr.  Lane  were  seen  to  result 


I'NILATKKAL    K\<  I.ISK  »\. 


411 


from  obstinate  constipation."  He  then  refers  to  Dr.  Goodhart's  views 
upon  this  subject  ns  follows: — 

"But  better  criticism  than  any  I  can  make  is  to  be  found  in  an 
address,  'Round  about  Constipation,'  by  Dr.  J.  F.  G-oodhart,  and,  if 
I  may  be  permitted  to  do  so,  I  will  quote  from  it  a  few  remarks  which 
directly  traverse  many  of  Mr.  Lane's  contentions  and  at  the  same  time 
recount  nothing  more  than  the  everyday  experience  of  most  of  us.  Dr. 
Goodhart  says :  (1)  "  A  mere  adhesion,  such  as  seems  often  to  be 
accepted  as  a  sufficient  explanation  of  obstruction  of  the  pylorus  or 
intestine,  I  have  little  belief  in,  because  you  rarely,  I  think,  find  such 
localised  adhesions  in  the  post-mortem  room  where  there  lias  been  any 
evidence  of  their  presence  during  the  life  of  the  patient."  (2)  "  There 
are  many  people  who  live  through  their  adult  life  in  the  belief  that  if 
the  bowels  do  not  act  for  two  or  three  days  they  will  get  a  block — that 
is,  there  will  come  obstruction  of  the  bowels.  So  many  of  us  act,  too, 
as  if  we  believe  it,  that  we  encourage  the  same  doctrine.  But  it  is  not 
a  fact.  I  can  say  positively  that  in  thirty-five  years  of  work  I  have 
only  seen  one  case  of  this  kind  and  in  consequence  I  made  a  wrong 
diagnosis."  (3)  "A  mere  intestinal  accumulation  never  produces 
obstruction."  (4)  "I  have  often  been  struck  with  the  fact  that  of  all 
of  those  who  suffer  from  constipation  how  few  there  are  who  give  any 
sign  of  retention."  Lastly,  speaking  of  intestinal  auto-intoxication,  to 
which  Mr.  Lane  attributes  many  of  the  symptoms  he  enumerates,  Dr. 
Goodhart  says:  "  I  think  the  time  has  come  to  make  a  protest  when 
we  are  becoming  overridden  by  the  minuteness  and  ingenuity  with 
which  this  doctrine  is  now  elaborated.  I  hear  of  nothing  now  hut 
auto-infection  and  auto-intoxication  .  .  .  and  really  one  would  almost 
think  from  the  contumely  that  is  heaped  upon  our  uncomely  colon, 
that  the  evil  that  it  is  supposed  to  do  us,  and  the  bits,  and  large  bits 
too,  of  which  it  is  now  ofttimes  bereft  by  the  surgeon,  that  happy  would 
be  the  man  who  could  .  .  .  live  without  it." 

Many  patients  who  suffer  from  chronic  constipation  are  "  nerve 
wrecks  "  or  neurasthenics  ;  whether  their  nervous  condition  is  primary 
or  secondary  to  the  constipation  is  an  open  question,  but  I  believe  that 
the  constipation  is  merely  an  incident  in  their  history  of  aches  and 
pains.  Their  nervous  energy  is  barely  equal  to  the  demands  made 
upon  it  by  work  or  worry  or  both,  so  that  in  many  cases  constipation 
can  be  said  to  be  a  "mental  preoccupation  "  disease,  which  is  beyond 
the  reach  of  surgery,  but  an  operation,  however,  may  generate  hope  and 
do  some  temporary  good. 

Recently  one  of  us  (R.  P.  R.)  had  a  servant  girl  under  his  care,  who  complained  that  the 
bowels  were  not  opened  more  than  once  a  fortnight  without  medicine,  and  that  she  could 
not  take  any  exercise  because  of  the  pain  that  she  suffered.  She  had  not  done  any  work 
for  two  years.  About  that  time  the  right,  kidney  had  been  fixed,  and  had  given  temporary 
relief.  The  doctor  who  knew  her  from  childhood  wrote  and  said  that  he  regarded  her  as  a 
neurotic  patient,  and  that  her  father  also  was  a  man  of  no  courage,  but  shirked  work  on 
the  slightest  excuse.  Drugs  were  tried  and  belladonna  certainly  gave  some  relief,  but 
dieting  could  not  be  carried  out  properly  for  an  out-patient,  and  she  refused  to  take 
exercises.  She  clamoured  for  an  operation,  and  having  regard  to  the  teaching  of  Lane, 
that  constipation  may  be  due  to  kinking  of  the  hepatic  flexure  which  may  result  from 
mobility  of  the  kidney,  or  from  the  operative  fixation  of  the  latter,  it  was  decided  to  explore. 
The  operation  was  performed  after  a  week's  observation  in  hospital,  during  which  time 
the  bowels  were  not  moved,  but  the  patient  ate  freely  of  ordinary  full  diet.     No  purgatives 


412 


OPERATIONS  ON  THE  ABDOMEN. 


or  enemata  were  given.  At  the  operation,  the  caecum  and  colon  were  first  examined, 
especial  attention  being  paid  to  the  hepatic  flexure  and  caecum,  but  nothing  abnorma 
could  be  discovered.  The  right  kidney  was  quite  fixed,  the  left  had  its  normal  degree  of 
mobility.  The  liver  was  lower  and  more  movable  than  normal.  The  intestine  was 
nowhere  distended  or  constricted,  but  seemed  to  be  peculiarly  empty  considering  the 
duration  of  the  constipation.  The  stomach  and  pylorus  were  examined  and  they  were 
normal.  This  examination  was  made,  because  of  the  common  error  of  attributing  con- 
stipation really  due  to  disorders  of  the  stomacli  or  obstructions  of  the  pylorus  to  diseases 
of  the  intestines.  The  whole  length  of  the  intestine  was  examined,  especial  care  being 
taken  to  follow  the  duodenum  :  but  no  abnormality  was  noticed,  beyond  perhaps  an 
unusual  thinness  of  the  wall  of  the  ileum  ;  but  peristalsis  could  be  seen  to  occur  in  it. 
There  was  no  volvulus  of  the  sigmoid  colon,  and  there  were  no  peritonaeal  adhesions 
anywhere.  The  appendix  was  normal,  and  the  right  ureter  was  also  normal  as  far  as  it 
could  be  examined  with  the  hand  in  the  abdomen.     The  uterus  and  pelvic  organs  were 


Fig.  157. 


Obstruction. 


Descending 
colon 


Anastomosis 


Caecum- —    W=- 


Sigmoid 


Appendix'qpen 

Bilateral  exclusion.     The  excluded  loop  must  be  drained  through  the  distal 
end,  or  through  a  cascal  or  appendicular  fistula. 

normal  and  not  displaced  in  any  way.  There  being  no  indication  for  ileo-colostomy  or 
even  for  appendicostomy,  the  abdomen  was  closed.  The  patient  made  a  rapid  recovery, 
and  she  does  not  complain  of  any  pain.  The  bowels  are  open  once  every  day  or  every 
alternate  day  with  the  aid  of  a  mixture  containing  five  minims  each  of  the  tinctures  of 
belladonna  and  nux  vomica.  The  patient  herself  says  that  she  is  quite  well  now,  and 
she  is  at  work. 

Some  form  of  unilateral  exclusion  is  done  for  irremovable  growth  of 
the  colon ;  the  objection  to  this  is  that  accumulation  of  intestinal 
secretions  and  of  discharges  from  the  growth  may  occur  above  the 
obstruction  in  the  excluded  intestine,  and  this  may  lead  to  inflammation 
or  even  perforation  ;  fortius  reason,  simple  entero-anastomosis  is  to  be 
preferred  in  cases  of  growth,  and  it  also  takes  less  time,  which  is 
important  in  cases  of  intestinal  obstruction. 

Bilateral  exclusion  (Fig.  157)  involves  two  divisions  of  the 
intestine,  above  and  below  the  growth  or  disease,  the  central  and 
peripheral  ends  being  joined  together.     The  ends  of  the  excluded  loop 


BILATERAL    EXCLUSION. 


4*3 


can  be  inverted  or  drained  at  one  or  both  extremities  ;  the  distal 
extremity  should  usually  be  chosen  for  drainage  because  peristalsis  will 
then  aid  it.  In  case  of  obstruction,  however,  the  fistula  should  be 
proximal  to  the  obstruction.  A  valvular  csecostomy  or  an  appendi- 
costomy  may  serve  admirably  for  draining  an  excluded  cascum  and 
ascending  colon  in  case  of  irremovable  growth  of  the  latter,  for  which 
bilateral  exclusion  has  been  performed. 

It  is  not  safe  to  close  an  excluded  loop  entirely,  especially  if  the 
intestine  is  diseased.  The  exclusion  with  drainage  into  the  intestine 
of  Monprofit  is  to  be  preferred  to  bilateral  exclusion  with  drainage 
on  to  the  surface.  Intestinal  exclusion  in  one  form  or  another  has  a 
wide  range  of  possible  application,  and  is  pregnant  with  possibilities. 
Summer  gives  the  following  example  of  Monprofit's  method.     With  an 


Fig.  158. 

Anastomosis 


Obstruction 


scending 
Colon 


aatomosis 


Rectum 


Appendix 

Exclusion  with  drainage.     The  proximal  part  of  the  ileum  has  been  joined 
to  the  transverse  colon,  the  distal  part  to  the  sigmoid  loop. 


irremovable  obstruction  by  growth  in  the  ascending  colon,  the  ileum 
may  be  severed,  and  its  proximal  segment  joined  to  the  sigmoid  flexure, 
and  the  distal  or  csecal  extremity  implanted  into  the  side  of  the  trans- 
verse or  descending  colon  (Fig.  158).  Clinical  experience  has  shown 
that  the  ileo-caecal  valve  does  not  prevent  the  passage  of  the  contents 
of  the  caecum  into  the  ileum  and  thus  into  the  colon  below  the  growth. 
Summer  speaks  well  of  this  method,  but  he  suggests  an  improvement. 
The  ileum  not  being  divided  but  "approximated  to  the  sigmoid,  and  two 
anastomotic  openings  made  between  these  openings,  the  ileum  should 
be  occluded  by  a  purse-string  suture,  and  both  limbs  fastened  to  the 
sigmoid  so  as  to  close  any  opening  that  might  permit  a  loop  of  intestine 
becoming  strangulated."  I  have  not  tried  this  plan,  but  I  should  be 
afraid  that  either  leakage  or  infection  might  occur  at  the  site  of  the 
ligature  (vide  Fig.  159).  Neither  unilateral  exclusion  nor  entero-anas- 
tomosis  is  sufficient  to  prevent  leakage  from  a  fistula  in  the  small 
intestine,  and  it  is  better  as  a  rule  to  resect  than  to  perform  bilateral 


4i4 


OPERATIONS  OX  THE  ABDOMEN. 


exclusion  in  these  cases.  In  some  cases,  however,  it  may  be  easier 
and  safer  to  perform  bilateral  exclusion  especially  for  entero-vaginal 
fistula.  Lance  (These  cle  Paris,  1903,  Xo.  348;  quoted  by  Moynihan, 
Lancet,  vol.  ii.  1904,  p.  1012)  has  collected  the  records  of  76  cases  of 
bilateral  exclusion  performed  upon  the  human  subject.  In  eight  01 
these  the  operation  was  undertaken  for  the  treatment  of  faecal  fistula 
following  operation  for  strangulated  hernia.  All  the  patients  recovered, 
but  in  three  of  them  the  fistulous  loop  was  afterwards  excised. 
The  remaining  exclusions  were  for  growth,  chronic  intussusception, 
tuberculosis  of  the  large  intestine,  entero-vaginal  fistula,  &c.  "In  no 
case  was  there  any  ill  effect  attributable  directly  to  the  method."  As 
a  rule  when  a  fistula  from  the  excluded  loop  was  not  already  present  the 


Obstruction 


Descending 
Colon 


Caecum 


Ileum 
Appendix 
Exclusion  with  drainage  as  suggested  by  Summer. 


two  ends  of  the  intestine  were  brought  to  the  skin  and  sutured  there. 
This  procedure  is  sometimes  known  as  "  Hochenegg's  method"  of 
exclusion.  The  pre-existing  fistulas  closed  "in  all  the  cases  except 
those  in  which  malignant  disease  was  present.  As  a  rule  only  one 
end  of  the  loop  remained  permanently  open,  the  other  gradually 
dwindling  in  size,  and  eventually  becoming  quite  closed  "  (Moynihan). 


CLOSURE   OF  F.ECAL  FISTULA   OR  ARTIFICIAL  ANUS. 

Fig.  160  shows,  diagrammatically,  some  of  the  chief  points  of  differ- 
ence between  a  faecal  fistula  and  an  artificial  anus.  Before  operating, 
certain  points  of  much  practical  importance  should  be  considered,  and 
first  how  far  any  spur  or  septum  is  developed.  The  more  marked 
this  is,  the  less  is  the  chance  of  closing  the  opening  by  any  slight 
plastic  operation  such  as  paring  and  suturing  the  edges  of  the  opening. 
The  spur  being  left  behind,  the  faeces  will  make  their  way  through  the 
sutures,  and  the  longer  this  condition  is  allowed  to  remain,  the  more, 
of  necessity,  will  the  lower  segment  of  intestine  atrophy,  and  the  more 


CLOSURE   OF   F^CAL   FISTULA,    ETC. 


415 


marked  will  be  the  difference  between  the  two  parts  of  the  bowel. 
( Ither  important  points  are  the  nutrition  of  the  patient  and  the  condition 
of  the  ana  surrounding  the  wound.  The  higher  the  fistula  is  situated 
in  the  small  intestine  the  more  will  the  nutrition  have  suffered,  and 
the  more  urgent  will  be  the  need  for  an  early  operation  for  closing  the 
fistula.  The  more  profuse  and  liquid  is  the  discharge  and  the  higher 
the  leak,  the  more  infiltrated  will  be  the  eczematous  area  around. 

Previous  Treatment. — Small  fsecal  fistulas  often  close  spontaneously, 
others  may  he  easily  closed  by 

inversion  within  a  few  days  of  Fi<j.  iG°- 

their  formation  for  temporarily 
draining  distended  intestine  in 
intestinal  obstruction  or  peri- 
tonitis ;  this  can  be  done  under 
cocaine  anaesthesia  if  performed 
early  before  dense  adhesions 
have  formed,  and  the  parietal 
wound  has  contracted. 

Formerly  the  cautery  was 
used  for  narrow  fistulas,  but 
this  method  is  not  to  be 
recommended  in  preference  to 
more  certain  and  less  painful 
methods  ;  extra-peritonseal  in- 
version can  generally  be  per- 
formed in  these  cases  without 
risk  to  the  patient,  but  this 
method  often  fails,  because  the 
tissues  sutured  are  not  healthy, 
and  particularly  because  of  the 
absence  of  the  serous  coat 
and  the  adhesive  lymph  derived 
from  it  ;  none  of  the  other 
coats  adhere  so  well  and  so 
quickly. 

The  pressure  of  a  truss  is 
very  rarely  successful  and  is 
painful.  The  destruction  of 
the  spur  may  be  effected  by 
means  of  Mr.  Paul's  enterotome 
which  exerts  elastic  or  spring 
pressure  upon  the  spur,  which 
is  held  between  the  jaws  of  the  enterotome.  The  pressure  can  be 
gradually  increased  by  means  of  a  screw.  The  instrument  bites 
through  and  safely  destroys  most  of  the  spur  in  three  or  four  days. 

A  somewhat  similar  instrument  may  be  used  to  make  a  communica- 
tion through  the  base  of  the  spur  when  the  two  pieces  of  bowel  are  in 
contact  for  some  distance  from  the  apertures  ;  this  makes  the  subse- 
quent operation  for  closing  the  fistula  much  easier,  and  may  render  a 
resection  unnecessary  in  some  cases. 

Sir  W.  M.  Banks  (Clin.  Notes,  p.  94)  describes  the  following  simple 
and  ingenious  method.    Where  the  septum  or  spur  is  not  well  developed, 


U,  Upper.  L,  Lower  bowel.  I,  Fsecal  fistula. 
The  gut  is  not  bent  very  acutely  on  itself,  and 
there  is  no  spur.  The  opening  in  the  bowel  is 
usually  small  and  communicates  with  the  skin 
generally  by  a  sinus-like  track.  II.,  III.,  Artificial 
anus.  The  bowel  is  here  more  acutely  bent  and 
a  spur  is  present.  In  an  artificial  anus  the  open- 
ing communicates  more  directly  with  the  surface 
than  is  here  shown.  IV.,  Double  fascal  fistula. 
(Greig  Smith.) 


416 


OPERATIONS    ON    TJ1K    ABDOMEN. 


it  may  be  expected  to  succeed.  In  an  artificial  anus  in  the  groin,  after 
a  femoral  hernia,  he  introduced  a  thick  piece  of  india-rubber  tubing, 
pushing  one  end  up  the  ascending  and  the  other  down  the  descending 
bowel.  It  was  secured  by  silk  brought  out  of  the  opening.  It  was 
calculated  that  the  pressure  of  the  tubing  against  the  projecting  spur 
would  press  it  back,  and  allow  the  faeces  to  pass  round  the  corner 
without  passing  out  of  the  artificial  anus.  At  the  end  of  seven  weeks 
nearly  all  the  faeces  passed  by  the  rectum  instead  of  by  the  artificial 

anus,  this  being  reduced   to  a 
Fl°-  l6x-  sinus,  giving  vent  to  a  few  drops 

g    Ft  of  yellowish  fluid.     At  the  end 

"^  £:  s        °f  three  months  this  completely 

_M       closed.  This  is  a  tedious  process, 
f        which  is  only  suitable  for  a  few 
AD      cases.     In  fistulas  with  consider- 
able spur  formation  and  artificial 
"B       anus  in  the  small   intestine  it 
is  usually  imperative  to  operate 
without  delay  to  prevent  wast- 
ing;   and   resection  of  all   the 
diseased  part,  with  end  to  end 

(-rn union  of  the  intestine  above  and 

<JjzJ  -  ..... F  below,  is  the  most  certain  and 

-AD  satisfactory  way  of  attaining  this 

end,    although    other    methods 
— B  may  seem  safer  at  first  sight. 

Operation. 

Three  methods  will  be  men- 
tioned, i.  Here  the  peritonseal 
sac  is  not  opened.     The  mar- 

ethod  of  gins  of  the  fistula  having  been 

closing  fecal  fistula.  sufficiently  freed,  they  are  pared 

Fi,  Fistula  in  abdominal  wall  communicating  and  brought  together  with   cat- 

with  the  bowel.     G.  Granulations  lining  the  gut    and  silk   sutures   and    kept 

fecal   fistula.     S,  Skin.     M,  Muscular   layer,  apposed     {vide    Figs.     l6l     and 

F,  Sub-peritonaeal  tissue.     AD,  Adhesions  be-  162).  This        method        can 

tween  bowel  and  peritoneum  surrounding  the  only  be   suitable   to   small  facal 

fistula,    b,  Bowel.  fistulas  where   the    exposure   of 

The  broken  hue  in  the  upper  diagram  shows  „,  1  •    ,    -a-    „       j 

iU    .    .  .  ,  ..    __f *,        °.    ..       .  mucous  membrane  is  trifling  and 

the  incisions  around  the  fistula  and  in  the  sub-  .  ° 

peritoneal  areolar  tissue.     The  lower  diagram     n°   sPur  1S   P^sent.      It  usually 

shows  the  operation  completed  and  the  sutures     fails  u*om  tne  separation  of  the 

placed.    (Greig  Smith.)  edges  of  the  fistula  not  being  free 

enough,  owing  to  the  operator's 

fear  of  opening  the  peritonsealsac,  thus  causing  tension  on  the  sutures 

(vide  p.  415). 

The  late  Mr.  Greig  Smith  (Abdom.  Surg.,  p.  728)  spoke  highly  of 

the    following  operation,  which  may  be  used  both  for  cases  of  faecal 

fistula  and  artificial  anus.     In  applying  the  method,  however,  to  cases 

of  artificial  anus,  the  spur  must  be  first  diminished  and  the  lower  part 

of  the  bowel   dilated  to  some   extent.     In  order  to  accomplish  this, 

Mi-. Greig  Smith  advises  the  introduction  of  an  india-rubber  tube,  after 

Banks'  plan,  for  some  days  before  the  operation  is  performed.     A  brisk 


CLOSUIIK    OF    F.FCAL    FISTULA.    FTC. 


417 


purge  should  be  given  early  on  the  preceding  day  to  empty  the  intestines 
above  the  fistula,  and  the  bowel  below  should  be  cleared  of  scybala  by 
means  of  an  injection  of  soap  and  water  either  by  the  anus  or  through 
the   artificial  anus  if  practicable.     No  food  should  be  given  by  the 

mouth  for  twelve  hours  before  the  operation,  and  only  small  quantities 
of  fluid  for  several  days  after  it. 

Am  granulations  having  been  scraped  away  and  the  aperture  in  the 
bowel  plugged  by  a  sponge,  two  incisions  are  made,  one  above  and  one 
below  the  fistula,  and  joined  by  curved  incisions  which  include  the 
fistula.  The  extra-peritonseal  fatty  tissue  having  been  reached,  the 
parietal  peritonaeum  is  separated  from  the  abdominal  wall  all  round 
the  fistula  for  at  least  two  inches.  This  step  will  be  best  carried  out 
by  commencing  the  separation  at  the  extremities  of  the  incisions  which 
are  most   remote   from  the  fistula,  and  working  towards  the  latter. 

Fig.  162. 


Part  of  bowel  to  toe  removed. 

Excision  of  fecal  fistula  and  enteroplasty. 

A,  All  the  inflamed  tissues  around  the  opening  are  removed,  an  elliptical  or 
oval  incision  being  made  along  the  intestine.  B,  The  longitudinal  wound  is 
retracted  and  converted  into  a  transverse  one.  The  deep  stitch  which  pierces  all 
the  coats  is  being  inserted.     C,  Inversion  by  means  of  Cushing's  suture. 


The  bowel  with  the  loosened  peritonaeum  can  now  be  lifted  out  through 
the  incision  in  the  parietes.  If  there  is  any  difficulty  in  doing  this,  a 
little  more  detachment  of  peritonaeum  will  make  it  easy.  The  fistulous 
track  is  now  cut  away  down  to  the  level  of  the  bowel,  and  the  opening 
in  the  latter  closed  by  one  or  more  rows  of  Lembert's  sutures  inverting 
the  rawed  edges  (Fig.  161).  The  line  of  suture  must  be  transverse  to 
the  axis  of  the  bowel,  so  that  the  lumen  of  the  latter  may  not  be 
narrowed.  This  is  especially  important  when  the  opening  is  a  large 
one  (vide  Fig.  162).  The  intestine  and  peritonaeum  are  now  replaced 
and  the  parietal  incision  closed,  with  the  exception  of  a  small  opening 
through  which  a  drain  is  passed  down  to  the  sutured  gut.  This 
method  may  fail  on  account  of  want  of  removal  of  unhealthy  tissues  and 
the  absence  of  the  normal  peritonseal  covering  of  the  bowel.  The 
subperitoneal  fat  and  the  external  surface  of  the  parietal  peritonaeum 
are  very  poor  substitutes,  which  do  not  unite  nearly  so  readily  and 
securely  as  the  visceral  peritonaeum.  Narrowing  of  the  lumen  either 
s. — vol.  11.  27 


418  OPERATIONS   ON   THE   ABDOMEN. 

from  kinking,  pre-existing  spur,  or  improper  inversion,  may  also  defeat 
the  object  of  the  operation. 

ii.  and  iii.  Here  the  peritonseal  sac  is  opened. 

ii.  Closure  of  the  opening  without  complete  resection  of  the 
bowel. — The  preliminary  steps  as  to  diet  and  treatment  of  the  ecze- 
matous  skin  given  below  (p.  419)  should  be  carefully  attended  to.  The 
following  account  is  taken  from  the  report  of  a  patient  under  my  care 
in  Guy's  Hospital  in  August,  1895  : — 

At  an  operation  for  acute  intestinal  obstruction  due  to  bands,  a  gangrenous  patch 
had  been  found  in  the  ileum,  and  the  intestine  had  been  drained  through  ;i  Paul's  glass 
tube.  This  the  patient  pulled  out,  and  an  artificial  anus  resulted.  The  gut  was  plugged 
with  small  sponges  tied  on  silk  and  pushed  about  two  inches  above  and  below  the 
opening.  Two  curved  incisions  were  then  made  so  as  to  include  an  oval  three  inches 
and  a  half  long  and  an  inch  and  a  half  wide.  In  the  centre  of  this  lay  the  opening 
surrounded  by  the  usual  eczematous  margin,  most  of  which  was  enclosed  by  the  above 
incisions.  The  incisions  passed  through  the  rectus  on  each  side.  After  the  posterior 
layers  of  the  sheath  had  been  reached  the  incisions  were  very  cautiously  deepened 
until  the  peritonaeum  was  reached.  In  opening  this  an  exploring  finger  was  introduced 
through  each  lateral  cut  so  as  to  make  certain  that  no  coils  of  intestine  were  adherent 
beneath.  The  finger  being  used  as  a  director,  the  pcritonamin  was  cut  through  along 
the  lateral  incisions  in  their  whole  extent.  An  oval  island  of  the  tissue  forming  the 
abdominal  wall  was  now  set  free,  and  could  be  drawn  forward  with  the  bowel  adherent 
to  it  below,  and  showing  the  sponges  which  had  been  introduced  as  plugs  bulging  out 
its  coats.  The  bowel  in  which  lay  the  artificial  anus  was  now  separated  from  adjacent 
coils,  and  the  adhesions  which  bound  it  to  the  parietes,  partly  with  a  steel  director, 
partly  with  blunt-pointed  scissors,  used  at  one  time  closed  and  at  another  open. 
Sponges  and  iodoform  tampons  had  previously  been  packed  around  so  as  to  soak  up 
any  blood.  When  the  artificial  anus  had  been  separated  from  all  adhesions  it  was 
found  to  be  about  two  inches  and  a  half  long.  Its  edges  were  pared,  and  the  plugging 
sponges  having  been  removed,  the  opening  was  closed  with  a  double  silk  suture — first  a 
continuous  one  taking  up  all  the  coats,  and  then  a  row  of  Lembert's  securing  sufficient 
inversion.  These  were  carried  well  beyond  the  actual  limits  of  the  opening  (Fig.  99^ 
P-  353)-  A  little  iodoform  having  been  rubbed  in  along  the  line  of  suture,  the  intestine 
was  returned.  A  few  tags  of  omentum  which  were  adherent  to  the  abdominal  wall  in 
the  vicinity  of  the  wound  were  detached  and  tied.  When  the  intestine  was  returned 
the  interior  of  the  abdomen  was  quite  free  from  all  blood  or  other  discharges.  The 
edges  of  the  wound  weir  then  brought  together' .as  Ear  as  possible,  but  this  was  only 
feasible  above  and  below.  In  the  centre  was  a  lozenge-shaped  gap,  measuring  two 
inches  and  a  half  long  by  an  inch  wide,  at  the  bottom  of  which  lay  the  sutured 
intestine.  The  gap  was  lightly  plugged  with  iodoform  gauze  wrung  out  of  carbolic 
acid  lotion  (1  in  20).  The  patient  made  a  good  recovery,  the  only  drawback  being  his 
weak  condition,  due  to  his  having  been  fed  so  long  (seventy-two  hours,  including  the 
time  before  and  after  the  operation)  by  enemata.  Flatus  was  passed  on  the  second 
day,  and  the  bowels  acted  well  two  days  later.  A  fortnight  after  the  operation  I 
placed  numerous  large  grafts,  cut  from  the  shoulders  by  Thiersch's  method,  on  the 
granulating  surface  which  represented  the  remains  of  the  oval  gap  in  the  parietes. 
All  was  soundly  healed  within  live  weeks  of  the  operation.  I  lost  sight  of  the  patient 
for  five  months,  when  he  returned  with  a  ventral  hernia.  This  he  attributed  to  his 
having  had  scarlet  fever,  and  to  the  pad  of  the  belt  with  which  he  had  Keen  supplied 
having  shrunk  after  the  baking  to  which  it  and  his  clothing  had  been  submitted.  He 
was  otherwise  in  excellent  health,  without  any  flatulence  or  constipation,  enjoying  his 
food  and  able  to  go  about  helping  his  father,  who  is  a  costermonger.  He  was  supplied 
with  a  new  pud.  If  the  hernia  increase,  it  will.  1  think.be  now  possible  to  pare  the 
edges  of  the  old  oval  gap,  and  to  bring  them  together,  a  step  quite  impossible  at  the 
time  of  the  operation. 

For  a  consideration  of  the  methods  of  treating  ventral  hernia  by  overlapping  and  by 
the  introduction  of  wire  filigree,  the  reader  is  referred  to  p.  103,  Figs.  43  to  50. 


CLOSURE    OF  FJRCAL   FISTULA,    FTC.  419 

iii.  Closure  of  the  Artificial  Anus  with  complete  resection  of  the 
bowel. — If  this  step  be  needed  I  know  of  no  clearer  account  tlian  that 
of  Mr.  Makins  (St.  Thomas's  Hosp.  Rep.,  vol.  xiii.  p.  18).  The  skill 
with  which  the  operation  was  carried  out  was  only  equalled  by  the 
thoughtfulness  with  which  it  was  planned. 

The  patient  was  2r.  The  artificial  anus,  dating  to  a  hernia,  was  high  up  in  the 
small  intestine,  and  opened  about  ail  inch  and  a  half  above  the  centre  of  1'oupart's 
ligament.  Here,  at  the  bottom  of  a  small  pit,  the  mucous  membrane  of  the  intestine 
was  slightly  prolapsed.  The  gut  was  firmly  attached:  the  finger  only  passed  into  the 
upper  opening;  the  lower  could  not  be  found.  First,  the  usual  cczematous  condition 
was  very  much  improved  by  the  use  of  a  small  shield,  and  mopping  away  of  discharge 
with  absorbent  wool.  No  food  was  given  by  the  mouth  after  the  evening  of  the  second 
day  before  the  operation,  nutrient  enemata  being  given  every  four  hours.  During  the 
day  before,  the  upper  end  of  the  bowel  was  washed  out  with  injections  of  salicylic 
lotion.  As  bile-stained  fluid  was  escaping  from  the  fistula  an  hour  before  the  operation, 
this  washing  out  was  repeated.  Before  beginning  the  operation  a  bit  of  carbolised 
sponge  attached  to  string  was  passed  for  two  inches  into  the  upper  end  of  the  bowel. 
A  vertical  incision  of  two  inches  and  a  half  being  made  through  the  abdominal  wall, 
the  upper  end  of  the  intestine,  normal  in  size,  was  dissected  free  from  its  adhesions  ;  the 
lower  end,  lying  just  below  it,  was  contracted  to  the  size  of  a  pencil,  with  an  opening 
only  large  enough  to  admit  a  director.* 

The  two  ends  of  the  gut  being  now  provisionally  clamped  with  forceps  (Fig.  137), 
sheathed  in  tubing,  they  were  drawn  out,  and  a  number  of  sponges  attached  to  string 
packed  round  them.  The  sponge  was  then  drawn  from  the  upper  end  of  the  intestine 
and  about  an  inch  removed  from  the  upper  end  and  two  inches  and  a  half  from  the 
lower  one,  together  with  a  wedge  of  mesentery  four  inches  long  by  three-quarters  of  an 
inch  wide.f  The  cut  surfaces  then  nearly  corresponded.  The  bleeding  points  having  been 
tied  in  the  mesentery,  this  was  united  with  six  silk  sutures,  and  the  gut  then  sutured 
as  follows  : — A  first  row  of  twenty-five  very  fine  Chinese-twist  stitches  were  passed  with 
a  small  curved  needle  through  the  whole  thickness  of  the  gut,  about  one-tenth  of  an 
inch  from  its  free  margin,  commencing  at  the  mesenteric  border.  These  were  tied  in 
batches  of  five  at  a  time.  Then  a  second  row  of  Lembert's  sutures  (Figs.  99  and  353) 
,  were  passed  and  tied  in  the  same  manner.  During  the  stitching,  which  took  about 
three-quarters  of  an  hour,  the  gut  was  kept  moist  with  warm  salicylic  lotion.  After 
the  bowel  was  closed  and  returned,  it  was  found  impossible  to  close  the  whole  wound. 
As  this  could  only  be  brought  together  above  and  below,  the  granulations  were  shaved 
away  and  the  intestine  left  at  the  bottom  of  a  deep  pit.  Iodoform-gauze  and  pine- 
wood  dressings  were  applied.  The  patient  made  a  good  recovery.  Two  days  later  the 
intestine  could  be  seen  at  the  bottom  of  the  wound  covered  with  lymph  and  showing 
vermicular  movements.  The  bowels  acted  naturally  two  days  after  the  operation.  No 
fseces  came  by  the  wound,  but  twelve  sutures  were  thus  discharged. 

It  is  easier  and  much  better  to  use  continuous  sutures,  and  catgut 
is  better  than  silk  for  the  deep  suture  which  pieces  all  the  coats. 
Catgut,  being  absorbable,  leads  to  less  sloughing,  less  risk  of  leakage, 
and  earlier  healing  of  the  mucosa.  Silk  may  remain  partly  attached 
for  some  time,  and  thus  it  keeps  up  ulceration.  Resection  and  end  to 
end  union  are  fully  described  at  pp.  384,  393. 

In  certain  cases  the  methods  already  given  may  not  be  applicable 
or  suitable,  and  in  these  short  circuiting  or  exclusion  (vide  pp.  402,  414, 

*  Over  two  months  had  elapsed  since  the  formation  of  the  fistula,  and  one  month  since 
the  last  proper  action  of  the  bowels. 

t  It  is  simpler  not  to  excise  a  wedge  of  mesentery,  but  to  tie  it  in  sections  to  the  bowel, 
and  before  dividing  either  this  or  the  near  mesentery. 

27—2 


420  OPERATIONS  ON  THE  ABDOMEN. 

Figs.  155 — 159)  mil.v  be  safer,  although  they  are  less  satisfactory  than 
the  direct  treatment  of  the  fistula  as  a  rule. 

In  a  case  of  gangrenous  strangulated  caeca]  umbilical  hernia  in  a  very  stout  old  lad}', 
one  of  us  (R.  P.  Et.)  had  to  resect  the  caBcum  and  three  feel  of  the  ileum.  After  emptying 
the  intestine  as  we'll  as  possible,  end  to  end  union  of  the  equal  ends  of  the  ileum  and 
ascending  colon  was  adopted.  A  fist  ula  followed,  owing  partly  to  the  gangrenous  condition 
of  the  abdominal  wall.  A  month  later  it  was  clear  that  no  local  interference  was  likely 
to  he  successful  ;  therefore  a  gum  elastic  catheter  was  passed  into  the  ileum,  and  ileo- 
sigmoidostomy  performed  through  a  left  lateral  incision  well  away  from  the  fistula.  The 
catheter  was  very  useful  as  a  guide  to  the  lower  part  of  the  small  intestine  The  fistulous 
end  of  the  ileum  was  then  inverted.  The  patient  died  about  twelve  hours  later  from 
cardiac  failure. 

Another  case  of  anastomosisof  the  lower  part  of  the  ileum  to  the  transverse  colon,  with 
inversion  of  the  fistulous  ends  of  ileum  and  colon,  proved  more  successful.  This  operation 
was  undertaken  to  close  the  artificial  anus  left  after  an  extensive  resection  for  growth. 

Tuberculous  disease,  especially  of  the  ileo-caecal  region,  may  be  too 
extensive  for  resection  to  be  contemplated,  and  the  patient's  condition 
may  be  too  grave  to  allow  such  a  severe  operation  ;  unilateral  or 
bilateral  exclusion  may  then  be  resorted  to,  and  may  give  much,  if  not 
complete,  relief.*  Duodenal  fistula  may  be  treated  by  posterior  gastro- 
jejunostomy, with  occlusion  of  the  pylorus,  by  a  temporary  jejunostomy, 
or  by  inversion  or  resection,  which  may  be  a  very  difficult  and  severe 
operation  for  the  marasmic  subjects  of  this  high  fistula;  fistula? 
between  the  small  intestine  and  the  vagiua  may  be  treated  by  bilateral 
exclusion  in  some  cases. 

ENTEROPLASTY. 

This  term  has  been  given  to  an  operation  for  the  relief  (short  of 
resection)  of  strictures  of  the  intestine  believed  to  be  innocent.  It  is 
based  upon  a  similar  operation  which  has  been  successfully  performed 
upon  the  constricted  pylorus  and  the  first  part  of  the  duodenum 
following  upon  simple  ulceration  (vide  Fig.  162). 

Innocent  intestinal  strictures  are  very  rare,  hut  they  may  arise  from 
contraction  of  tuberculous  ulcers  of  the  small  or  large  intestine,  or 
they  may  follow  dysenteric  ulceration  of  the  latter.  Sargent  (Ann.  oj 
Surg.,  1904,  vol.  xxxix.  p.  733)  has  related  three  cases  of  stricture  of 
the  small  intestine  following  strangulated  hernia.  Mr.  Sargent  also 
presented  a  table  of  18  collected  cases,  including  his  own.  In  six  of 
these  there  were  two  strictures,  and  most  of  the  single  strictures  were 
extensive  and  not  annular.  In  six  no  operation  was  performed  ;  in  two 
enteroplasty  was  performed  successfully,  one  by  Mollard  and  Bernay 
and  the  other  by  Abbott. 

Primary  resection  was  successful  in  three  cases,  and  secondary 
resection  after  a  preliminary  enterostomy  succeeded  in  another  case 
(Alexis  Thomson).  Enterostomy  failed  to  save  three  late  cases. 
Lateral  anastomosis  was  successful  in  one  case.  One  patient  died  of 
peritonitis,  although  the  anastomosis  did  not  leak. 

The  late  Mr.  H.   W.   Allingham's  two  cases   of  enteroplasty   were 

*  Mr.  Houghton  {Lancet,  1902,  vol.  ii.  p.  1128)  showed  a  man,  before  the  Harveian 
Society,  in  whom  he  had  anastomosed  the  ileum  to  the  ascending  colon  for  tuberculous 
fistula  of  the  caecum.     No  fajcal  discharge  came  through  the  fistula,  which  remained  open. 


ENTEROPLASTY. 


421 


the  first  to  be  published  (Lancet,  vol.  i.  1894,  p.  1550).  One  such 
Btricture  occurred  in  a  woman,  aged  48,  at  the  junction  of  the  ileum 
and  jejunum,  the  other  in  the  sigmoid  of  a  patient  aged  73.  It  is 
simply  stated  that  "  the  stricture  was  innocent,"  and  "  not  malignant." 
As  the  cases  were  published  within  two  months  of  the  operation,  the 
nature  of  the  stricture  must  remain  very  doubtful.  The  age  of  the 
last  patient,  the  site  of  the  stricture  in  the  sigmoid,  and  the  absence  of 
any  history  of  dysentery  are  very  suspicious,  although  there  are  several 
specimens  of  innocent  stricture  of  the  colon  in  the  Guy's  Hospital 
museum,  careful  microscopical  examination  having  failed  to  discover 
any  sign  of  carcinoma.  Some  of  these  are  undoubtedly  tuberculous. 
In  each  case  the  stricture  was  divided  in  the  following  way :  The 
bowel  having  been  drawn  out,  shut  off  with  sponges,  and  clamps 
applied  above  and  below,  the  bowel  and  stricture  were  divided  longi- 
tudinally for  three  inches  on  the  side  of  the  gut  opposite  to  the 
mesenteric  attachment.  Each  lip  of  the  longitudinal  incision  was  then 
caught  hold  of  at  about  its  centre,  pulled  apart  so  that  at  first  it  gave 
the  appearance  of  a  diamond-shaped  opening,  and  then,  by  further 
pulling  in  the  same  direction,  the  original  longitudinal  incision  was 
made  into  one  transverse  to  the  long  axis  of  the  bowel.  The  opening 
was  then  closed,  first  with  a  continuous  suture  uniting  the  mucous 
membrane,  and  then  by  Lembert's  interrupted  sutures.  It  is  better 
to  make  the  deep  stitch  pierce  all  the  coats,  and  thus  to  secure  a 
firmer  hold,  as  well  as  avoid  the  risk  of  eversion  of  the  mucous  membrane. 
In  any  case  of  stricture  of  the  large  intestine,  unless  there  is  some  very 
strong  evidence  in  favour  of  its  innocency,  it  is  safer  to  excise  it,  for 
the  chances  in  favour  of  the  presence  of  carcinoma  are  enormous. 

In  many  cases  of  stricture  of  the  small  intestine,  enteroplasty, 
however  ideal  it  may  seem,  may  not  be  suitable  on  account  of  the 
existence  of  multiple  strictures,  or  extensive  ones.  Moreover,  active 
ulceration  at  the  site  of  the  stricture  is  very  common,  and  this  may 
persist  and  lead  to  re-formation  of  the  stricture.  It  should  also  be 
born  in  mind  that  carcinoma  does  occasionally  occur  in  the  small 
intestine,  and  even  in  comparatively  young  people.  In  other  cases  of 
acute  following  upon  chronic  obstruction,  the  bowel  may  be  so  damaged, 
that  enteroplasty  is  out  of  the  question,  and  resection  or  enterostomy 
has  to  be  adopted. 

Sargent  draws  attention  to  the  risk  of  spur  formation  at  the  mesenteric 
attachment  in  performing  enteroplasty.  In  some  cases  lateral  anasto- 
mosis undoubtedly  offers  a  better  prospect,  although  for  a  narrow 
healed  annular  stricture  of  the  small  intestine  enteroplasty  is  the 
simplest  and  safest  operation. 


CHAPTER  VI. 

OPERATIVE  INTERFERENCE  IN  GUNSHOT 

AND  OTHER  INJURIES  OF  THE  ABDOMEN. 

RUPTURE  OF  THE  INTESTINE. 

GUNSHOT    AND    OTHER    INJURIES. 

We  owe  the  great  advances  lately  made  here,  in  the  first  place,  to 
antiseptic  surgery,  and,  in  the  second,  to  the  zeal  with  which  American 
surgeons  have  taken  up  the  matter  and  made  known  their  results, 
unsuccessful  as  well  as  successful. 

The  South  African  and  Japanese  wars  have  greatly  altered  our  views 
upon  military  abdominal  surgery,  hoth  by  increasing  our  knowledge  of 
the  ('fleets  of  modern  projectiles,  and  also  by  making  us  realise  the 
dreadful  difficulties  which  make  it  impracticable  to  treat  military  wounds 
radically  and  without  dela}\  In  civil  life  it  is  quite  different,  for  it  is 
generally  possible  to  operate  under  good  conditions  within  a  tew  hours 
of  the  catastrophe. 

i.  Examination  of  the  Wound  with  regard  to  Penetration. —  Blacken- 
ing of  the  wound  and  the  clothes  with  powder  suggests  a  close  shot  and 
probable  penetration. 

A.  13.  Johnson's  experiments  (Ann.  of  Surg.,  vol.  xxxix.  1904,  p.  798) 
have  shown  that  the  powder  marks  which  are  produced  upon  the  skin 
and  clothes  b}r  smokeless  powder  are  much  less  distinct  and  definite 
than  those  caused  by  black  powder.  With  Mauser  and  Colt  pistols 
loaded  with  smokeless  powder,  and  fired  at  a  distance  of  more  than  one 
foot,  no  marks  are  formed  upon  the  naked  skin,  and  only  very  faint  ones 
at  a  distance  of  three  inches.  Edges  clean  cut  and  equally  stained 
show  that  the  bullet  has  struck  perpendicularly.  Unequal  staining 
and  raggedness  suggest  obliquity  of  impact;  and  the  less  perpendicular 
this  is,  the  less  the  probability  of  penetration.  If  there  exists  a  con- 
tinuous track  of  tenderness,  especially  if  accompanied  with  slight 
redness,  from  the  wound  for  some  distance  over  the  abdominal  surface, 
it  is  fair  to  infer  that  the  missile  has  wormed  itself  between  the  layers 
without  penetration  (Parkes). 

Symptoms  indicating  Penetration  and  Injury  of  the  Viscera. 

(i)  There  may  be  none  at  all  at  first,  but  symptoms  of  hemorrhage  or 
of  early  peritonitis  may  soon  appear.  Dr.  Malcolm  Harris*  has  very 
properly  laid  great  stress  upon  this  fact,  and  rightly  advocates  early 
exploration  without  waiting  for  signs  of  these  grave  conditions  to 
develop.     In  civil  practice  this  is  generally  possible,    but  it  is  nearly 

*  Ann.  of  Surg.,  1904,  vol.  xxxix.,  p.  356. 


GUNSHOT   AND   OTHER   INJURIES. 


423 


always  impracticable  and  very  dangerous  under  tho  circumstances 
of  war.  (ii)  Escape  of  fasces,  bile,  or  urine  from  the  wound  is,  of 
course,  diagnostic  of  penetration,  but  rare,  (iii)  Repeated  hsemate- 
ntesis  indicates  penetration  and  injury  to  the  stomach  or  small  intestine 
high  up.  It  may,  however,  be  due  to  contusion,  (iv)  Profuse  hemor- 
rhage per  anum  points  to  penetration  and  injury  of  intestine,  but  is 
seldom  seen  sufficiently  early  to  be  of  value,  (v)  Hematuria  indicates 
injury  of  some  part  of  the  urinary  tract,  (vi)  Escape  of  blood  from  the 
wound,  if  too  profuse  to  be  accounted  for  by  a  wound  of  a  vessel  in  the 
abdominal  wall,  points  to  penetration  and  visceral  injury,  (vii)  Shock. 
This  does  not  go  for  much  unless  haemorrhage  is  clearly  present  also, 
owing  to  the  great  difference  in  individual  peculiarities. 

Dr.  Crile  has  shown  that  shock  varies  very  much  with  the  situation  of 
the  internal  injuries,  those  involving  the  diaphragm  or  the  stomach 
being  attended  with  far  more  depression  than  those  involving  the  pelvic 
or  lower  abdominal  viscera. 

(viii)  Pain,  tenderness,  and  rigidity  are  the  earliest  and  the  most 
reliable  signs  of  peritonaeal  irritation,  and  when  all  three  are  associated 
together,  it  is  almost  certain  that  perforation  of  one  of  the  viscera  has 
occurred. 

Vomiting  is  an  uncertain  symptom,  and  its  absence  is  therefore  not 
to  be  relied  upon.  Rapidly  vanishing  liver  dulness  with  the  abdomen 
still  flat  may  indicate  penetration  and  the  escape  of  gas  from  the 
stomach  or  intestine,  but,  if  delayed,  the  tympanites  may  be  due  to 
paralysis  of  the  intestines  from  shock  or  peritonitis. 

(ix)  Circumscribed  dulness,  and  rarely  bulging  near  the  wound  or 
into  the  rectum  or  vagina,  ma}r  indicate  bleeding  from  a  large  vessel 
and  accumulation  of  blood  in  the  peritonaeum,  and  probable  visceral 
injury,  but,  to  be  of  value,  these  signs  must  come  on  within  a  few  hours. 
Free  fluid  may  be  indicated  by  shifting  dulness  in  the  flanks,  but  blood 
generally  clots,  and  the  dulness  may  not  move  upon  changing  the 
position  of  the  patient.  The  signs  of  severe  internal  haemorrhage  are 
well  known,  but  stress  may  be  laid  upon  the  following  :  rapid  small 
pulse,  shallow  sighing  respiration,  restlessness,  pallor  and  shrinking 
of  the  features,  dilated  pupils,  cold  clammy  skin,  tinnitus  aurium, 
dimness  of  vision,  and  delirium.  The  more  gradual  the  haemorrhage, 
the  less  will  these  signs  and  symptoms  be  noticed  until  a  sudden 
collapse  occurs.  A  diminishing  count  of  red  corpuscles  is  a  sign  of 
bleeding  that  may  help  in  some  cases.  It  is  simply  waste  of  time  to 
endeavour  to  demonstrate  the  existence  of  perforation  of  the  intestines 
b}r  rectal  insufflation  of  gas  or  air,  and  the  same  may  be  said  of  Connell's 
method  of  injection  of  saline  solution  into  the  peritonaeal  cavity  through 
the  wound,  and  the  examination  of  some  of  the  fluid  later  for 
faeces,  &c.  The  symptoms  of  peritonitis  come  on  sooner  or  later,  and 
when  they  are  well  developed,  an  operation  offers  but  a  forlorn  hope. 

Paralysis  of  any  part  below  the  level  of  the  wound  is  a  most  grave 
complication,  indicating,  as  it  does,  injury  to  cord  or  nerves,  as  well 
as,  probably,  to  viscera. 

Other  points  will  be  the  size  of  the  bullet  and  the  amount  of 
fulminative  or  powder,  the  distance  and  direction  in  which  the  firearm 
was  held.  A  single  opening  gives,  per  se,  a  faint  hope  that  there  is  no 
penetration. 


424  OPERATIONS   ON   THE   ABDOMEN. 

In  cases  of  doubl  as  to  penetration,  the  wound  will  be  first  enlarged, 
and  the  line  of  damage  to  the  tissues  carefully  followed  up,  any  explor- 
ing instruments  being  kept  Btrictly  aseptic. 

Probable  Amount  oj  Damage. — Dr.  Parkes  (Ann.  of Surg.,  November, 

1887)  gives  the  following  suggestions: — "An  antero-posterior  shot 
below  the  level  of  the  umbilicus  and  well  towards  the  lateral  Burfaces 
of  the  body  will  he  very  likely  to  miss  the  small  intestines  entirely, 
and  expend  its  damage  on  the  large  bowel.  The  same  kind  of  wound 
high  in  the  lateral  surfaces  may  pass  into  or  through  the  liver  without 
injuring  the  intestines,  or  the  spleen  alone  if  the  entrance  is  on  the 
left  side. 

"If  the  wound  is  so  situated  that  the  bullet  enters  the  abdomen 
through  the  diaphragm,  adding  injury  of  abdominal  viscera  to  that  of 
the  contents  of  the  chest,  the  surgeon's  help  will  probably  be  of  little 
use.  A  wound  of  entrance  and  exit,  or  an  entrance  wound  alone, 
showing  passage  of  the  ball  from  side  to  side  through  the  abdomen, 
means  the  worst  of  injuries,  and  suggests  the  need  of  the  greatest 
care  in  staying  of  hemorrhage,  repair  of  intestines,  and  toilet  of  the 
contents. 

"  Antero-posterior  perforation,  if  complete,  can  only  fail  to  wound 
the  small  intestines  when  situated  well  on  the  outskirts  of  the  surface 
of  the  abdomen ;  seemingly  there  can  be  no  exception  to  this  proposi- 
tion, save  in  those  extremely  rare  instances  in  which  the  perforating 
body  traverses  the  cavity  without  injuring  the  contents.* 

"  Penetration  through  the  posterior  walls  of  the  cavity,  if  complete, 
with  likelihood  of  laceration  of  important  fixed  organs,  argues  an  injury 
of  the  most  severe  character,  one  in  which  the  surgeon's  aid  will  be  of 
no  avail  in  the  majority  of  cases.  The  exceptions  in  which  the  severity 
will  not  prove  insurmountable  will  be  transit  through  the  space 
between  the  lower  end  of  the  kidney  and  the  crest  of  the  ilium,  and  in 
wounds  occupying  the  outskirts  of  the  entire  posterior  surface.  .  .  . 
Many  instances  are  recorded  of  recovery  from  posterior  penetration 
of  the  large  and  fixed  viscera  of  the  abdomen  without  any  surgical 
operation." 

Mr.  Makins  {Surgical  Experiences  in  South  Africa,  1901,  chap,  xi.) 
agrees  with  most  of  these  conclusions,  and  adds  that  wounds  passing 
directly  backwards  from  the  iliac  regions  were  very  unfavourable  on 
account  of  the  liability  of  injury  of  the  iliac  vessels.  Vertical  wounds 
implicating  the  diaphragm  and  abdomen  or  abdomen  and  pelvis  were 
not  very  unfavourable.  Penetrations  from  the  buttocks  to  below  the 
umbilicus  often  did  well,  and  perforations  of  the  pelvic  viscera  were 
comparatively  favourable. 

"Explosive"  wounds  due  to  large  leaden  bullets  of  the  Mai tini-Henry 
or  "  Express  "  type  were  very  serious.  Watson  Cheyne  (Brit.  Med. 
Journ.,  May  12,  1900)  recorded  a  remarkable  case  in  which  a  spent 
bullet  ruptured  the  intestine  in  two  places  without  piercing  the  skin 
of  the  abdomen. 


*   With  modern  bullets  it  i-  by  no  means  uncommon  for  the  projectile  to  traverse  the 
peritoneal  cavity  without  leading  to  any  symptoms  or  signs  of  perforation  of  the  hollow 


(ilTNSHOT   AND    OTHER    INJUR  IKS.  425 

Question  of  the  Advisability  of  Operative  Interference. — A.  In 
Civil  Practice. — If  a  capable  and  experienced  surgeon  is  available 
an  exploration  should  be  undertaken  at  the  earliest  possible  moment 
in  order  to  anticipate  the  onset  of  peritonitis,  and  to  prevent  any 
avoidable  increase  of  internal  haemorrhage. 

For  these  reasons  it  is  not  even  wise  to  wait  and  hope  that  any 
shock  which  may  be  present  may  pass  off;  but  it  is  better  to  combat 
this  by  infusion  and  injection  of  ergot,  adrenalin,  or  strychnine  during 
the  operation,  after  the  bleeding  points  have  been  secured. 

When  grave  doubt  exists  as  to  the  existence  of  penetration,  it  is 
imperative  to  settle  the  question  by  exploration,  for  it  is  far  better  for 
a  careful  and  aseptic  surgeon  to  perform  an  occasional  blank  exploration 
than  to  neglect  an  early  perforation  of  the  bowel  until  symptoms  of 
peritonitis  supervene,  and  the  chance  of  a  successful  operation  has 
greatly  diminished.  l>y  operating  early  astonishing  recoveries  occur 
from  most  extensive  visceral  injuries  and  peritonaeal  extravasations. 

Dr.  Harris  (loc.  cit.)  records  sixteen  consecutive  operations  for  pene- 
trating gunshot  and  other  wounds  of  the  abdomen,  with  thirteen 
recoveries.  In  all  but  one  of  these  cases  the  operation  was  performed 
within  three  hours  of  the  accident.  One  patient  died  upon  the  operating 
table  from  profuse  haemorrhage,  the  source  of  which  could  not  be 
discovered  and  controlled  in  time  to  save  the  man's  life.  Another 
man  suffered  severely  from  shock  and  injuries  of  both  lungs,  as  well 
as  haemorrhage  into  the  spinal  canal.  The  remaining  death  was 
due  to  peritonitis,  although  the  operation  was  performed  within  an 
hour  of  the  shooting  ;  the  eight  perforations  of  the  small  intestine, 
sigmoid,  and  transverse  colon  had  been  well  closed.  In  one  case,  there 
was  no  visceral  injury,  but  only  haemorrhage  from  a  large  artery  in  the 
great  omentum  just  below  the  stomach.  There  were  two  blank  explora- 
tions, but  the  bullet  was  found  and  removed  in  each  case,  and  both 
patients  recovered.  "  But,  excluding  these  cases,  we  still  have  11 
cases  with  perforation  and  haemorrhage  in  which  operation  was  absolutely 
indicated,  with  but  one  death.  Instead  of  the  usual  mortality  rate  of 
60  per  cent,  to  70  per  cent,  following  operation,  we  have  over  go  per 
cent,  recoveries."  Dr.  Harris  gives  two  reasons  for  his  good  results: 
the  adoption  of  immediate  operation  and  drainage  when  the  gastro- 
intestinal tract  has  been  opened. 

Fenner  {Ann.  of  Surg.,  January,  1902)  records  six  successful  opera- 
tions for  penetrating  wounds  of  the  abdomen.  One  patient  recovered 
although  there  were  multiple  perforations  of  the  ileum ;  another  got 
well  in  spite  of  wounds  of  the  diaphragm,  stomach,  liver,  and  pleura, 
with  pneumothorax  and  pneumonia  later. 

Dr.  Fenner  also  published  notes  of  152  operations  which  were  per- 
formed in  hospital  practice  between  1892  and  1901.  There  were  87 
deaths,  a  mortality  of  37*2  per  cent. ;  113  of  the  operations  were  for 
gunshot  injuries,  with  78  deaths,  a  mortality  of  69  per  cent.  The 
remaining  39  were  for  stab  wounds,  with  9  deaths,  a  mortality  of  only 
23  per  cent. 

Because  it  is  impossible  to  tell  from  the  general  symptoms  and 
external  appearances  whether  visceral  injuries  have  occurred,  Fenner 
advocates  early  exploration,  and  a  systematic  examination  of  all  the 
intestine  and  other  abdominal  viscera. 


426  OPERATIONS   ON    THE    ABDOMEN 

Miihr  (J /■<•//.  fa  r  Klin.  Chir.y  vol.  lxiii.,  Nos.  land  2)  records  forty-eight  operations  whiofa 
were  performed  within  Eourand  five  In  mis  of  the  shooting.  The  mortality  in  these  cases  was 
Mik  1.1-5  I"'1'  cent.,  which  he  estimates  to  !"•  Less  than  a  third  of  the  ordinary  death-rate. 

II.  W.  Johnson,  of  Haiti re  (  Vew    Tort,   Hied.  Journ.,   March  26,1904)  records  five 

successful  operations  for  penetrating  wounds  of  the  abdomen.  One  patienl  bad  seventeen 
perioral  ions  of  the  small  intestine,  and  eleven  rents  of  the  mesentery  ;  fecal  extra vasat  Ion 
had  occurred  in  enormous  quantities,  bu1  the  patient  was  discharged  well  on  the  1  wenty-firsl 
day.  Amvx  {Med.  Bee.,  Sept.  20,  1902)  records  a  recovery  after  nineteen  perforations  of  the 
small  intestine,  caecum,  colon,  and  sigmoid  flexure  ami  four  lacerations  of  the  mesenl 
Resection  of  eleven  inches  of  small  intestine  was  necessary,  ami  an  anastomosis  made 
with  a  Murphy  button.  The  remaining  seven  perforations  were  sutured.  Operation  com- 
menced two  hours  after  the  shout  im_r  and  lasted  three  hours.  A  gluteal  abscess  had  to  be 
opened  later,  and  the  bullet  was  found  and  removed. 

Brown  (New  York.  Med.  amd  Surg.  Journ.,  April  16, 1904)  publishes  nine  recent  opera- 
tions, with  three  deaths,  one  from  shock  and  two  from  peritonitis  which  existed  at  the  time 
of  the  operations. 

Occasionally  a  late  operation  may  succeed,  although  recovery  is  rarely 
to  be  expected  after  twenty-four  hours.  Pettus  {New  York  Med.  Journ., 
Aug.  30,  1902)  records  the  case  of  a  patient  who  recovered  although 
the  operation  was  delayed  for  thirty-one  hours,  and  seven  perforations 
of  the  small  intestine  had  to  be  sutured.  Irrigation  and  drainage  were 
employed. 

Prof.  Nancrede  (Ann.  of  Surg.,  June,  1887,  p.  474)  thus  states  the 
advantages  of  an  operation  : — "  We  can  either  forestall  septic  peri- 
tonitis or  reduce  its  dangers  to  a  minimum;  we  can  prevent  saprsemia 
— a  common  cause  of  death,  as  I  believe.  .  .  .  Should  peritonitis  have 
set  in,  we  can  afford  sufficient  drainage  for  the  effusions,  which 
may  in  themselves  be  already  poisonous,  or,  as  we  have  shown,  will 
assuredly  become  the  chief  cause  of  danger;  we  can  substitute  for 
adhesions  of  doubtful  permanency  certain  methods  which  secure  the 
escape  of  the  injured  portions  of  gut  into  the  lumen  of  the  bowel ; 
we  can  prevent  the  fatal  results  which  must  follow  the  casting  off  of  a 
decomposing  slough  of  a  wounded  portion  of  omentum  or  mesentery 
into  the  general  peritonsenl  cavity  ;  we  can  arrest  haemorrhage,  which 
from  its  amount  will  prove  fatal,  or  from  decomposition  will  equally 
produce  lethal  results;  we  can  restore  the  continuity  of  the  gut,  if  it 
be  nearly  or  completely  severed,  the  former  condition  being  not 
uncommon  ;  we  can  avoid  the  risk  of  faecal  fistula  ;  .  .  .  and  we  can 
remove  a  hopelessly  damaged  kidney  or  spleen,  and  repair  a  wounded 
pancreas  or  liver."* 

With  regard  to  the  presence  of  peritonitis,  the  late  Mr.  Greig  Smith 
wrote  (loc.  supra  cit.,  p.  704)  :  "  Undoubted  and  severe  peritonitis 
existing  on  the  second  and  third  day,  is  by  most  authorities  recognised 
as  a  contra-indication.  In  such  cases  it  isimprobable  that  the  sites  of 
perforation  could  be  found  ;  and,  if  they  were,  that  they  could  be  dealt 
with  without  the  production  of  excessive  traumatism.  There  is  little 
use  in  cleansing  the  cavity  if  it  is  to  he  at  once  refilled,  ami  there  is 
little  use  in  looking  for  the  perforations  if  they  can  neither  be  closed 

*  It  is  rare  to  have  to  remove  either  the  kidney  or  the  spleen  in  modern  military  prac- 
tice, for  the  wounds  which  the  Mauser  and  similar  1  bullets  inflict  are  usually  quite  small. 
so  that  packing  or  suture  generally  serve  to  arrest  the  hemorrhage.  Similar  perforations 
of  the  liver  also  recover  spontaneously  in  many  cases.  With  sporting  bullets  and  shell 
wounds  things  are  very  different. 


GUNSHOT   AND   OTHER   INJURIES.  427 

nor  fixed  in  the  wound,  while  there  is  positive  danger  in  adding  to  (he 
risk  from  traumatism.  In  such  cases  the  most  that  can  be  done  is  to 
make  a  small  parietal  opening  with  the  help  of  local  anaesthesia,  and 

permit  the  discharge  of  the  noxious  fluids,  giving  the  patient  the 
benefit  of  the  remote  chance  of  spontaneous  cure  with  intestinal 
fistula." 

It  is  no  doubt  still  true  that  when  well-marked  symptoms  of  peritonitis 
have  appeared  surgical  intervention  is  almost  hopeless,  but  occasionally 
marvellous  recoveries  occur,  and  therefore  it  is  well  to  let  the  pus  out 
and  drain  in  every  case.  In  late  cases,  this  is  all  that  can  be  done 
without  doing  more  harm  than  good  in  the  desperate  condition  of  the 
patient.  The  lesions  produced  by  the  rude  implements  of  civil  life 
are  far  more  serious  and  extensive  than  those  due  to  the  modern 
military  bullet  of  small  calibre  and  high  velocity. 

B.  In  Military  Practice. — Our  views  upon  military  surgery  have 
been  greatly  modified  by  the  knowledge  derived  from  the  effects  of 
modern  projectiles  used  in  the  South  African  and  Japanese  wars,  and 
also  from  a  fuller  appreciation  of  the  difficulties  which  make  it  impos- 
sible to  treat  military  wounds  in  the  same  radical  way  that  is  generally 
possible  and  imperative  in  civil  life. 

Up  to  the  time  of  the  Boer  war  these  wounds  were  considered  to  be 
almost  necessarily  fatal  if  an  abdominal  section  were  not  immediately 
performed,  death  resulting  usually  from  haemorrhage  or  from  septic 
peritonitis. 

The  results  of  abdominal  wounds  made  by  the  Mauser  bullet  have, 
however,  produced  practically  a  revolution  as  regards  the  question 
now  under  consideration.  For  it  has  been  found  that  these  injuries, 
when  not  immediately  fatal,  have  been  attended  with  far  better  results 
under  expectant  than  operative  treatment,  because  of  the  great 
dangers  of  operating  under  the  very  unfavourable  conditions  which  are 
inseparable  from  war.  Mr.  Makins  (loc.  cit.)  divides  these  difficulties 
into  administrative  and  surgical. 

(a)  Administrative. — The  surgical  staff  of  a  field  hospital  is  better 
employed  in  attending  to  more  hopeful  cases ;  and  the  number  of 
assistants  required  at  a  laparotomy  cannot  be  spared  at  the  time  when 
that  operation  would  be  hopeful. 

(b)  Surgical. — The  diagnosis  of  a  perforating  lesion  is  difficult,  an 
exploration  being  the  only  sure  way.  The  difficulties  of  temperature,  of 
wind  and  dust,  and  of  getting  a  sufficient  amount  of  water  are  very 
great.  Moreover,  it  is  almost  impossible  to  provide  the  rest  and 
attention  which  are  required  in  the  after-treatment  of  these  cases. 

It  is  not  surprising,  therefore,  that  early  explorations  are  not 
attended  with  great  success,  and  that  surgeons  have  wisely  limited 
their  number  to  a  minimum. 

Major  Mallins  (Report  on  Surgical  Cases  noted  in  the  South  African 
War,  Surgeon-General  Stevenson,  1905)  records  207  cases  of  penetrating 
wounds  of  the  abdomen,  of  which  143  recovered ;  in  40  per  cent,  of 
these  it  was  impossible  to  diagnose  a  visceral  lesion,  as  symptoms  were 
absent.  Twenty-six  laparotomies  were  performed,  with  only  eight 
recoveries.  Most  of  the  operations  were  performed  after  the  develop- 
ment of  peritonitis,  so  that  a  mortality  of  69*2  per  cent,  is  not 
surprising. 


428  ol'KKATIONS   ON    T11K     \I',|k>MI.\ 

La  Garde  (Med.  News,  Nov.  15,  1902)  mentions  thai  in  the 
Surgeon-General's  report  for  1900  116  operations  for  penetrating 
wounds  <>l  the  abdomen  are  recorded,  with  a  mortality  of  70  per  cent  ; 

the  Large  majority  of  those  that  recovered  had  110  intestinal  injury. 

I  will  quote  some  of  Mr.  Makins'  instructive  conclusions  upon  this 
subject  (loc.  supra  <-it.). 

"  (1)  Wounds  in  the  intestinal  area  should  he  watched  with  care.  In 
face  of  the  numerous  spontaneous  recoveries  in  such  eases,  habitual 
abdominal  exploration  is  not  justified  under  the  conditions  usually 
prevailing  in  the  field. 

"  (2)  The  very  large  number  excluded  by  this  rule  from  operation 
Leads  us  to  a  smaller  and  less  satisfactory  number  to  be  divided  into 
two  categories,  (a)  Patients  who  die  within  the  first  twelve  hours. 
Some  of  these  patients  are  hopeless  from  the  first;  a  few  might  be  saved 
by  an  operation  under  more  favourable  circumstances,  (b)  Patients 
with  very  severe  injuries,  as  evidenced  by  the  escape  of  faeces,  or  with 
wounds  from  Hank  to  flank  or  taking  an  antero-posterior  course  in  the 
abdominal  area.  These  patients  die,  and  the  majority  of  them  will 
always  die  whether  operated  on  or  not.  The  undertaking  of  opera- 
tions on  them  is  unpleasant  to  the  surgeon,  as  being  unlikely  to  he 
attended  with  any  great  degree  of  success,  whence  the  impression  may 
gain  ground  that  patients  are  killed  by  the  operation.  None  the  less  I 
think  these  operations  ought  to  he  undertaken  when  the  attendant 
conditions  allow,  and  it  is  from  this  class  that  the  real  successes  will 
be  drawn  in  the  future. 

"  The  history  of  such  injuries  after  all  corresponds  exactly  with  what 
we  were  long  familiar  with  in  traumatic  ruptures  in  civil  practice,  and 
now  know  may  he  avoided  by  sufficiently  early  interference.  The  whole 
question  here  is  one  of  time,  and  this  will  always  be  the  trouble  in 
military  work." 

"  (3)  The  expectant  attitude  which  is  obligatory  under  the  above  rules, 
in  doubtful  cases,  brings  us  face  to  face  with  a  large  proportion  of 
patients  in  the  early  or  late  stage  of  peritonaea!  septicaemia.  These  eases 
run  on  exactly  the  same  lines  as  those  in  which  the  same  condition 
is  secondary  to  spontaneous  rupture  of  the  bowel,  in  which  we  con- 
sider it  our  duty  to  operate  and  in  which  a  definite  percentage  of 
recoveries  is  obtained.  Hence  another  unpleasant  duty  is  here 
imposed  upon  the  surgeon. 

"  (4)  The  treatment  of  the  cases  in  which  an  expectant  attitude  is 
followed  by  the  advent  of  localised  suppuration  presents  no  difficulty. 
Simple  incision  alone  is  needed,  and  healing  follows.  As  a  rule  this  is 
a  late  condition. 

"  (5)  Cases  of  injury  to  the  colon,  in  which  the  posterior  aspect  is 
involved,  should  he  treated  by  free  opening  up  of  the  wound,  and  either 
by  suture  of  the  bowel  or  else  its  fixation  to  the  surface." 

"  Under  really  satisfactory  conditions  nothing  that  1  saw  in  my  South 
African  experience,  would  lead  me  to  recommend  any  deviation  from 
the  ordinary  rules  of  modern  surgery,  except  in  so  far  as  I  should  be 
more  readily  inclined  to  believe  that  wounds  in  certain  positions, 
already  indicated,  might  occur  without  perforation  of  the  bowel  when 
produced  by  small  calibre  bullets ;  and  further,  in  cases  where  I 
believed  the  fixed  portion  of  the  large  bowel  was  the  segment  of  the 


GUNSHOT   AND    OTHER   INJURIES.  429 

alimentary  canal  that  had  been  exposed  to  risk,  I  should  not  be 
inclined  to  operate  hastily." 

"  A  careful  consideration  of  the  whole  of  the  cases  that  I  saw  leaves  me 
with  the  firm  impression  that  perforating  wounds  of  the  small  intestine 
differ  in  no  way  in  their  results  and  consequences  when  produced  by 
small  calibre  bullets  from  those  of  every  day  experience,  although  when 
there  is  reason  merely  to  suspect  their  presence  an  exploration  is  not 
indicated  under  circumstances  that  may  add  fresh  danger  to  the  patient." 

Sir  F.  Treves  (Brit.  Med.  Journ.,  vol.  i.  1901,  p.  11 56)  mentions  cases 
in  which  the  abdomen  was  completely  traversed  in  various  directions,  and 
yet,  in  spite  of  prolonged  exposure  and  tedious  transport,  recovery  took 
place  with  only  very  slight  symptoms.  In  the  earlier  part  of  the  war 
he  describes  undertaking  several  abdominal  sections,  but  he  found  that 
he  was  doing  more  harm  than  good,  as  the  coils  of  intestine  already 
adhered  and  sealed  the  wounds,  there  being  no  prolapse  of  mucous 
membrane  or  escape  of  intestinal  contents.  Treves  concludes  that  it  is 
impossible  to  operate  successfully  in  cases  in  which  the  abdomen  is 
traversed  above  the  umbilicus,  owing  to  the  multiple  character  of  the 
injuries;  whilst  the  cases  in  which  the  abdomen  is  traversed  below  the 
umbilicus  get  well  without  operation.  He  advises  operation  only  when 
the  bullet  has  escaped,  and  so  its  course  is  known,  and  when  the 
general  condition  is  good  and  there  are  signs  of  abdominal  haemorrhage 
continuing. 

It  must  be  remembered,  however,  that  this  refers  only  to  wounds 
produced  by  bullets  such  as  the  Mauser,  which  does  not  spread  on 
impact,  is  of  small  diameter,  and  has  a  great  velocity.  Where  the 
bullet  producing  the  wound  is  one  which  causes  more  damage  than  the 
Mauser,  the  expectant  treatment  is  hardly  likely  to  be  successful,  and 
in  such  cases  it  is  certainly  justifiable  to  urge  as  early  an  operation  as 
is  possible  after  the  diagnosis  of  peritoneal  perforation  is  made. 

Bowlby  in  A  Civilian  War  Hospital  (1901)  quotes  the  interesting 
case  of  a  man  who  was  wounded  by  a  Krag  bullet  at  target  practice  in 
the  Philippines.  The  projectile  entered  two  inches  above  the  left 
costal  margin  in  the  mammary  line,  and  took  a  downward  course  to 
the  left  loin,  where  it  lodged.  The  patient  was  admitted  into  hospital 
within  an  hour,  and  Robinson  decided  to  go  against  the  usual  practice 
and  operate  at  once.  On  exploring  through  a  wound  near  the  middle 
line  he  discovered  and  removed  a  large  amount  of  fluid  and  clotted 
blood  ;  the  bullet  had  pierced  the  omentum  and  mesentery,  but  had 
not  injured  the  intestines;  the  vessels  were  tied,  and  the  patient 
recovered.  Several  successful  early  operations  were  performed  during 
the  South  African  war,  but  the  difficulties  in  the  way  of  operating  in 
time  were  very  great,  and  the  unfavourable  conditions  generally 
prevented  such  operations  being  done,  or  contributed  towards  their 
failure. 

Different  reasons  are  given  for  the  spontaneous  recoveries  that  more 
or  less  frequently  occurred  from  wounds  in  which  the  projectiles  must 
have  traversed  the  intestinal  area.  Bowlby  (loc.  supra  cit.)  believes 
that  the  intestines  entirely  escape,  and  quotes  Cheatle's  casein  support 
of  this  opinion.  The  patient  was  shot  through  the  right  loin,  and  the 
bullet  emerged  near  the  left  anterior  superior  spine.  After  forty-eight 
hours  the  man  died,   and   two    small  perforations  were  found  in  the 


430  OPERATIONS  ON  THE  ABDOMEN. 

caecum,  and  a  laceration  of  the  sigmoid,  but  no  sign  of  injury  of  the 
small  intestine  ;  there  was  no  peritonitis,  which  might  have  obliterated 

tin  evidence  of  perforation  of  the  bowel.  Bowlby  states  that  as  far  as 
he  is  aware  "the  actual  proof  afforded  by  demonstration  of  wounded 
intestine  which  has  healed  is  wanting."  Such  proof  must  be  very 
difficult  to  obtain,  of  course,  as  the  patients  get  well  as  a  rule,  and  if 
any  die  from  some  other  cause,  all  signs  of  small  perforations  may 
have  become  obliterated.  There  does  not  seem  to  be  any  reason  why 
spontaneous  recovery  from  very  small  perforations  of  empty  small 
intestine  should  not  occur  occasionally,  and  such  perforations  of  the 
stomach  are  well  known  to  recover  without  operation  sometimes,  and 
the  following  is  a  good  example  (from  the  Boston  Med.  and  Surg.  Journ. 
March  19,  1903).  A  soldier  was  shot  from  front  to  back  in  the 
epigastrium,  and  remained  upon  the  ground  without  food  for  nine  days  ; 
the  enemy  gave  him  water  only  ;  the  stomach  was  probably  empty  at 
the  time  of  the  injury,  and  this  no  doubt  accounted  for  the  man's 
recovery.  Some  years  afterwards  he  died,  and  it  was  found  that  the 
bullet  had  pierced  both  walls  of  the  stomach. 

Mr.  Makins  (Joe.  cit.)  believes  that  the  recoveries  are  largely  due  to 
the  state  of  hunger  at  the  time  of  the  shooting  and  the  very  small 
amount  of  extravasation  and  infection,  if  any,  that  follows.  The 
scarcity  of  drink  and  the  enforced  rest  of  the  bowel  and  abdominal  wall 
are  also  conducive  to  the  spontaneous  closure  of  the  small  perforations 
with  lymph. 

The  minimal  nature  of  the  primary  infection  may  be  a  factor,  and 
this  may  be  confirmed  by  the  better  prognosis  of  wounds  of  the  large 
bowel  except  of  those  of  the  transverse  colon,  owing  to  the  dryness  of 
their  contents  and  their  comparative  fixation,  both  of  which  limit 
extravasation  (Makins).  Patients  with  perforation  of  the  peritoneal 
surfaces  of  the  large  intestine  often  got  well  after  the  formation 
and  evacuation  of  a  localised  abscess,  whereas  Mr.  Makins  saw  no 
similar  recovery  from  perforation  of  the  small  intestine.  He,  there- 
fore, concludes  that  spontaneous  recovery  after  perforation  of  the  small 
intestine  must  be  very  rare,  but  the  absence  of  localised  suppuration 
may  be  due  to  the  less  infective  nature  of  the  contents  of  the  small 
intestine,  especially  during  semi-starvation.  After  all,  spontaneous 
recoveries  are  so  rare  and  uncertain  that  under  favourable  circumstances 
the  chances  of  the  patient  would  be  far  better  after  an  early  exploration 
by  a  good  surgeon.  Unfortunately  the  circumstances  of  war  are  so 
unfavourable,  that  it  is  only  occasionally  possible  to  undertake  opera- 
tions early  enough  to  arrest  serious  internal  haemorrhage  or  forestall 
the  onset  of  peritonitis.  Primary  laparotomies  were,  therefore,  very 
rare  in  the  latter  part  of  the  South  African  war,  and  also  in  the 
practice  of  both  Russian  and  Japanese  surgeons  during  the  recent 
war  in  the  far  East,  and  the  excellent  results  obtained  fully  justified 
this  line  of  treatment. 

Mr.  C.  A.  Gill  {Lancet,  1906,  vol.  i.  p.  1467)  concludes  from  his  experi- 
ence of  the  South  African  and  Japanese  wars  that  there  is  a  danger  for 
the  pendulum  to  swing  too  far  towards  non-interference,  and  he 
particularly  draws  attention  to  the  need  of  more  care  in  the  early 
treatment  and  prevention  of  shock  and  sepsis.  Each  Japanese  soldier 
carried  tabloids  of  perchloride  of  mercury  in  addition  to  the  usual  first 


GUNSHOT   AND   OTHER   INJURIES.  431 

field  dressing.  One  or  more  tabloids  can  be  dissolved  in  the  soldier's 
water  bottle,  if  no  other  receptacle  is  available.  The  wound  should  be 
cleaned  and  washed  with  the  lotion,  dried,  and  covered  with  the 
dressing.  There  should  be  facilities  for  urgent  operations  at  the  field 
hospitals,  but  nil  other  operations  should  be  deferred  until  the  stationary 
field  hospital  or  general  hospital  is  reached. 

Mr.  Makins  lays  great  stress  on  the  need  of  absolute  starvation  in 
every  case  where  perforation  of  the  alimentary  canal  is  suspected.  At 
the  end  of  twenty-four  hours  or  more,  warm  water  in  small  quantities 
may  be  cautiously  given,  and  later  milk,  in  teaspoonfuls  only  at  first. 
Morphia  should  not  be  given  in  doubtful  cases,  for  it  masks  the  early 
symptoms  of  peritonitis,  which  should  be  carefully  looked  for,  so  that 
an  operation  may  be  undertaken  if  possible  while  there  is  still  some 
hope  of  recovery. 

Operation. — An  excellent  account  of  this  will  be  found  in  the  very 
helpful  article  of  Prof.  Nancrede  to  which  reference  has  been  already 
made. 

With  the  utmost  care  the  preliminary  details  of  preparation  are 
entered  into  first — viz.,  the  cleaning  and  shaving  of  the  skin,  the 
providing  of  abundance  of  water  recently  sterilised  by  boiling,  or  a 
2  per  cent,  solution  of  boracic  acid,  or  a  \  per  cent,  solution  of 
salicylic  acid,  plenty  of  sterile  gauze  lying  in  the  hot  sterilised 
water,  to  cover  the  intestines  with,  abundance  of  ligatures  of  gut  and 
silk  of  different  sizes.  In  addition  to  the  usual  instruments,  several 
pairs  of  intestinal  clamps  should  be  at  hand,  or  failing  these,  strips  of 
gauze  may  be  passed  through  the  mesenteries  and  clamped  with 
Spencer  Wells'  forceps. 

"  Now  as  to  technique.  The  patient's  limbs  and  trunk  must  be 
carefully  wrapped  in  blankets ;  and  sterilised  towels  must  be  so 
arranged  as  to  prevent  any  accidental  contamination  of  the  peritonseal 
cavity.  If  not  previously  done,  the  urine  should  now  be  drawn 
off.  .  .  .  Ether  should  be  most  cautiously  administered.  The 
incision  should  always  be  through  the  rectus  sheath  near  the  middle 
line,*  as  otherwise  it  is  almost  impossible  to  gain  a  proper  view  of  the 
parts,  and  should  usually  extend  from  a  short  distance  above  the 
umbilicus  to  about  two  inches  above  the  pubes.  The  rectus  muscle  is 
displaced  outwards  within  its  sheath,  before  the 'posterior  layer  of  its 
sheath  and  peritonaeum  are  incised.  The  abdomen  having  been 
opened,  any  clots  or  blood  which  obscure  the  operating  field  may  be 
removed,  but  otherwise,  unless  it  is  manifest  that  severe  haemorrhage 
is  going  on,  the  small  intestines,!  which  usually  first  present,  should 
be  carefully  gone  over,  inch  by  inch,  from  the  stomach  to  the  ileo- 
caecal  valve,  keeping  them  constantly  enveloped  in  towels  wrung  out  of 

*  This  point  has  been  much  disputed.  No  hard-and-fast  rule  should  be  made,  but  as 
a  rule  the  incision  should  be  median.  The  late  Mr.  Greig  Smith  pointed  out  that  the 
following  cases  require  it  :  cases  where  the  ball  has  crossed  the  middle  line,  entering  at 
one  side  and  passing  towards  the  other,  and  others  where  the  ball,  entering  near  the 
middle  line,  passes  either  directly  backwards  or  in  an  uncertain  direction.  I  have  alluded 
to  this  matter  later  (p.  437). 

f  Dr.  Barnard  (loc.  supra  cit.~)  points  out  that  wounds  of  the  duodenum  are  very 
rarely  met  with,  and  that  wounds  of  the  upper  aspect  of  the  transverse  colon  and  of  the^ 
omentum  at  this  level  are  amongst  the  most  difficult  to  discover. 


432         OPERATIONS  ON  THE  ABDOMEN. 

hot  water  (sterilised).  It  is  better  to  return  each  piece  of  intestine 
immediately  niter  examining  it,  evisceration  and  its  attendant  dang< 
being  avoided  if  possible.  It  is  important  to  remember  that  the  small 
intestine  may  move  far  away  from  the  position  which  it  occupied  when 
injured,  s<»  that  ii  bullet  passing  across  the  lower  abdomen  may  pierce 
the  intestines  in  several  places,  and  some  of  these  perforations  may  be 
discovered  later  at  the  upper  part  of  the  abdominal  cavity.  Therefore 
the  only  safe  way  is  to  examine  every  inch  of  small  intestine  carefully, 
however  well  and  certainly  the  course  of  the  bullet  may  be  known. 
Makins  {loc.  '-it.)  draws  attention  to  the  fact  that  there  is  generally  a 
characteristic  area  of  redness  around  perforations  of  the  intestines. 
This  is  of  great  help  in  finding  the  lesions.  He  also  points  out  that 
wounds  near  the  mesenteric  border  are  quite  common  in  military  prac- 
tice, which  is  in  contrast  with  civil  practice,  and  adds  considerably  to 
the  risks  of  haemorrhage  and  septic  infection.  Afterwards  the  stomach, 
spleen,  liver,  pancreas,  large  bowel,  kidneys,  bladder,  omentum, 
mesentery,*  and  abdominal  vessels  must  be  examined.  I  do  not  mean 
that,  if  various  wounds  are  discovered,  say  in  the  small  intestine,  and 
the  place  of  exit  of  the  ball  from  the  abdominal  cavity,  all  in  Buch 
relations   as  would  absolutely  exclude  injury  of  the  stomach, t  liver, 

*  ••  Wounds  of  the  mesentery,  when  they  are  but  perforations,  can  be  passed  without 
any  additional  interference,  unless  attended  with  haemorrhaee.  in  which  case  deligation  of 
the  injured  vessel  is  required.  Large  lacerations  should  be  closed  with  a  running  suture 
to  avoid  the  future  possibility  of  an  incarceration  and  obstruction  of  a  loop  of  the  intestine 
in  the  opening.  On  account  of  the  extreme  delicacy  of  the  membrane,  its  closure  is  often 
attended  with  some  difficulty,  which  may  be  frequently" overcome  by  introducing  the 
sutures  near  the  edge  of  a  vessel,  as  this  region  affords  the  strongest  grasp  for  the  suture" 
(Shackner.  loc.  supra  cit.~).  If  it  be  the  omentum  which  is  wounded,  or  contains  a  large 
hematoma,  it  should  be  ligatured  and  cut  away. 

t  Cases  of  wounds  of  all  these  viscera  have  been  treated  by  laparotomy  and  suture. 
Thus,  Mr.  Dalton,  of  St.  Louis  (Ann.  of  Surg.,  August,  1S88),  records  a  case  of  bullet- 
wound  of  stomach  and  liver  thus  treated  successfully.  The  wounds  in  the  stomach  were 
those  of  entrance  and  exit,  and  situated,  the  former  on  the  anterior  surface,  the  latter 
near  the  upper  border ;  both  were  closed  with  Lembert's  sutures.  The  lower  margin  of 
the  left  lobe  of  the  liver  was  ploughed  through  by  the  b  illet  an  inch  and  a  quarter  from 
the  transverse  fissure,  leaving  a  V-shaped  wound  half  an  inch  in  depth.  This 
by  one  catgut  suture,  of  large  size,  passed  on  either  side,  an  inch  from  the  margin  of  the 
wound,  and  dipping  deeply,  on  account  of  the  great  friability  of  the  tissue,  into  the  liver 
■It  acted  well,  bringing  the  wound  together  Bnugly."  There  were  no  other 
injuries  save  a  slight  contusion  on  the  transverse  colon,  probably  due  I  al  violence 

of  the  ball,  which  was  not   found.     The  operation   was   rendered  difficult    by   re]" 
vomiting  of  black  gromous  fluid,  necessitating  turning  the  patient  on  bis  Bide  each  timet 
••  which  was  awkward  with  an  open  belly."     The  operation  was  a  prompt  one — two  hours 
after  the  injury  ;  recovery  followed.     In   Dr.   K  '/■■'.    Vi  of,  May  14,  18S7)  the 

wound  of  entrance  in  the  Btomach  was  near  the  pylorus  on  the  anterior  surface,  that  of 
exit  much  more  difficult  to  find,  being  on  the  lower  border  and  posterior  surface,  and 
obscured  by  clot.  Though  there  were  other  most  serious  injuries  of  superior  mesenteric 
vein  and  right  kidney  requiring  nephrectomy,  the  patienl  survived  till  the  fifteenth  day, 
death  being  due  to  diffuse  suppuration  of  the  clot  in  the  mesentery,  and  gangrenous 
ration  at  one  spot  in  the  intestine.  Other  means  of  meeting  haemorrhage  from  the 
liver  are  plugging  with  a  tampon  of  aseptic  gauze  when  the  wound  is  large  and  the 
haemorrhage  great,  and  applying  firm  pressure,  and.  in  the  case  of  obstinate  oozing  from 
an  abrasion,  the  application  of  a  crystal  of  iron  persulphate,  or  the  Paquelin*s  cautery. 
Wounds  in  the  gall-bladder  are  treated  like  those  of  intestine.     Wounds  of  the  kidney  or 


GUNSHOT   AND   OTHER    INJURIES.  433 

kidneys,  spleen,  or  bladder,  such  a  detailed  examination  should  be 
made — far  from  it,  for  every  unnecessary  manipulation  is  injurious — 
but  I  do  advise  that,  rather  than  overlook  a  wound,  much  manipula- 
tion which  the  result  proves  to  have  been  unnecessary  had  better  be 
made.  Of  course  the  source  of  a  severe  hemorrhage  must  be  at 
once  sought  for,  and  any  wounds  of  the  hollow  viscera  ignored  for  the 
time  being,  care,  however,  being  taken  that  the  general  peritoneal 
cavity  is  protected  from  fecal  extravasation  by  removing  the  per- 
forated loops  of  intestine  outside  the  abdomen,  keeping  them  wrapped 
in  warm,  moist  cloths;  such  hemorrhage  is,  however,  most  unusual. 
Whichever  plan  is  pursued,  let  everything  be  done  methodically,  and 
each  injury  repaired  as  it  is  detected,  as  this  saves  much  time  and 
renders  any  oversight  almost  impossible.  All  wounds  of  the  bowel, 
however  trivial,  should  be  minutely  cleansed,  coaptated  by  the 
Lembert  suture  of  fine  silk  introduced  with  an  ordinary  sewing-needle, 
and  the  suture  line  rubbed  over  with  a  little  iodoform."*  The  sutures 
should  be  introduced  so  that  the  sutured  wound  may  be  transverse  to 
the  axis  of  the  bowel,  in  order  to  avoid  narrowing  of  the  lumen  as  far 
as  possible.  For  large  perforations  two  rows  of  sutures  are  safer,  a 
deep  one  piercing  all  the  layers,  and  an  outer  sero-muscular  stitch. 
In  smaller  punctures,  a  sero-muscular  pursestring  suture,  as  recom- 
mended by  Senn,  may  suffice  (Journ.  Amer.  Med.  Assoc,  Nov.  8, 
1902).  "  When  necessary  from  the  size  or  number  of  the  wounds,  a 
portion  or  whole  calibre  of  the  gut  must  be  exsected.f  Wounds  of 
the  liver,  if  situated  at  the  free  border  of  the  organ,  should,  if 
possible,  be  coaptated  with  dry  aseptic  gut,  which  will  soon  swell  and 
fill  the  track  made  by  the  needles.  If  this  cannot  be  done,  the 
hemorrhage  may  perhaps  be  arrested  by  the  judicious  use  of  the 
thermo-cautery.  Unless  the  bleeding  be  free,  the  wound  should  be 
plugged  with  an  iodoform-gauze  tampon,  which  is  to  remain  for 
forty-eight  hours." 

"  Wounds  of  the  pancreas"  {vide  Ch.  X.),  "spleen,  or  kidneys  must 
be  treated  in  a  similar  manner,  or,  if  these  measures  fail,  either  spleen 
or  kidney  must  be  excised.  Since  a  wounded  splenic  artery  would 
lead  to  gangrene  of  the  organ,  it  must  be  removed"  (vide  p.  528)« 
"  The  same  advice  holds  good  for  wound  of  a  renal  artery,  but  in 
these  cases  death  from  hemorrhage  will  usually  result  before  art 
can  intervene ;  still  such  possible  complications  must  be  provided 
for.  Wounds  of  the  bladder  had  best  be  sewn  with  inverting  sero- 
muscular sutures  of  silk  or  reliable  catgut  in  one  or  two  layers ;  and 

spleen  must  be  treated,  according  to  their  nature,  either  by  suture,  as  in  the  liver,  or  by 
gauze  packing.  If  the  haemorrhage  is  too  severe  for  the  above,  the  organ  must  be  removed. 
Dr.  Keen  in  his  case  alluded  to  above,  the  kidney  being  badly  lacerated,  adopted  this  step. 
The  ureter  should  be  examined,  and,  if  found  divided,  sutured,  or  failing  this,  the  kidney 
should  be  removed. 

*  Wherever  possible,  the  sutures  should  be  introduced  parallel  with  the  long  axi3  of 
the  intestine,  as  by  this  its  lumen  is  least  narrowed. 

t  Of  all  the  wounds  of  the  intestine  those  of  the  rectum  are  most  difficult  to  detect, 
and  therefore  very  fatal.  Dr.  Morton  (Joe.  supra  cit.~)  suggests  that  inflation  with  a  rubber 
bag  may  be  of  assistance  here.  He  also  alludes  to  two  cases  in  which  the  diaphragm  was 
wounded.  In  each  case  a  hernia  of  viscera  into  the  thorax  existed  ;  this  was  reduced,  the 
wound  sutured  with  catgut,  and  recovery  ensued. 

S. — VOL.  II.  28 


434  OPERATIONS  ON  THE  ABDOMEN 

the  needle  should  he  a  round  one,  as  small  as  can  be  made  to  carry 
the  thread.  Contused  bowel  will  almost  certainly  slouch,  so  that  the 
injured  portion  had  better  be  excised  and  the  healthy  peritoneal 
surfaces  united  by  suture.  Wounded  or  contused  omentum  or 
mesentery  must  also  be  excised,  and  the  edges  carefully  united  by 
interrupted  sutures.  The  experience  of  at  least  one  case  has  shown 
that  since  an  omental  slough  cannot  be  eliminated  into  the  lumen  of 
the  bowel,  as  occurs  in  wounds  of  the  intestine,  a  fatal  generalised 
peritonitis  will  result  from  the  local  gangrene.  All  bleeding  must 
be  checked,  even  from  the  smallest  vessels,  for  quite  extensive  oozing 
will  occur  from  most  insignificant  vascular  orifices,  because  they  are 
situated  in  a  closed  cavity,  and,  although  the  amount  lost  may  not 
be  dangerous  per  se,  it  will  prove  so  as  a  source  of  septicaemia  or 
peritonitis." 

This  was  so  in  Dr.  Keen's  case  (loc.  supra  cit.).  The  haemorrhage 
here  extended  fan-shaped  in  a  moderately  thick  layer  between  the 
two  layers  of  the  mesentery,  its  periphery  extending  almost  two  feet 
along  the  bowel,  and  its  point  being  at  the  mesenteric  attachment 
to  the  spine.  The  chief  bleeding  came  from  a  hole  in  the  superior 
mesenteric  vein,  and  was  secured,  after  much  difficulty,  by  a  laterally 
placed  ligature  of  chromic  gut.  In  spite  of  the  most  careful  antiseptic 
precautions  and  unremitting  after-treatment,  the  patient  died,  on  the 
fifteenth  da}r,  of  suppuration  in  this  clot,  and  gangrene  of  the  intestine 
connected  with  this  part  of  the  mesentery.  Wounds  of  the  spleen 
must  be  treated  by  the  methods  already  given  for  the  liver  and 
kidney.     The  treatment  of  those  in  the  bladder  is  given  fully  later. 

If  a  segment  of  bowel  is  to  be  excised,  the  cuts  should  be  made 
at  such  points  as  correspond  to  the  distribution  of  a  large  mesenteric 
branch  in  order  to  secure  a  due  blood-supply  to  the  edges  of  the 
incisions,  and  the  parts  to  be  removed  should  be  laid  upon  a  large* 
flat  sponge,  or  folded  napkins,  to  prevent  faecal  extravasation  into 
the  abdominal  cavity.  To  avoid  escape  of  faeces  during  excision  of 
intestine,  the  simplest  of  all  clamps  is  small  rubber  tubing  made 
to  pierce  the  mesentei'y  on  each  side  of  the  wound,  at  a  spot  devoid 
of  vessels,  passed  round  the  intestine,  and  knotted  once,  or,  better, 
clamped  with  Spencer  Wells's  forceps  (Dr.  Shackner,  Ann.  of  Surg., 
June,  1890).  Proper  intestinal  clamp  forceps,  such  as  those  of  Doyen 
or  Carwardine,  are  far  more  useful  than  rubber  tubing;  and  if  sheathed 
in  tubing  and  not  clamped  too  lightly,  they  need  not  damage  the 
intestine.  For  a  rapid  resection  Barker's  method  is  an  excellent 
one.  The  mesentery  should  be  tied  before  it  is  divided,  parallel 
with  and  near  the  bowel ;  and  if  the  ligatures  are  applied  as  recommended 
by  Mr.  Barker,  very  few  are  required,  and  no  rent  remains  needing 
suture.  Moreover,  no  kink  occurs  at  the  mesenteric  border  of  the 
sutured  bowel  (vide  p.  398). 

"  Should  the  pulse  fail  at  any  time  during  the  operation,  owing  to 
irritation  and  paresis  of  the  abdominal  sympathetic,  flushing  the 
intestines  and  peritonaeal  cavity  with  hot  water  will  often  at  once 
remove  the  unfavourable  condition.  The  most  scrupulous  care  must 
be  exercised  in  the  peritonaeal  toilet,  which  can  be  most  quickly  and 
effectively  made  by  thorough  irrigation  of  the  cavity  with  warm 
sterilised  water,  and  subsequent  careful  removal  of  all   fluid    in    the 


GUNSHOT   AND    OTHER   INJURIES.  435 

ordinary  manner  by  gauze  rolls,  especial  attention  being  paid  to  the 
case  of  the  pelvis  and  the  renal  regions. 

"  When  possible,  the  peritonaeum  should  be  united  over  the  orifices 
of  entrance  and  exit  of  the  ball,*  and  a  little  iodoform  rubbed  in.   .   .   . 

When  incipient  peritonitis  exists,  or  a  faecal  extravasation  has 
occurred,  drainage  should  be  established  by  means  of  cigarette  drains 
passed  into  the  pelvis,  and  in  the  various  otber  directions  that  may  be 
indicated  by  the  position  of  the  sutured  perforations.  If  all  goes  well 
these  drains  may  be  removed  after  thirty-six  hours,  but  if  pus  is 
coming  away  the  tubes  must  be  sterilised  and  replaced.  The  patient 
should  be  propped  up  in  the  Fowler  position  to  facilitate  drainage. 

Le  Conte  advises  drainage  through  the  loin  in  cases  in  which  the 
lesser  sac  has  been  opened.  This  provides  better  drainage,  but  care 
must  be  taken  to  avoid  the  important  structures  lying  behind  the 
lesser  sac. 

As  many  of  the  above  points  may  be  considered  to  be  unsettled  till 
more  cases  give  us  better  light,  1  have  added,  for  contrast,  the  views  of 
another  American  surgeon,  Dr.  McGraw,  of  Detroit  (Trans.  Amer.  Surg. 
Assoc,  May,  1889).  It  will  be  seen  that  in  some  most  important  points 
— e.g.,  the  site  of  the  incision  and  the  question  of  how  best  to  examine 
the  intestines — they  are  directly  opposed  to  those  of  Dr.  Nancrede. 
Dr.  McGraw's  chief  propositions  are  as  follows  : — 

(i.)  Bullets  which  enter  the  abdominal  cavity  pass  in  a  nearly  abso- 
lutely straight  line  from  the  orifice  of  entrance  to  that  of  exit,  or 
their  final  stopping-place  in  the  viscera.  (ii.)  An  incision  made 
directly  in  the  course  of  the  ball  will  give  the  shortest  route  to  the 
injured  parts.  If  balls  pass  through  the  abdomen  in  straight  lines, 
a  cut  over  the  path  of  a  ball  will  open  the  nearest  possible  way  to 
the  wound  underneath,  provided  the  viscera  have  not  shifted  their 
places  since  the  shooting.  Even  then  they  could  be  easily  brought 
into  the  wound  for  the  purpose  of  repair.  Coils  of  viscera  which 
could  not  be  so  brought  could  not  possibly  have  been  struck  by 
the  ball.  I  disagree  with  this  view,  for  recent  records  show  very 
clearly  that  it  is  not  safe  to  arrive  at  conclusions  from  the  probable 
course  of  the  bullet,  and  that  a  thorough  examination  is  the  only 
certain  and  reliable  way  of  finding  out  the  extent  of  the  internal 
injuries.  Such  an  examination  can  be  best  made  through  an  incision 
near  the  middle  line,  where  the  length  of  the  wound  can  be  increased 
to  the  desired  degree  without  the  same  risk  of  ventral  hernia  as  must 
be  associated  with  extensive  lateral  or  irregular  wounds.  The 
aponeurosis  of  the  rectus  sheath  should  be  overlapped  as  usual, 
(iii.)  If  a  gunshot  wound  of  the  intestine  will  not  under  pressure 
permit  discharge  of  its  contents,  it  has  been  closed  by  the  eversion 
of  the  mucous  membrane  or  by  the  exudation  of  plastic  lymph.  In 
either  case  the  wound  would  probably  recover  without  suture  if  kept 
perfectly  aseptic,  and  if  the  bowels  are  kept  perfectly  quiet,  but  no  one 
should  put  his  trust  in  such  a  possibility,  and  every  perforation  must 
be  closed  and  inverted  if  practicable,  (iv.)  An  empty  condition  of 
the    alimentary    canal   is   most    favourable    for    healing.       To    secure 

*  If  the  track  of  the  ball  is  likely  to  be  septic,  it  should  be  treated  by  incision,  cleansing, 
and  drainage. 

28—2 


436  OPERATIONS  ON  THE  ABDOMEN. 

this  as  far  as  possible,  it  may  be  proper,  in  some  cases  of  injuiy  of  the 
bowel  after  a  hearty  meal,  to  evacuate  the  Btomacfa  by  a  syphon.  This 
would  be  especially  indicated  in  wounds  of  the  stomach,  duodenum, 
and  upper  part  of  the  jejunum,  whether  the  surgeon  does  or  does  not 
decide  on  operative  treatment.  (v.)  Senn's  method  of  hydrogen-gas 
insufflation,  however  admirable  in  recent  cases,  should  be  used  with 
great  caution  after  the  lapse  of  a  few  hours.  The  distension  and 
motion  of  the  gut  caused  by  the  insufflation  might  rupture  inflam- 
matory adhesions,  break  open  intestinal  wounds  that  had  nearly  healed, 
and  make  general  a  peritonitis  which  had  become  circumscribed. 
It  may  be  added  that  it  also  wastes  valuable  time,  and  increases 
distension,  which  seriously  interferes  with  a  successful  laparotomy 
later.  It  is  not  surprising  that  this  method  has  been  generally 
discarded,  (vi.)  The  dangers  of  the  operation  are  directly  in  pro- 
portion to  its  length  and  to  the  amount  of  evisceration.  The  length 
of  an  operation  may  be  lessened — (1)  By  strictly  limiting  the  examina- 
tion of  the  viscera  to  such  of  them  as  may  have  been  in  the  course  of 
the  ball.  (2)  By  suturing  wounds  in  the  gut,  wherever  it  is  possible, 
instead  of  excising  them.  The  latter  should  be  reserved  for  wounds 
that  do  not  permit  inversion  and  suture.  (3)  By  omitting  all  operative 
procedures,  even  suture,  in  all  wounds  which  have  become  so  thoroughly 
occluded  by  plastic  material  that  the  contents  of  the  bowel  cannot  be 
passed  through  them.  (4)  When  many  wounds  occur  near  together 
by  operating  first  on  those  wounds  which  imperatively  demand  it,  and 
leaving  to  the  last  those  which  may  recover  without  operation.  If  the 
stomach  and  intestine  are  both  perforated,  the  small  intestine  should 
be  first  attended  to,  as  the  stomach,  if  empty,  may  recover  without 
suture.  So,  too,  large  wounds  should  be  sutured  before  small  ones, 
discharging  wounds  before  those  which  are  occluded.  (5)  By  never 
turning  out  all  the  intestines  except,  first,  when  haemorrhage  is  other- 
wise uncontrollable,  or,  second,  when  there  is  evidently  a  discharging 
wound  which  cannot  otherwise  be  found.  "  The  examination  of  the 
whole  intestine  by  slipping  it,  from  one  end  to  the  other,  through  the 
fingers,  though  not  causing  the  exposure  of  evisceration,  nevertheless 
consumes  an  enormous  amount  of  time,  and  reduces  very  materially 
the  strength  of  the  patient.  In  my  opinion,  surgeons  have  exagge- 
rated the  difficulties  in  the  way  of  discovering  wounds  which  have 
made  this  procedure  necessary.  The  incision  over  the  course  of 
the  ball  will  aid  materially  in  the  diagnosis  by  exclusion,  for  no  in- 
testine which  cannot  be  brought  into  the  path  of  the  missile  could 
possibly  have  been  hit  by  it.  It  is  not  probable  that  a  gut  would 
slip  more  than  three  or  four  inches  away  from  the  place  it  occupied 
when  wounded,  and,  with  the  incision  I  have  mentioned,  the  necessity 
would  rarely  occur  of  examining  any  other  viscera  than  those  in 
the  immediate  neighbourhood  of  the  wound."  "  Let  us  suppose  that 
a  surgeon  in  operating  has  repaired  all  the  wounds  he  has  been  able 
to  find  in  or  near  the  course  of  the  ball ;  he  has  washed  out  the 
abdominal  cavity;  he  has  with  his  hands  gently  pressed  upon  all  the 
viscera  which  could  possibly  have  been  injured,  and  his  hands  have 
come  out  unstained ;  he  has  furthermore  with  soft  sponges  wiped  out 
the  lower  part  of  the  abdominal  cavity  without  finding  blood  or  faeces. 
Shall  he  then,  without  any  evidence  whatever  of  an  additional  wound, 


GUNSHOT   AND    OTHER   INJURIES.  437 

subject  his  already  exhausted  patient  to  a  most  dangerous  procedure  on 
the  mere  suspicion  that  there  might  he  a  still  undiscovered  wound?" 
Many  recently  published  cases  prove  that  this  conclusion  is  not 
warranted,  and  the  following  case  illustrates  this  point.  The  bullet 
entered  above  and  behind  the  left  anterior  superior  spine  of  the  ilium. 
At  the  operation,  which  took  place  within  an  hour,  Harris  discovered 
two  perforations  in  the  sigmoid  flexure,  one  very  low  down,  four  per- 
forations of  the  jejunum  near  the  middle  of  it.  "  These  were  thought 
to  be  all  the  perforations,  but  the  colon  and  stomach  were  examined  as 
a  matter  of  routine.  On  drawing  down  the  transverse  colon,  which 
was  well  to  the  upper  part  of  the  abdomen,  much  to  our  surprise,  two 
perforations  were  found  in  it.  It  seems  almost  impossible  that  a  bullet 
entering  at  the  point  indicated  in  this  case,  and  travelling  approxi- 
mately from  before  backward,  could  perforate  the  sigmoid  low  down 
the  transverse  colon  twice,  and  the  jejunum  four  times,  yet  such  are 
the  facts,  which  are  explainable  by  the  great  mobility  of  nearly  all  parts 
of  the  intestinal  tract."  The  patient  died  of  peritonitis,  but  all  the 
perforations  had  been  well  closed  (Harris,  loc.  supra  cit.). 

It  will  be  seen  that  the  diversity  of  opinion  as  to  the  site  of  the 
incision,  and  the  desirability  of  turning  out  all  the  intestines  for 
examination,  turns  on  the  question  of  how  best  all  injuries  of  the 
peritoneal  sac  can  be  detected.  The  advocates  of  the  latter  step 
and  median  free  incision  claim  that  by  this  alone  can  the  needful 
inspection  be  made  of  all  the  viscera,  both  free  and  fixed,  hollow  and 
solid  ;  they  point  to  numerous  cases  in  which  even  by  this  means  of 
complete  examination  injuries  have  been  overlooked  that  have  marred 
the  success  of  an  otherwise  complete  and  most  hopeful  operation  ; 
they  hold  that  the  median  incision  alone  will  meet  those  cases  where 
the  course  of  the  ball  is  not  direct,  but  erratic,  or  where  by  moving 
the  patient  a  long  distance,  or  from  peritonitis  setting  in  late,  peristalsis 
has  altered  the  position  of  the  bowels.  I  think  the  published  evidence 
shows  clearly  that  the  median  incision  is  the  wiser,  save  in  a  few  cases, 
as  where  the  wound  lies  well  away  to  one  side,  as  here  the  colon  may 
be  found  shot  through,  and  only  this  organ  and  the  contiguous  small 
intestine  and  the  kidney  behind  will  require  examination.  It  must  not 
be  forgotten  that  with  the  great  advantage  of  more  complete  exploration 
which  the  median  incision  affords  goes  the  greater  risk  of  shock  and  of 
general  contamination  of  the  peritonaeal  sac,  as  coils  which  are  possibly 
leaking  are  drawn  up  into  the  wound.  This  will  have  to  be  met  by 
careful  irrigation  later.  With  regard  to  turning  out  all  the  intestines, 
the  advocates  of  this  plan  claim  that  by  this  alone  can  all  the  wounds 
be  found,  and  that  this  step,  by  the  more  rapid  searching  which  it 
allows,  in  reality  diminishes  shock.  Till  more  cases  have  been  pub- 
lished— and  surgeons  owe  a  great  debt  to  the  candour  and  fulness  with 
which  the  American  surgeons  have  made  known  their  failures  as  well 
as  their  successes — each  case  must  be  decided  on  its  merits.  In  early 
operations  evisceration  does  not  involve  much  danger  from  shock,  for 
the  intestines  can  be  easily  replaced.  On  the  other  hand,  it  is  rarely 
necessary  in  these  cases,  for  a  satisfactory  examination  can  be  made 
without  it.  In  late  cases,  with  peritonitis  and  distension  of  the 
intestines,  evisceration  is  a  serious  thing,  for  it  may  be  very  difficult 
to  replace  the  intestines  afterwards,   and  shock  is  greatly  increased 


438  OPERATIONS  ON  THE  ABDOMEN. 

by  exposure,  traction  of  the  coils  on  the  mesentery,  and  the  manipula- 
tions which  are  necessary  to  get  the  intestines  back  again.  The 
points  which  will  aid  the  surgeon  in  coming  to  a  decision  on  the  above 
two  steps  are  any  obliquity  of  the  wound  of  entrance,  and  of  the  com-'' 
of  the  hall  ;  the  position  of  the  wound  of  entrance,  whether  near  the 
middle  or  the  lateral  parts  of  the  abdomen  ;  any  evidence  of  its  having 
passed  from  side  to  side;  entire  uncertainty  as  to  its  course  ;  the  time 
that  has  elapsed  since  the  injury  ;  the  interval  between  this  and  the 
last  meal;  and  whether  the  patient  has  been  kept  quiet. 

In  cases  where  the  presence  of  multiple  wounds,  or  the  severity  of 
one,  entails  the  risk  of  sloughing,  or  where  multiple  suturing  will 
produce  dangerous  stenosis,  resection  must  be  performed  on  the  lines 
already  fully  given  at  pp.  388,  393.  Two  very  interesting  cases  are 
recorded  by  American  surgeons  in  which  Murphy's  button  was 
employed  successfully.  In  one  (Dr.  G.  F.  Wilson,  Ann.  of  Surg., 
September,  1895),  after  one  wound  of  the  ileum  had  been  found,  and 
closed  with  Lembert's  sutures,  eight  other  openings  were  found,  at 
a  considerable  distance  from  the  first,  three  being  very  close  together. 
Again,  some  little  distance  further  off,  the  bullet  had  passed  through 
the  mesenteric  border  of  the  intestine,  so  interrupting  the  blood- 
supply  that  a  slough  would  surely  have  resulted.  A  single  resection 
was  accordingly  determined  on,  and  the  portion  removed  measured, 
without  stretching,  just  forty-three  inches.  The  patient  recovered,  and 
the  button  was  passed  on  the  ninth  day.  In  the  second  case  (Dr.  J.  W. 
Walker,  Ann.  of  Surg.,  January,  1896),  a  resection  of  two  inches  of 
the  ileum  was  successfully  performed.  The  button  was  here  passed 
on  the  fifteenth  day.  As  Dr.  Walker  remarks,  if  Murphy's  button 
be  used  at  one  place  and  another  wound  require  suture  lower  down, 
any  unavoidable  constriction  which  the  latter  may  occasion  will 
cause  anxiety  as  to  the  safe  passage  of  the  button.  Many  successful 
cases  have  been  published  since.  Nearly  all  experienced  surgeons 
prefer  direct  suture  to  mechanical  contrivances,  but  there  is  little  doubt 
but  that  the  Murphy  button  is  safer  for  the  inexperienced  worker 
under  difficult  circumstances. 

The  chief  points  in  the  after-treatment  are — rectal  feeding  for  forty- 
eight  hours  or  longer  if  the  stomach  or  upper  part  of  the  intestine  has 
been  injured;  morphine  injections,  combined  with  atropine  (about 
y\j  gr.),  for  the  first  thirty-six  or  forty-eight  hours,  rather  than  opium  ; 
careful  use  of  saline  aperients — e.g.,  Seidlitz  powders — a  little  later. 

I  append  the  following  as  instances  of  what  injuries  the  surgeon  may 
expect  to  have  to  deal  with  : — Bullet  wound  near  umbilicus  ;  seven 
openings  in  alimentary  canal,  viz.,  three  openings  close  together  in  the 
small  intestine  (three  and  a  quarter  feet  below  the  duodenum),  two  open- 
ings in  the  descending  colon,  and  two  in  the  rectum  ;  no  great  extrava- 
sation ;  also  a  large  vein  wound  in  the  mesentery  ;  death  from 
peritonitis;  bullet  found  near  ischial  spine  (Annandale,  Lancet,  April 
15,  1885).  Pistol  wound  near  navel :  seventeen  hours  later,  operation 
(two  pints  of  bloody  serum  let  out,  with  small  clots,  but  no  faeces) ;  seven 
penetrating  wounds  of  intestine,  six  in  the  small,  one  in  the  sigmoid 
containing  the  bullet ;  all  the  openings  plugged  with  ragged,  everted 
mucous  membrane  ;  no  faecal  escape  till  edges  were  separated  ;  careful 
suturing  and  toilet ;  recovery  after  a  very  critical  condition  for  a  week 


RUPTURE   OF   THE    INTESTINE.  439 

(Bull,  Ann.  of  Sun/.,  May,  1885).  Bullet  entrance  close  to  navel: 
operation  two  hours  later;  abdominal  cavity  full  of  blood  ;  a  spurting 
artery  in  the  mesentery;  eleven  wounds  requiring  suture  in  small 
intestine,  and  two  in  ascending  colon;  no  faecal  extravasation,  but  a 
melon-seed  body  found  and  removed  ;  on  tbe  thirteenth  day  great 
rectal  tenesmus  led  to  discovery  of  blood-effusion  in  pelvis;  tbree 
pints  let  out  by  incision  about  two  inches  within  anus;  recovery; 
bullet  passed  per  anum  (Hamilton,  Joiirn.  Amer.  Med.  Assoc,  Aug.  22, 
1885;  Ann.ofSurg.,  November,  1885).  Bullet  entrance  three  and  a  half 
inches  above  umbilicus,  and  just  to  left  of  middle  line  :  operation 
within  twenty-four  hours ;  rent  in  omentum  close  to  great  curvature 
of  stomacb,  and  two  linear  rents  in  tbis  viscus,  found  with  much 
difficulty  ;  operation  bad  to  be  concluded  quickly  from  patient's  critical 
condition  ;  death  from  acute  peritonitis  within  a  few  hours ;  four 
wounds  found  in  upper  part  of  jejunum,  all  within  a  distance  of  tbree 
inches  (Briddon,  New  York  Surg.  Soc,  Dec.  8,  1886  ;  Ann.  of  Surg., 
April,  1887).  Bullet  wound  two  incbes  above  and  two  inches  inside 
right  anterior  superior  spine  :  operation  in  nine  hours  ;  wound  found  in 
ascending  colon,  pouring  out  fasces  ;  another  wound  in  colon,  also 
pouring  out  faeces;  both  sutured;  recovery  (McGraw,  Chicago  Med. 
Journ.  and  Exam.,  July,  1887;  Ann.  of  Surg.,  December,  1887). 

A  very  complete  table,  containing  234  cases,  is  given  by  Dr.  T.  S.  K. 
Morton  {Journ.  Amer.  Med.  Assoc.,  Jan.  4,  1890)  ;  others  by  Sir  W. 
MacCormac  and  Mr.  Barker  will  be  found  in  the  Brit.  Med.  Journ., 
May  11,  1887,  and  March  17,  1888. 

Other  papers  will  be  found  in  the  Annals  of  Surgery.  One  of 
the  most  interesting  is  by  Dr.  A.  B.  Miles  (vol.  ii.  1893,  p.  623). 
Thirteen  cases  are  given,  with  five  recoveries.  In  proof  of  the  severity 
of  these  cases,  of  the  recoveries  one  patient  had  sixteen,  another  four- 
teen, and  a  third  ten  wounds  of  the  small  intestine.  One  of  the  fatal 
cases  was  due  to  the  discharge  of  both  barrels  of  an  ordinary  shot-gun 
into  the  right  iliac  fossa. 

The  valuable  contributions  of  Makins,  Bowlby,  Stevenson,  Treves, 
and  others  upon  the  South  African  war  have  been  already  referred  to. 
Still  more  recent  and  some  very  instructive  papers  have  been  written 
by  Harris,  Fenner,  Gill,  Le  Con'te,  La  Garde,  and  have  been  alluded  to. 

An  interesting  case  is  recorded  by  Senn  {Ann.  of  Surg.,  1905,  vol.  xli. 
p.  637).  The  jejunum,  ileum,  hepatic  flexure  of  the  colon,  ascending 
colon,  and  caecum  were  wounded.  Some  of  the  jejunum  had  to  be 
resected,  tbe  other  intestinal  and  some  mesenteric  wounds  were  closed 
mostly  by  two  rows  of  sutures,  the  peritonaeum  was  wiped  out,  and  the 
patient  recovered. 

Brewer  {Ann.  of  Surg.,  1904,  vol.  xxxix.  p.  100)  records  a  successful 
operation  for  a  pistol  wound  of  the  liver,  gall-bladder  and  stomach,  and 
mesocolon ;  three  perforations  of  the  stomach  and  one  ragged  one  in 
the  gall-bladder  were  sutured,  and  much  blood  removed.  Two  days 
later  the  wound  had  to  be  reopened  owing  to  an  accumulation  of 
biliary  discharge  from  the  liver  wound. 

RUPTURE    OF  THE   INTESTINE. 
Tbe  following  remarks  are  taken  from  the  Cartwright  Prize  Essay  by 
Dr.  B.  F.  Curtis,  of  New  York  (Amer.  Journ.  Med,  Sci,,  October,  1887)  : 


440  OPERATIONS  ON  THE  ABDOMEN. 

Relative  frequency  of  rupture  in  113  cases. — Duodenum,  6;  jejunum, 
44;  ileum,  38 ;  "  other  parts  of  small  intestine,"  21;  large  intestine, 
4.  While  the  duodenum  and  large  intestine  escape  from  their 
sheltered  position,  the  jejunum  is  mosl  frequently  ruptured  in  its 
first  three  feet,  the  ileum  in  its  last  three.  Faecal  extravasation 
is  almost  invariably  present.  The  most  frequent  and  important  com- 
plication of  ruptured  intestine  is  laceration  or  contusion  of  the 
mesentery;  this  is  important  from  the  rapidly  fatal  hemorrhage,  or 
later  gangrene.  The  cases  of  ruptured  intestine  fall  clinically  into 
three  classes.  (A)  The  shock  never  leaves  the  patient,  may  never 
lessen,  hut  pass,  rapidly  or  slowly,  into  fatal  collapse.  This  may  he 
due  (1)  to  the  shock  of  the  accident;  (2)  to  haemorrhage;  (3)  to  faecal 
extravasation.  (B)  Those  in  which  evident  peritonitis  develops.  The 
diagnosis  is  easiest  in  these  cases,  but  unfortunately  they  are  not  the 
most  common.  (C)  The  most  common.  Instead  of  evident  peritonitis 
setting  in  after  reaction  has  taken  place,  vague  symptoms  appear,  keep- 
ing the  surgeon  in  expectation  of  it,  but  giving  nothing  on  which  he 
can  found  a  positive  diagnosis,  for  the  same  slight  indications  are 
common  in  cases  in  which  ultimate  recovery  has  taken  place.  Patient 
is  apathetic,  seemingly  satisfied  with  his  condition,  and  thus  mis- 
leading; or,  getting  gradually  weaker,  and  therefore  being  less  able  to 
complain,  appears  to  be  improving.  Peritonitis  in  this  group  of  cases 
develops  so  slowly  that  its  beginning  cannot  he  noted.  Duration  of 
life. — The  average  taken  from  113  cases  is  forty-eight  hours.  Chief 
points  in  the  diagnosis  of  rupture  oj  intestine. — Cause,  e.g.,  a  kick. 
This  was  so  in  28  per  cent,  of  the  cases.  The  intestine  is  crushed 
between  the  spine  and  the  force  employed.  The  severer  the  injury — 
e.g.,  a  kick  by  a  horse — the  more  likely  is  the  intestine  to  have  been 
injured.  Senn  (Amer.  Journ.  Med.  Sci.,  June,  1904)  draws  attention 
to  the  possible  occurrence  of  rupture  of  the  intestine  from  indirect 
violence,  such  as  falls  upon  the  buttocks,  and  records  the  interesting 
case  of  a  woman  wdio  fell  upon  the  right  buttock,  and  six  hours  later 
was  seized  with  violent  abdominal  pain.  "When  Senn  saw  her  two 
days  later,  she  was  very  ill  with  general  peritonitis,  and  upon  exploring 
a  small  laceration  of  the  jejunum  was  discovered  after  a  long  search. 
As  the  patient  was  in  a  very  grave  condition,  the  perforation  was 
sutured  to  the  abdominal  wound.  Rectal  feeding  was  adopted  for  eleven 
weeks,  during  which  time  several  attempts  were  made  to  close  the 
fistula  by  means  of  the  cautery.  Resection  was  ultimately  performed, 
and  proved  successful.  Rigidity  of  the  abdominal  wall  and  pain  and 
tenderness  at  one  spot  are  the  most  reliable  symptoms.  Tympanites, 
a  later  sign,*  is  of  grave  omen,  as  it  greatly  embarrasses  operative  inter- 
ference. Shockt  and  vomiting  afford  less  valuable  evidence,  unless 
persistent.  The  absence  of  each  has  led  to  fatal  delays.  Le  Conte 
(Ann.  of  Surg.  1903,  vol.  xxxvii.  p.  525),  in  his  address  on  "  Surgery" 
before  the  Philadelphia  Academy  of  Surgery,  discusses  the  diagnosis  of 
intestinal  injuries  very  thoroughly,  and  lays  stress  upon  the  importance 

*  When  present  early  and  :il'ili>liin^  the  liver  dulness  this  is  almost  pathognomonic 
of  injury  to  the  alimentary  canal 

t  Shock  is  quite  unreliable,  as  it  depends  not  only  on  the  severity  of  the  injury,  but 
on  the  idiosyncrasy  of  the  patient. 


RUPTURE   OF    THE    INTESTINE. 


441 


and  gravity  of  a  steadily  increasing  pulse  rate,  an  anxious,  careworn, 
and  painful  expression  of  the  face,  and  the  recurrence  of  vomiting 
after  reaction.  Brewer  also  read  a  valuable  paper  upon  this  subject 
before  the  New  York  Surgical  Society  [Ann.  of  Surg.,  [903,  vol.  xxxvii. 

]>.  197),  and  Btrongly  advocates  early  operation.  Jle  places  most 
reliance  upon  the  association  of  pain,  tenderness,  and  rigidity.  Evidence 
of  the  presence  of  free  fluid  in  the  peritonaeum  is  also  important.  The 
signs  of  internal  haemorrhage  have  already  been  alluded  to  at  p.  423. 
A  certain  diagnosis  is  seldom  possible  for  twelve  hours  or  longer,  hut 
the  surgeon  should  not  wait  on  this  account.  The  risk  nowadays  of 
doing  harm  by  exploring,  in  cases  where  no  laceration  of  the  intestine 
or  mesentery  is  present,  is  much  less  than  that  of  waiting  to  explore 
until  the  onset  of  a  septic  peritonitis  affords  certain  evidence.  As  in 
intestinal  obstruction,  abdominal  section  is  the  only  means  of  clearing 
up  the  diagnosis. 

Mr.  Ivohson  (Clin.  Soc.  Trans.,  vol.  xxi.  p.  130)  advises  as  follows 
on  the  question  of  operation  :  "  In  cases  of  doubt  one  is  so  prone  to 
wait,  hoping  for  the  turn  of  events,  and  then  to  arrange  to  operate 
when  too  late,  that  it  is  well  to  have  some  formulated  rule,  and  for 
my  own  guidance  I  have  adopted  the  following.  In  cases  where 
there  is  a  reasonable  helief  that  the  intestine  is  wounded  exploration 
by  a  small  median  incision  must  be  made,  when,  if  there  is  any  rupture 
of  the  howel,  flatus,  or  serum  tinged  with  blood,  or  faeculent  material 
will  escape  through  the  small  peritonaeal  opening,  which  can  be  enlarged 
and  necessary  treatment  adopted  ;  but  should  no  flatus  or  fluid  appear  and 
the  peritonaeum  prove  to  be  healthy,  the  small  wound  can  be  closed." 

That  the  hest  chance  is  afforded  by  early  operation,  as  soon  as  the 
period  of  shock  has  passed  off,  is  proved  by  recorded  results  (Battle). 
This  surgeon  points  out  (loc.  infra  cit.)  that  in  the  second  paper  read 
before  the  Clinical  Society  (Trans.,  1890)  by  Mr.  Croft,  out  of  14 
cases  then  collected  only  one  was  completely  successful,  a  case  operated 
on  by  Mr.  Croft ;  and  between  1890  and  1894  Mr.  Battle  had  collected 
15  cases,  seven  of  which  recovered.  Senn  states  that  retro-peritonaeal 
emphysema  indicates  an  injury  of  the  duodenum  or  colon.  The 
prognosis  depends  on  the  extent  of  injury,  the  amount  of  extravasation, 
and  the  amount  of  delay  before  operating.  Siegel  collected  376  cases 
which  were  operated  upon,  with  a  mortality  of  51*6  per  cent.  The 
following  figures  concerning  these  cases  prove  the  importance  and 
value  of  early  operation  : — 

Cases  operated  upon  first  4  hours,  mortality I5'2  % 

„  ,,  ,.         ,,    5  to  8  hours,  mortality 44"4  % 

„  ,.  „        „   9  to  12  hours,  mortality         ....  63*6  % 

.,      later 7°'°  % 

Treatment. — Where  rupture  of  intestine  or  severe  haemorrhage  is 
probably  present,  exploration  should  take  place  as  soon  as  possible, 
shock  being  combated  by  infusion  and  injection  of  adrenalin,  ergot,  or 
strychnine,  before,  during,  or  after  the  operation.  Valuable  time  should 
not  he  wasted  in  the  hope  that  the  shock  may  pass  off,  for  it  may 
never  do  so,  and  meanwhile  peritonitis  is  developing  ;  ether  is  the  best 
anaesthetic  to  choose.  The  incision  should  be  near  the  middle  line 
and  should  be  a  long  one,  at  least  four  inches,  the  parietes  here  being 


442  OPERATIONS  ON  THE  ABDOMEN. 

normal,  not  distended  and  atrophied,  as  in  abdominal  tumours.  When 
all  the  intestine  has  to  be  drawn  out  and  examined — and  no  operation 
can  be  otherwise  complete — the  incision  should  be  eight  inches  Long. 
In  any  case  the  centre  should  he  at  the  umbilicus,  unless  it  is  clear 
that  it  is  the  stomach  that  is  injured.  It  should  not  lie  lower  down,  or 
the  attachment  of  the  mesentery  may  interfere  with  the  pulling  out  of 
the  intestine,  especially  if  it  he  short  and  thickened  with  fat.  Blood 
may  show  through  the  peritonaeum  before  this  is  opened.  When  this 
memhrane  is  incised  a  sponge  should  he  passed  in  on  clamp-forceps  to 
search  for  hlood,  freces,  or  pus.  If  haemorrhage  is  going  on,  the  open- 
ing the  abdomen  may  stop  it  (Partes,  Med.  News,  May  17,  1884),  or  it 
may  increase,  causing  grave  symptoms.  If  blood  well  up,  a  hand 
should  he  passed  in,  under  the  omentum,  upwards  and  backwards,  to 
make  pressure  on  the  abdominal  aorta  and  root  of  the  mesentery.  All 
the  small  intestine  is  then  turned  out  into  hot  aseptic  towels  ;  bleeding 
points  are  found,  and  secured  with  clamp-forceps,  while  the  pressure  is 
relaxed  to  note  the  effect  on  the  hleeding.  The  hleeding  having  heen 
arrested,  any  injury  to  the  intestine  is  sought  for.  If  a  rupture  is 
found,  the  part  should  he  kept  outside  in  a  hot  aseptic  towel,  while  the 
rest  is  returned.  If  haemorrhage  is  slight  or  absent,  the  intestine 
should  be  drawn  out  loop  by  loop,  and  inspected  till  the  whole  is 
examined.  Fsecal  extravasation  should  be  avoided  by  extremely  careful 
handling  of  the  intestine,  the  wound  thus  remaining  unsoiled.  When 
all  the  intestine  has  been  inspected,  the  peritonaaal  sac  should  he  care- 
fully cleansed,  as  at  p.  336.  Any  distended  coil  may  be  aspirated,  and 
the  puncture  tied  up  or  opened,  as  at  pp.  264,  335.  Small  ruptures 
will  often  admit  of  suture  without  resection.  When  the  case  is  too 
grave  to  admit  of  resection  being  performed  and  of  the  necessary  plastic 
repair  taking  place,  the  best  course  is  to  make  an  artificial  anus  by 
closing  the  ends  of  the  intestine  with  ligatures  or  clamps  ;  then,  having 
thoroughly  cleansed  the  peritonaeal  sac,  next  bring  the  ends  out  and 
insert  Paul's  tube  (pp.  349,  387),  or  suture  the  ends  of  the  intestine  to 
the  margins  of  the  wound.  Resection  takes  very  little  more  time,  how- 
ever, and  is  to  be  preferred  except  in  the  gravest  cases,  where  intestinal 
drainage  is  imperative  (vide  p.  393).  This  course  ought  not  to  take 
more  than  half  an  hour.  Where  the  injury  is  high  up  in  the  intestine 
(ride  p.  415)  additional  risk  must  he  run  in  order  to  avoid,  by  resection, 
the  artificial  anus,  which  is  so  harmful  here,  [f  the  anus  be  made  use 
of,  it,  should  be  closed  as  early  as  possible,  or  the  nutrition  will  suffer 
fatally  (p.  415).  Other  viscera  may  be  injured  and  have  to  be  dealt 
with;  thus  lacerations  of  the  liver,  spleen,  or  kidney  may  he  sutured  or 
packed  with  gauze.  Brewer  (loc.  cit.)  advocates  packing  in  preference 
to  splenectomy  in  all  but  the  gravest  fractures  of  the  spleen,  this  plan 
saving  time  and  being  attended  with  less  shock  ;  it  also  preserves  a 
valuable  organ.  The  risks  of  reactionary  haemorrhage  are  greater, 
however.  Nephrectomy  is  necessary  in  some  cases  ;  lacerations  of  the 
pancreas  are  generally  beyond  surgical  treatment,  on  account  of  the 
associated  lesions,  the  profound  shock,  and  the  difficulties  of  arresting 
haemorrhage  ;  glycosuria  may  indicate  the  occurrence  of  this  serious 
injury,  as  in  a  recent  case  under  the  care  of  Mi',  ('lenient  Lucas  (vide 
Ch.  X.).  Saline  infusion  may  be  resorted  to  with  great  advantage  early 
in  the  operation,  before  collapse,  perhaps  irrecoverable,  has  set  in.    No 


RUPTURE   OF   THE   INTESTINE.  443 

operation  should  bo  performed  if  grave  collapse   is  present.     If  the 

patient,  docs  not  respond  to  stimuli,  he  will  not  survive  laparotomy. 

The  following  are  some  of  the  conditions  which  have  been  met  with 
in  exploration  of  injury  to  the  intestine  : — 

In  Dr.  Wiggins'  case,  to  which  I  have  already  alluded,  thirty -six  hours  after  the  bo; 
had  been  kicked  by  a  horse,  the  abdomen  was  opened  and  the  small  intestine  withdrawn 
and  carefully  examined,  beginning  with  the  ileo-crccal  region.  Near  the  jejunum  a  bruised 
ami  livid  knuckle  was  discovered.  Though  no  perforation  was  made  out  in  it  prior  to  the 
resect  i>  hi.  a  small  perforat  ion  was  found  afterwards  near  the  mesenteric  border.  About  six 
inches  were  resected,  the  ends  being  united  by  Maunsell's  method.  Owing  to  the  patient 
"coming-to"  and  straining  while  the  resection  was  being  performed,  blood  and  faecal 
matter  escaped  into  the  peritonaea]  sac,  this  accident  being  due  to  the  safety-pins  used  as 
clamps  being  too  large.  A  50  per  cent,  solution  of  hydrogen  dioxide  was  poured  in,  and 
allowed  to  remain  while  the  ends  were  being  united,  and  the  cavity  was  afterwards  flushed 
with,  and  finally  left  full  of,  sterilised  salt  solution.  The  patient,  a  boy  aged  15,  made  a 
good  recovery  (New  York  Med.  Journ.,  Jan.  20,  1894). 

In  a  case  fully  reported  by  Mr.  Battle  {Lancet,  vol.  i.  1894,  p.  1121, 
a  paper  which  will  well  repay  perusal),  the  following  was  the  condition 
present  when  the  peritonaeum  was  opened*  : — 

A  gush  of  blood  followed,  and,  as  the  patient  was  straining,  a  coil  of  intestine  was 
forced  out.  A  rent  was  found  in  the  mesentery  of  this  coil,  bleeding  freely.  While  this 
haemorrhage  was  being  arrested  with  clamp-forceps,  the  open  end  of  a  piece  of  intestine 
sprang  into  the  wound.  The  other  end  was  found  by  tracing  the  mesentery  along. 
This  portion  of  mesentery  was  much  contused  and  lacerated,  and  there  was  a  second 
complete  rupture,  about  eight  inches  from  the  first.  Only  a  small  portion  of  the  contents 
had  escaped,  among  which  were  one  or  two  partly  digested  beans.  As  it  was  evident  that 
the  condition  of  the  mesentery  would  result  in  gangrene  if  it  were  left,  resection  was 
performed,  nearly  thirteen  inches  being  removed  with  a  large  wedge-shaped  piece  of 
mesentery.  While  a  lateral  anastomosis  was  being  performed  here  by  Senn's  method,  it 
was  discovered  that  a  third  rupture  existed,  about  a  foot  beyond  the  second.  This  rupture 
was  not  quite  complete.  It  was  closed  "  by  means  of  Senn's  plates,  cut  to  the  required 
size,  and  a  ring  of  Lembert's  sutures  used  to  further  strengthen  the  union. "f  The  patient 
did  well  until  the  fifth  day,  when  evidence  of  perforated  peritonitis  appeared.  The 
abdomen  was  again  opened,  and  it  was  found  that  the  end  to  end  union  had  broken  down, 
leading  to  leakage.     An  artificial  anus  was  made,  but  the  patient  never  rallied. 

Mr.  Croft  has  recorded  two  cases  of  rupture  of  the  small  intestine 
without  external  wound  {Clin.  Soc.  Trans.,  vol.  xxi.  p.  254,  and  vol. 
xxiii.  p.  141).  These  must  be  looked  upon  as  pioneering  cases,  as  far 
as  this  country  goes,  in  the  modern  treatment  of  these  injuries.  Both 
patients  recovered — the  one  completely,  after  primary  enterorraphy  by 
Lembert's  method ;  in  the  other  case  an  artificial  anus  was  made. 
This  was  closed  by  resection  of  the  intestines  four  weeks  later,  but 
the  patient  sank,  thirteen  hours  after  the  operation,  from  exhaustion, 
due    chiefly   to    "the   irrepressible    escape    of  intestinal   contents   at 


*  The  patient,  aged  24,  had  been  kicked  in  the  abdomen  by  a  horse.  He  was  admitted 
into  St.  Thomas's  Hospital  shortly  after,  and  was  operated  upon  about  six  hours  later, 
when  the  shock  had  passed  off. 

t  This  operation  lasted  over  two  hours,  and,  owing  to  the  increased  shock,  five  pints 
of  saline  solution  were  injected  with  a  good  effect. 


444  OPERATIONS  ON  THE  ABDOMEN. 

the  artificial   anus."     The  following  points  amongst  many   others  are 
noteworthy  in  the  two  lust  instructive  cases: — 

In  the  first  case,  three  separate  lesions  were  discovered ;  the  ileum  had  been  ruptured 
transversely  Eor  two-thirds  of  its  circumference  a1  the  junction  of  its  upper  and  middle 

thirds.  There  was  a  laceration  of  an  inch  and  a  half  in  the  mesentery  in  the 
neighbourhood,  and  a  considerable  rent  in  the  omentum  above  the  level  of  the 
umbilicus.  Faecal  peritonitis  had  spread  from  the  ruptured  intestine  into  the  iliac, 
umbilical,  and  hypogastric  regions,  eighteen  hours  and  a  half  having  elapsed  between  the 
injury  and  the  operation.  The  peritonaeum  was  very  carefully  irrigated  with  warm 
boracic  acid  solution  (from  16  to  20  per  cent.),  and  the  edges  of  the  ruptured  intestine 
brought  out  into  the  wound.  Mr.  Croft  points  out  that  the  result  of  this  case  Bhows 
that  it  would  probably  have  been  a  safe  practice  to  have  trimmed  the  edges  of  the 
ruptured  gut  and  completed  an  enterorraphy  by  Lembert's  sutures,  as  the  irrigation 
was  evidently  efficient.  This  would  have  saved  the  inanition  and  debility  consequent  on 
the  establishment  of  an  artificial  anus,  the  external  irritation  and  the  septic  condition  of 
the  parts  around  the  opening,  and  the  second  long  and  risky  operation  required  to 
close  it. 

In  the  second  case,  fourteen  hours  had  elapsed  between  the  operation  and  the  kick  from 
a  horse.  A  faint  faecal  odour  was  observed  when  the  peritoneal  sac  was  opened,  and 
about  an  ounce  and  a  half  of  faecal  fluid  was  found  extra vasated  between  some  coils  of 
intestine  adherent  to  each  other  and  the  omentum.  On  tearing  through  the  adhesions 
and  separating  the  coils  on  the  right  side,  about  two  inches  below  the  umbilicus,  a 
small  rupture  was  found  in  the  ileum,  situated  in  an  areola  of  inflamed  and  ecchymosed 
tissue.  Resection  of  the  damaged  intestine  was  performed,  the  ends  being  united 
by  about  forty  Lembert's  sutures.  The  peritoneal  sac  was  carefully  purified  with  a 
hot  20  per  cent,  solution  of  boracic  acid.  The  patient,  aged  14,  made  an  uninterrupted 
recovery. 

I  can  only  find  space  for  one  other  of  these  most  interesting  cases. 
It  is  recorded  by  Mr.  W.  T.  Thomas,  assistant  surgeon  to  the  Royal 
Infirmary  at  Liverpool  (Brit.  Med.  Journ.,  vol.  i.  1894,  p.  1355).  It 
presents  the  following  points  of  interest : — 

(1)  The  slightness  of  the  injury.  The  patient,  aged  55.  had.  twenty-four  hours 
before  the  operation,  struck  her  abdomen  against  a  chair  which  she  was  carrying  before 
her,  and  which  caught  against  a  doorpost.  (2)  The  absence  of  symptoms  in  a  case 
of  severe  septic  peritonitis,  only  distension  and  tenderness  being  present.  When  the 
abdomen  was  opened,  about  half  a  pint  of  putrid  serum,  with  large  yellowish  flakes 
of  puriform  lymph,  escaped.  The  intestines  were  all  distended,  and.  as  no  collapsed 
coils  could  be  found,  the  small  intestine  was  withdrawn.  After  two  feel  had  been 
examined,  a  perforation  was  found*  about,  three-quarters  of  an  inch  long,  from  which 
oozed  faecal  fluid.  This  was  closed  by  two  rows  of  continuous  Lembert's  sutures,  the 
mucous  membrane  being  carefully  tucked  in.  Thorough  irrigation  with  a  1  per  cent, 
solution  of  carbolic  acid  was  then  carried  out,  a  glass  tube  being  left  in.  The  patient 
made  a  good  recovery. 

Interesting  and  instructive  cases  will  be  found  related  in  the  recent 
papers  of  Brewer,  Senn,  and  Le  Conte,  which  have  been  already 
referred  to  ;  and  recoveries  are  now  fairly  common  at  all  large  general 
hospitals. 

*  The  site  of  the  rupture  was  not  given,  nor  is  it  stated  whether  much  difficulty  was 
met  with  in  dealing  with  the  distended  intestines. 


CHAPTER  VII. 
OPERATIONS    ON   THE    STOMACH. 

GASTROSTOMY.  —  GASTROTOMY.— DIGITAL       DILATATION 

OF    PYLORUS.— PYLOROPLASTY.— GASTRO-DUODENOS- 

TOMY.— PARTIAL       GASTRECTOMY.— GASTROCTOMY  — 

GASTROJEJUNOSTOMY.— DUODENOSTOMY    AND   JEJU- 

NOSTOMY. 

GASTROSTEMY. 
Indications. 

I.  Certain  cases  of  cancerous  stricture.  This  also  includes  invasion 
of  the  oesophagus  secondarily  from  primary  cancer  of  the  mediastinal 
glands,  &c.  2.  Cancerous  disease  of  the  pharynx  ;  and,  in  a  few  cases, 
malignant  disease  of  the  tonsil  or  back  of  the  tongue  not  admitting  of 
operation. 

A  very  interesting  case  is  given  by  Mr.  Whitehead  {Brit.  Med.  Jovrn.,  July  22,  1882). 
Here,  in  a  patient  aged  40,  excision  of  the  tongue  had  to  be  followed  by  tracheotomy 
and  gastrostomy,  owing  to  the  original  extent  of  the  disease.  At  the  last  report  the 
patient  was  alive,  four  months  after  the  gastrostomy,  five  after  the  removal  of  the 
tongue.  Two  such  cases  are  given  by  Mr.  Stonham  (Lancet,  Oct.  2,  1886).  One  patient 
survived  four  months,  the  other  one.  In  this  case  the  growth  was  so  extensive  as  to 
necessitate  tracheotomy  at  an  early  stage  of  the  gastrostomy.  Both  patients  experienced 
great  relief.  Tracheotomy  was  also  required  in  Mr.  King  Green's  case  (Lancet,  Feb.  3, 
1883),  though  here  the  disease  was  either  in  the  pharynx  or  upper  part  of  the  oesophagus. 
I  think  that  in  such  cases,  also,  the  last  few  months  of  life  might  often  be  rendered  much 
more  comfortable  by  a  timely  gastrostomy.  M.  Morestin  (Lancet,  1906,  vol.  i.  p.  634)  has 
recently  drawn  attention  to  this  subject  again. 

3.  Cicatricial  stricture,  whether  traumatic  or  syphilitic. 

The  first  of  these,  from  its  frequency,  requires  separate  notice. 

1.  Cancerous  Stricture. — Here  several  points  call  for  attention. 
Amongst  the  chief  are — the  question  of  the  treatment  of  oesophageal 
cancer  by  passage  of  tubes  or  gastrostomy,  the  mortality  of  the  latter 
operation,  and  the  best  date  for  performing  it. 

The  following  remarks  b_y  Mr.  Symonds  are  of  value  in  view  of  his 
large  experience  of  these  cases  : — 

"  I  would  put  the  general  question  of  treatment  in  the  following  way 
as  applying  to  all  cases.  (1)  While  the  patient  can  swallow  fluids  and 
semi-solids,  and  while  a  bougie  can  be  passed  and  plenty  of  nourish- 
ment taken,  he  may  be  left  alone  so  long  as  (a)  he  can  swallow  well  or 
(b)  a  small  bougie,  No.  12  catheter  gauge,  can  be  passed.  (2)  If  the 
dysphagia  increases,  even  though  a  bougie  can  be  passed,  then  a  tube 
must  be  inserted,  or  gastrostomy  must  be  performed.     These  conditions 


446  OPERATIONS   ON   THE    ABDOMEN. 

are  seen  in  the  soft  fungating  forms.  (3)  [fa  bougiecannol  be  passed, 
or  goes  with  difficulty,  then  the  same  course  must  be  followed,  as  we 
know  that  complete  closure  may  occur  at  any  time.  (4)  It'  both  condi- 
tions arise — i.e.,  the  patient  cannot  swallow,  and  a  bougie  cannot  be 
passed — then  immediate  mechanical  treatment  is  required"  {Lancet, 
1902,  vol.  ii.  p.  351). 

Between  treatment  by  gastrostomy  and  that  by  tubes  no  fair  com- 
parison can  be  made,  because  the  former  operation  has,  in  such  a  large 
number  of  cases,  been  performed  under  most  unfavourable  conditions. 
Much  too  often  it  has  been  put  off  till  the  patient,  scarcely  able  to 
swallow  liquids,  is  just  kept  alive  by  enemata.  Such  patients,  worn  out 
by  the  miseries  of  slow  starvation,  often  with  secondary  disease  and 
lung  and  pleural  trouble,  are  not  in  a  condition  to  he  submitted  to 
abdominal  section,  and  are  not  likely  to  respond  to  the  call  made  upon 
their  vitality  to  unite  two  serous  surfaces  firmly  together,  on  which 
depends  the  success  of  the  operation.  I  do  not  think  that  I  exaggerate 
if  1  say  that,  in  a  distinct  proportion  of  the  cases  in  which  the  surgeon 
is  asked  to  perform  gastrostomy,  the  hand  of  death  is  already  on  the 
patient,  and  something  next  door  to  the  decomposition  of  the  grave  has 
already  set  in,  owing  to  the  extension  of  the  disease. 

In  advising  gastrostomy,  each  case  must  be  decided  on  its  merits  ;  the 
patients  here  are  not  only  adults,  but  well  on  in  life,  and,  when  assured 
that  the  end  is  certain,  the  surgeon  may  in  most  cases,  having  put  all 
the  risks  before  the  patient,  leave  it  to  him  to  decide.  But  I  think 
that  if  the  patient,  having  previously  declined  it,  only  asks  for  operation 
when  it  is  clearly  too  late,  the  surgeon  should  he  firm  enough  to  decline 
to  operate  where,  on  every  ground,  his  interference  will  he  hope! 

The  following  points  help  in  a  decision  between  gastrostomy,  bougies, 
and  tubage  :  i.  Food  taken. — As  long  as  pulpy,  semi-solid,  or  a  pro- 
portion of  solid  food  is  taken,  the  occasional  passage  of  a  bougie  should 
be  persevered  with.  Bougies  should  not  be  passed  for  the  object  of 
dilating  the  stricture.  "  It  is  injurious  in  that  it  irritates  and  leads  to 
increase  of  obstruction  ;  it  may  split  a  hard  stricture,  and  set  up  rigor 
and  fever  from  absorption"  (Symonds,  Lancet,  vol.  ii.  1902,  p.  353). 
A  small  bougie  may  be  passed,  "  simply  to  secure  the  route,  so  that  at 
any  time  a  tube  can  he  passed  tor  feeding  purposes  or  the  time  fixed 
tor  gastrostomy."  But  when  the  patient  is  becoming  restricted  to  liquids, 
a  tube  should  be  introduced,  or  failing  this,  a  gastrostomy  performed. 
When  the  patient  is  fed  by  enemata  only,  and  merely  takes  ice  by  the 
mouth,  it  is  too  late  to  operate,  ii.  Amount  of  pain  felt  with  and 
difficulty  in  passing  bougies  <>r  tubes. — Any  sensation  of  a  rough,  raw 
Burface,  any  blood  or  broken-down  tissue  on  the  bougie,  increased 
expectoration,  dyspnoea,  paroxysmal  cough  (this  may  occur  after  even  a 
teaspoonful  of  thuds),  fcetor  of  sputum  or  bougie,  make  it  evident  that 
the  passage  of  instruments  causes  advance  of  ulceration  and  sloughing; 
when  this  is  increasingly  accompanied  with  pain  and  evidence  of  lar\  mjeal 
irritation,  gastrostomy  should  he  proposed,  iii.  Site  of  stricture. — The 
lower  down  this  is,  the  more  difficulty  will  there  usually  be  in  dealing 
with  it  by  dilatation,  and  the  nearer  are  important  parts,  iv.  Condition 
of  patient. — Here  the  rate  of  emaciation  must  he  watched  ;  anything  like 
loss  of  one  to  two  pounds  a  week  is  Very  ominous.  How  far  is  the  strength 
preserved?  how  far  does  the  patient  tend  to  give  up  his  life-habits? 


CASTKOSTUMY. 


4-47 


how  far  ia  he  bedridden?  Where  the  pulse  Is  thready,  the  extremities 
cold,  the  temperature  never  up  to  normal,  the  case  has  gone  too  far. 
v.  Condition  of  viscera. — Evidence  of  implication  of  trachea  or  bronchi, 
of  pleuritic  effusion,  and  of  broncho-pneumonia  must  I"-  sought  for. 
Phthisis  Bometimea  d<  velopa  or  is  reawakened  in  these  patients,  and  is 
very  apt  to  be  overlooked  on  account  of  the  masking  of  the  Bymptoma 
by  the  disease  of  the  oesophagus.     It'  there  is  reason  to  believe  that  the 

growth  has  extended  beyond  the  (esophagus,  operation  should  usually  he 

declined,  vi.  Rank  of  life. — A  patient  who  can  afford  all  the  luxuries  of 
life,  and  who  can  have  everything  done  to  palliate  his  condition,  is 
obviously  in  a  very  different  condition  from  one  in  a  humbler  position. 
I  would  thus  sum  up  this  question  of  gastrostomy  or  tubage  : — As 
Long  as  a  patient  can  swallow  sufficient  food  by  this  means,  treatment 
by  tubes  is  far  preferable.  Whenever  they  can  be  introduced,  the 
tubea  ingeniously  devised  by  Mr.  Symonds*  are  to  be  preferred. 
These  have  a  funnel-shaped  extremity  resting  on  the  upper  end  of  the 
stricture,  are  introduced  on  a  whalebone  guide,  and  are  kept  in  situ  by 
a  loop  of  silk  which  is  passed  round  the  ear.  They  have  the  great 
advantage  of  allowing  the  patient  to  swallow  his  saliva  and  food,  and 
thus  retain  the  pleasures  of  taste.  These  tubes  may  be  retained  in 
position  for  months  ;  in  one  case  under  the  care  of  Mr.  Symonds  the 
tube  was  worn  unchanged  for  thirteen  months.  If  the  silk  break,  great 
trouble  may  accompany  the  removal  of  the  tube,  but  this  rarely  occurs 
when  the  silk  is  protected  by  rubber  tubing. 

In  one  patient,  who  bit  through  the  silk,  the  latter  blocked  the  narrow  part  of  the 
lumen  of  the  tube.  Prolonged  attempts  to  withdraw  the  tube  were  of  no  avail,  until,  at 
the  patient's  suggestion,  another  Symonds'  tube  was  introduced  into  the  original  one. 
The  introducer  was  withdrawn  and  traction  made  on  the  string  of  the  second  tube  ;  this 
was  at  once  successful,  the  tubes  keeping  together  by  suction. 

Except  for  certain  short  strictures  situated  from  ten  to  fourteen  inches 
from  the  teeth,  Mr.  Symonds  now  uses  his  long  rubber  tube,  which  may 
last  for  about  nine  months.  It  should  never  be  removed  for  cleansing 
purposes,  on  account  of  the  difficulty  of  replacing  it,  unless  this  is 
attempted  at  once.  Saliva  cannot  be  swallowed,  as  a  rule,  when  this 
tube  is  in.  The  tube  should  not  be  passed  when  the  patient  is  under  an 
anaesthetic,  for  it  may  enter  the  larynx  and  trachea  when  the  former 
is  insensitive,  and  this  has  been  attended  with  disastrous  consequences. 

Any  surgeon  treating  cancerous  stricture  here  by.  tubage  must 
remember  that  treatment  of  cancer  in  this  way  is  contrary  to  what 
is  generally  practised,  and  is  only  justifiable  here  on  special  grounds — 
e.g.,  the  fatality  of  the  disease  and  the  risks  of  gastrostomy  ;  that  these 
risks    have    been    enormously    increased    by   the    way    in    which    this 

*  Clin.  Soe.  Iran*.,  vols,  xviii.  p.  155.  xxii.  p.  306  ;  Brit.  Med.  Journ.,  April  23, 1887. 
See  also  Dr.  Eodman's  two  ca~es,  Brit.  .Med.  Journ.,  May  25,  1889.  It  is  clear  from  these 
cases  that  the  patients  can  be  kept  alive  as  long  and  gain  weight  equally  by  tubage  as  by 
gastrostomy,  and  that  in  some  cases  even  a  malignant  stricture  can  be  dilated.  On  the 
other  hand,  the  passage  of  tubes,  where  there  is  considerable  narrowing,  clearly  requires 
some  force,  and  thus  needs  skilled  and  very  careful  hands.  Even  in  such  hand?,  fatal 
mischief  has  been  inflicted.  Furthermore,  the  blocking  of  the  smaller  tubes,  which  alone 
will  pass  in  the  later  stages  through  tight  and  ulcerating  strictures,  may  necessitate 
frequent  changing,  irritation,  and  thus  hasten  sloughing  of  the  growth.  The  close 
contiguity  of  this  to  the  trachea,  pleurae,  (See.,  must  not  be  forgotten. 


448  OPERATIONS  ON  THE  ABDOMEN. 

operation  has  been  deferred  ;  that  in  these  cases  a  time  may  come  when 
tubes  can  no  longer  be  made  use  of;  and  that  if  gastrostomy  has  been 
deferred  till  now,  it  can  only  be  performed  with  greatly  increased  risk. 
In  other  words,  the  patient  should  understand  that  if  he  slums  the 
risks  of  an  early  operation,  he  renders  himself  liable  to  other,  but  as 
serious,  risks  by  deferring  it  till  an  hour  when  he  can  only  ask  for  it, 
and  the  surgeon  only  attempt  it,  as  an  almost  utterly  forlorn  hope. 

The  question  of  which  gives  the  greatest  comfort  cannot  be  answered 
dogmatically.  But  no  one  who  has  seen  many  cases  of  gastrostomy, 
and  met  with  a  fair  proportion  of  success,  will  hesitate  to  prefer  the 
result  of  this,  if  performed  early,  with  its  gain  of  weight  and  freedom  from 
pain  and  irritation  during  the  few  months  which  in  any  case  remain, 
to  the  passage  of  tubes  necessarily  more  and  more  frequent  and  difficult 
as  the  case  progresses,  with  the  not  infrequent  distress  and  choking 
when  they  are  introduced,  the  blockage  of  the  hollow  ones  b}r  sputum 
or  food,  and  the  needful  withdrawal  and  reintroduction,  easily  effected, 
no  doubt,  for  some  time,  but  ever  irritating  and  fretting  the  growth. 

Mr.  Symonds  (loc.  supra  cit.)  summarises  his  views  upon  the  subject 
as  follows  : — 

"  i.  In  cricoid  obstruction  the  long  rubber  tube  gives  excellent 
results.  When  not  well  borne  gastrostomy,  if  selected,  should  be 
performed  early.  2.  In  disease  of  the  central  portion  the  short  tube  is 
serviceable  in  a  fair  number  of  cases,  and  when  it  acts  well  is  superior 
to  any  other  method.  It  must  be  replaced  by  the  long  feeding  tube 
when  pulmonary  symptoms  arise.  3.  In  disease  of  the  cardiac  orifice 
tubage  is  so  uncertain  that  gastrostomy  should  be  performed  when 
dysphagia  becomes  serious." 

I  have  performed  gastrostomy  twelve  times,  in  each  case  for  cancer 
of  the  oesophagus  :  in  six  patients  the  operation  was  asked  for  too 
late ;  in  one,  my  seventh  case,  the  patient  died  from  an  accident  for 
which  I  am  responsible ;  the  other  five  recovered  well.  One,  a 
young  married  woman,  had  had  symptoms  six  months  ;  she  was  in  the 
fourth  month  of  pregnancy  when  operated  on  :  she  lived  in  comfort 
for  six  months,  and  died  of  extension  to  the  lung  a  month  after  giving 
birth  to  a  child  at  the  full  time.  Another  patient  lived  between  three 
and  four  months,  and  would  have  survived  longer  if  it  had  not  been 
for  his  carelessness  as  to  exposure.  A  third  was  alive  and  progressing 
satisfactorily  when  last  heard  of,  four  months  after  the  operation.  The 
fourth  is  still  alive,  four  months  after  his  operation.  The  fifth  made  a 
good  recoveiy,  but  I  lost  sight  of  the  case  nine  weeks  after  the  operation. 

E-obson  and  Moynihan  (Diseases  of  the  Stomach,  1904)  state  that 
three  deaths  occurred  in  nine  gastrostomies  performed  before  1896,  and 
only  three  deaths  in  thirty-four  of  these  operations  since  1896. 

T.  P.  Legg  (Lancet,  vol.  i.  1905,  p.  174),  in  fifteen  gastrostomies  for 
cancer  of  the  oesophagus,  had  three  deaths  within  a  fortnight  of  the 
operation;  nine  survived  for  periods  varying  from  six  weeks  to  seven 
months,  and  two  of  these  were  still  living  when  Mr.  Legg  wrote  his 
paper*  they  had  survived  for  six  weeks  and  five  months  respectively. 

Operation  (Figs.  163 — 171). — Those  precautions  being  taken  against 
shock,  such  as  warm  wraps,  hot-water  bed,  table,  or  bottles,  ether  is 
given  if  the  condition  of  the  lungs  admits  of  it,  and  if  it  is  quietly 
taken  without  troublesome,    heaving    breathing.       The    surgeon    will 


CAST  I  {OSTOMY. 


449 


usually  find  it  most  convenient  to  stand  on  the  right  side  and  to  have 
his  patient  drawn  over  to  this  side  of  the  table.  The  shoulders  should 
be  somewhat  raised  and  the  hips  slightly  flexed,  to  relax  as  much  as 
possible  the  tension  of  the  soft  parts,  which  often  fall  with  embarrass- 
ing sharpness  over  the  epigastric  angle  from  the  prominent  ribs  down 
to  the  wasted,  retracted  umbilical  region  (Fig.  163). 

Sir  Henry  Howse  {Diet.  Pract.  Surg.,  p.  590)  recommends  the 
following  incisions  :  (1)  An  oblique  one,  about  two  inches  and  a  half 
long,  parallel  with  and  about  one  inch  below  the  lower  margin  of  the 
left  costal  cartilages.  This  incision  should  start  about  an  inch  and  a 
half  from  the  middle  line,  and  its  length  must  depend  on  the  varying 
development  of  the  rectus  muscle.  It  should  not  go  higher  than  the 
above    point,    as    it    will    not    leave 

enough  free  skin  and  muscle  between  Fig.  163. 

the  cartilages  and  the  incision  to  fasten 
the  sutures  to.  This  first  incision  is 
only  to  be  carried  through  the  skin 
and  fascia.  When  made,  the  sheath 
of  the  rectus  will  be  seen  at  the 
inner  end,  and  at  its  outer  end  a 
portion  of  the  linea  semilunaris  and 
of  the  external  oblique.  The  usual 
plan  of  continuing  the  operation  is  to 
have  the  muscles  and  fasciae  of  the 
abdomen  incised  in  the  same  way  as 
the  superficial  parts.  Howse  prefers 
to  continue  the  operation  as  follows: 
(2)  The  lips  of  the  wound  being  sepa- 
rated towards  the  inner  part  as  widely 
as  possible  b}r  retractors,   a   vertical 

incision  is  made  in  the  sheath  of  the  rectus  a  little  distance  from  its 
outer  margin.  The  vertical  fibres  of  this  muscle  will  then  be  seen,  and 
these  should  be  separated,  not  cut,  with  a  steel  director,  and  the  posterior 
part  of  the  sheath  exposed.     This  may  then  be  incised  vertically. 

From  my  experience  of  12  cases  I  prefer,  as  simpler,  a  single 
vertical  incision  (Fig.  163)  beginning  opposite  to  the  end  of  the  eighth 
intercostal  space  and  passing  down  for  two  inches  over  the  rectus — 
i.e.,  about  two  inches  from  the  linea  alba.  The  fibres  of  the  rectus, 
being  exposed,  are  separated  with  a  steel  director,  or  the  muscle  may  be 
drawn  well  outwards.  The  posterior  layer  of  the  rectus  sheath  and  the 
peritonaeum  are  divided  together,  the  incision  being  about  an  inch  and  a 
half  long.     A  finger  is  now  introduced  (Fig.  163)  to  feel  for  the  stomach. 

As  a  rule,  the  contracted  stomach  lies  high  up  under  the  left  lobe  of 
the  liver,  and  requires  to  be  hooked  downwards  and  forwards  into  the 
wound.  Not  infrequently  the  great  omentum  presents  first,  and  it  is 
easy,  hy  seeking  too  low  down,  to  draw  up  the  colon.  In  case  of 
difficulty  the  best'  plan  is  to  find  the  anterior  border  of  the  liver,  trace 
up  the  under- surface  to  the  portal  fissure,  and  thence  along  the  lesser 
omentum  to  the  stomach.  This  is  told  by  its  thicker,  more  substantial 
feel,  and  pink-red  colour. 

The  stomach  being  drawn  up,  a  partis  chosen  on  its  anterior  surface, 
free  from  vessels,  and  as  near  as  possible  to  the  cardiac  end. 

s. — vol.  11.  29 


The  finger  searching  for  the  stomach 
through  a  vertical  incision. 


450 


OPKRATIONS    ON    T1IK    AliDOMKX. 


A  number  of  different  methods  of  completing  the  operation  have  been 
devised,  the  object  being  to  produce  a  valvular  opening  into  the  Btomach 

and  thus  prevent  constant  leakage  and  its  attendant  troubles.  The 
methods  described  below  are  the  most  satisfactory,  and  each  of  them 
has  strong  supporters,  the  advantages  claimed  beingthe  formation  of  a 

satisfactory  valve  and  the  absence  of  leakage.  l>r.  Dennis  (Ann.  <>f  Simj., 
November,  1899,  p.  633)  describes  a  very  satisfactory  result  in  a  case 
of  cicatricial  stenosis  of  the  oesophagus,  operated  upon  by  Marwedel's 
method  two  years  previously.  The  man  could  remove  and  insert  the 
tube  without  any  trouble,  and  there  was  no  leakage  when  the  tube  was  out. 


Fig.  164. 
Tube 


Parietal 
suture 


Fig.  1G5. 


Tube 


Continuous 
Lembert 
suture 


Puncture 
into  stomach 


a  -   suture 


End  to  be  passed 
through    puncture 


Witzel's  method  of  gastrostomy.     Lembcrt's  sutures  are  placed  WitzePa  method  of 

in   the  walls  of  the  stomach  before  the  perforation   is  made.  gastrostomy.    The 

W  In  11  the  lower  suture  is  tightened  the  tube  and  the  aperture  are  two  sutures  have  been 

buried  by  two  sero-muscular  folds.     (Modified  from  Kocher.)  tied. 


The  results  obtained  by  the  methods  of  Albert  and  Ssabanijews- 
Frank  are  very  satisfactory,  these  methods  having,  moreover,  the  great 
advantage  of  being  extremely  simple  ami  quickly  performed. 

i.  Witzel's*  Method  (Figs.  164  and  165). — The  peritoneum  is 
opened  either  by  the  incision  parallel  to  the  left  border  of  the  ribs  or, 
as  I  prefer  (p.  449),  by  one  through  the  rectus  muscle.  The  stomach 
having  been  drawn  out,  a  very  small  opening  is  made  near  its  cardiac 
end,  and  a  snugly-fitting  rubber  tube  introduced,  and  then  buried  in 
the  wall  of  the  Btomach   for  ahoul  two  inches  by  Lembert's  sutures, 


*  Centr.  f.  f/tir.,  1891,  p.  Goi.  An  interesting  account  01  this  method  is  given  by 
Dr.  W.  Meyer  |  Ann.  of  Surg.,  vol.  i.  1893,  p.  592).  Wit/..]  gives  two  successful  cases.  Dr. 
Meyer  quotes  Mikulicz  as  having  operated  live  times  successfully,  and  as  recommending 
Witzel's  method  as  the 


GASTROSTOMY. 


45i 


two  folds  of  the  stomach  wall  being  stitched  over  the  tube,  as  seen  in 
Figs.  164  and  165.  A  continuous  Lembert  stitch  is  simpler,  quicker, 
and  just,  as  good  as  interrupted  sutures.  The  free  end  of  the  tube  is 
then  brought  out  of  the  wound,  while  the  area  around  it  is  stitched 
carefully  to  the  peritonaeum  on  either  side  of  the  wound  in  the  parietes. 
It  is  far  easier  and  safer  to  fix  the  stomach  to  the  parietal  peritonaeum 
and  rectus  sheath  before  the  opening  is  made  into  it  (vide  Fig.  164) ; 
and  the  tube  can  also  be  almost  completely  buried  before  the  perfora- 
tion is  made,  the  lower  end  of  the  tube  introduced  through  this,  and 


Fig.  166. 


Frank's  method  of  gastrostomy.  The  stomach  is  drawn  upwards,  while  below 
the  peritonaeum  and  deeper  layer  of  the  sheath  of  the  rectus  have  been  stitched  to 
it  by  a  continuous  suture.  Retractors  hold  the  fibres  of  the  rectus  apart.   (Kocher.) 

another  suture  is  used  to  bury  the  site  of  penetration  of  the  stomach. 
The  edges  of  the  wound  having  been  sutured,  the  upper  end  of  the 
tube  may  be  closed  with  a  clip,  and  a  sealed  dressing  applied.  Feed- 
ing by  the  stomach  is  begun  at  once.  Any  leakage  is  prevented,  not 
only  by  this  oblique  entrance  of  the  tube  into  the  stomach,  but,  as 
shown  by  a  specimen  obtained  from  a  patient  of  Dr.  Meyer  (loc.  supra 
cit.),  by  the  fact  that  Witzel's  ingenious  method  of  stitching  the  stomach 
walls  over  the  tube  causes  a  short  artificial  cone  to  protrude  obliquely 

29 — 2 


452 


OPERATIONS  ON  THE  ABDOMEN. 


into  the  lumen  of  the  stomach.*  Mikulicz  and  Helferich  have  shown 
that,  after  the  lapse  of  a  few  months,  the  oblique  passage  may  become 
a  direct  one. 

ii.  Mkthod  of  Frank  (Albert,  Ssabanijews-Frank). — The  peri- 
tonaeum is  opened  either  by  an  incision  parallel  with  the  costal  cartilages, 
or  by  one  just  within  the  linea  semilunaris  high  up.  The  stomach 
having  been  drawn  out,  along  conical  diverticulum  of  the  anterior  wall  of 
the  viscus  is  pulled  well  out  of  the  wound,  and  the  parietal  peritonaeum 


Fig.  167. 


#!» 


Gastrostomy  by  Frank's  method  completed.  Below  is  seen  the  chief  wound 
closed  by  a  continuous  suture.  Above  is  the  small  wound  through  which  the 
stomach  has  been  opened.     (Kocher.) 

and  the  posterior  layer  of  the  sheath  of  the  rectus  are  sutured  round 
its  base,  care  being  taken  not  to  constrict  it  too  much  (Fig.  166).  A 
continuous  suture  is  used,  and  every  care  taken  not  to  perforate  the 
mucous  coat  of  the  stomach.  A  small  transverse  incision  is  now  made 
through  the  skin  a  little  above  the  front  and  on  the  level  of  the  costal 
cartilages.     The  skin  between  the  two  openings  having  been  separated 

*i  Another  advantage  <>f  Witzel's  method  is  illustrated  by  one  of  his  cases.  In  a 
patient  who  had  been  operated  upon  for  cicatricial  stricture  of  the  oesophagus,  the  fistula 
closed  spontaneously  within  sixteen  days  after  the  stricture  had  been  dilated  and  the  tube 
removed  from  the  Btomach  (Meyer). 


GASTROSTOMY,  453 

iVoiu  the  Bubjacent  parts,  the  diverticulum  of  the  Btomach  is  drawn  up 
under  the  skin  and  over  the  costal  cartilages  as  far  as  the  small  skin 

incision,  to  the  edges  of  which  its  apex  is  united  by  a  few  sutures.  A 
small  opening  is  next  made  here  into  the  stomach,  and  the  orifice  fixed 
to  the  skin  by  one  or  two  points  of  suture  (Fig.  167).  The  lower  part 
of  the  wound  is  then  closed  by  a  continuous  suture.  As  a  result  the 
diverticulum  of  the  stomach  is  drawn  upwards,  its  base  is  gripped  by 
the  muscular  fibres  of  the  rectus,  while  a  short  upward-directed  sub- 
cutaneous oesophagus  is  also  formed.  All  escape  of  fluid  is  thus  pre- 
vented, and  the  patient  can  be  safely  fed  tit  once. 

Kocher  {Operative  San/cry,  1903,  p.  194)  uses  and  recommends  a 
combination  of  the  methods  of  Frank  and  Witzel,  on  account  of  the 
difficulty  of  getting  a  long  enough  cone  to  form  a  valvular  fistula  by 
Frank's  method  alone.  The  rectus  muscle  is  exposed  and  pulled  well 
outwards,  and  a  pouch  of  stomach  is  fixed  to  the  parietes  as  in  Frank's 
operation.  Then  a  rubber  tube  is  inserted  and  buried  after  Witzel's 
method,  and,  lastly,  the  stomach  wall  around  the  exit  of  the  tube  is 
sutured  to  the  skin  to  prevent  any  chance  leakage  into  the  wound. 

Fig. 168.  Fig. 169. 


Gastrostomy  by  Marwedel's  method,  Gastrostomy  by  Marwedel's  method. 

First  stage.  Second  stage. 

The  rectus  muscle,  by  its  tension,  helps  to  prevent  the  fistula  leaking. 
At  an  autopsy  it  was  discovered  that  the  opening  in  the  stomach  was 
small  and  drawn  in  ;  "  it  was  connected  with  the  opening  in  the  skin  by 
a  canal  one  and  three-qnarter  inches  long,  which  had  no  mucous  lining 
and  was  perfectly  smooth." 

Mr.  T.  P.  Legg  (Lancet,  1905,  vol.  i.  p.  1711)  draws  out  a  cone  of 
stomach  two  and  a  half  inches  long  if  possible,  and  pulls  this  for  one 
and  a  half  inches  to  left  through  the  rectus  muscle,  the  fibres  of  which 
have  been  separated  into  anterior  and  posterior  bundles.  The  base  of 
the  cone  is  fixed  on  its  right  border  by  about  five  stitches  to  the 
posterior  wall  of  the  rectus  sheath  and  peritoneum,  and  near  its 
extremity  it  is  secured  by  four  sero-muscular  suture  to  the  rectus 
sheath,  and  to  the  skin  wound,  which  is  an  inch  long  and  is  parallel  to 
the  rectus  muscle  fibres  and  the  original  wound.  The  latter  is  closed 
by  means  of  salmon  gut  sutures,  which  include  the  anterior  layer  of  the 
rectus  sheath,  and  some  of  the  fibres  of  the  muscle.  A  sealed  dressing 
is  applied  to  the  wound.  It  is  claimed  that  this  operation  provides  a 
better  sphincter  for  the  fistula,  owing  to  the  greater  length  of  cone  which 
is  surrounded  by  muscle  fibres.  In  only  one  of  the  fifteen  patients 
operated  upon  by  Mr.  Legg  was  there  any  leakage,  and  this  only  lasted 
a  month,  and  was  probably  due  to  the  sloughing  out  of  some  of  the 
stitches  which  occurred. 


454 


nl'KIIATIONS    ON    TIIK    A  lil  ><  ».M  K.N. 


iii.  Marwedel's  Method  (Figs.  i6cS  and  r.69). — The  stomach  is 
exposed  and  attached  to  the  abdominal  incision  by  a  continuous  suture. 
The  serous  and  muscular  coats  are  then  incised  vertically  to  the  extent 
of  aboul  two  inches,  and  dissected  from  the  mucous  membrane  on  either 

side.  A  small  incision  is  then  made  through  the  mucosa  at  the  lower 
end  of  the  incision,  and  a  rubber  tube  introduced  and  fixed  by  a  suture. 
The  tube  is  then  laid  vertically  along  the  mucous  membrane,  and  the 
incision  in  the  serous  and  muscular  coats  closed  over  it  as  shown  in 
Fig.  169.     An  oblique  valvular  aperture  is  thus  produced. 

iv.  Abbe's  Modification  of  Kader's  Method  (Ann.  of  Swrg., 
January,  1899,  p.  113). — Here  a  circular  valve  is  formed  in  the  following 
manner: — Through  the  abdominal  incision  a  conical  portion  of  the 
wall  of  the  stomach  is  withdrawn,  and  its  edges  sutured  to  the  parietal 


Fig.  170. 


Fig.  171. 


1  -  parse  -  strin  g 
suture 


r".u  puree -strinp 
Puncture  into  suture 

stomach 

Abbe's  mollification  of  Kader's  method  Abbe's  modification  of   Kader's  method 

of  gastrostomy.    Purse-string  and  parietal  of  gastrostomy.    Section  showing  the  effect 

sutures  placed.  The  area  of  stomach  exposed  of  tying  the  purse-string  BUtures. 

should  be  elliptical  in  a  vertical  direction. 

peritonaeum.  Two,  or  even  three,  concentric  purse-string  sutures  are 
then  passed  circularly  round  the  protruding  cone.  A  small  incision  is 
now  made  at  the  apex  of  the  cone,  through  which  a  tube  is  passed. 
The  nearest  purse-string  suture  is  now  drawn  tight  round  the  tube,  and 
the  latter  then  pushed  inwards  till  the  next  suture  comes  into  contact 
with  it,  when  it  is  also  drawn  tight.  In  the  same  manner  the  third 
suture  is  drawn  round  the  tube  after  further  inversion.  The  external 
wound  is  then  closed.  Feeding  through  the  tube  is  commenced  at 
once.  After  a  week  or  ten  days  the  tube  becomes  loosened,  and  is  then 
only  passed  at  meal-times.  The  inverted  cone  here  forms  a  circular 
valve  which  effectually  prevents  regurgitation.  This  was  so  in  each  of 
six  cases  descrihed  by  Dr.  Abbe,  and  in  one  case,  in  which  death  took 
place  from  haemorrhage  from  the  growth  four  days  after  operation,  there 
was  not  the  slightest  leakage  when  the  valve  was  tested  by  hydraulic 
pressure. 


GASTROSTOMY.  455 

v.  De  page's  Method  (Journ.-de-Chir.t  November  and  December,  1901). 
— A  part  of  the  anterior  wall  <>f  the  stomach  is  fixed  to  the  edges  of  the 
parietal  peritoneum  by  means  of  a  continuous  suture,  and  a  portion  of 
this  is  picked  up  and  (damped.  A  tongue-shaped  flap  is  cut  with  its  1.. 
upwards,  and  its  lower  edge  is  drawn  up,  so  that  a  long  elliptical 
wound  is  formed.  The  edges  of  this  are  sutured  in  two  layers,  one 
continuous  suture  uniting  the  mucous  membrane  and  the  other  inverting 
the  serous  coat. 

The  tube  thus  formed  is  sewn  to  the  edges  of  the  parietal  wound,  or 
if  long  enough  it  may  be  drawn  obliquely  through  the  parietes  to  a 
small  incision  near  the  xiphoid  cartilage.  This  operation  is  not  so 
simple  as  those  already  described,  and  should  not  be  chosen  when  it  is 
possible  to  draw  a  cone  of  the  stomach  itself  to  form  a  tube,  and  I 
prefer  Abbe's  modification  of  Kader's  operation  or  Witzel's  operation 
even  in  cases  of  contracted  stomach,  for  these  operations  are  easier  to 
perform,  and  accompanied  with  less  risk  of  haemorrhage  and  leakage  in 
these  marasmic  patients. 

For  the  first  few  days  milk  and  brand}',  just  warmed,  and  peptonised 
if  preferred,  should  be  the  chief  food,  given  with  the  yolks  of  one  or  two 
eggs.  A  little  later  beef-tea,  soups,  well-pulped  vegetables,  with  plenty 
of  fluid,  should  be  given.  In  Sir  Henry  Howse's  words,  "when  the 
larger  sizes  of  tubes  have  been  introduced,  solid  food  may  be  poured 
into  the  stomach  by  the  aid  of  a  large  wide-mouthed  syringe.  This 
food  should  be  minced  meat,  with  a  certain  proportion  of  vegetables,  all 
finely  ground  in  the  mincing  machine." 

Patients  are  often  very  ingenious  in  feeding  themselves.  Some,  to 
enjoy  the  taste  of  food,  have  masticated  solids  and  then  passed  them 
through  the  fistula.* 

If  the  operation  has  been  deferred  till  too  late,  and  it  is  absolutely 
needful  to  feed  the  patient  at  once,  the  best  method  will  probably  be 
either  Frank's  or  Kader's.  If  the  opening  is  deferred,  a  small  amount 
of  liquid  may  be  introduced  every  few  hours  through  one  of  the  large 
hypodermic  syringes  made  for  exploration,  and  holding  a  drachm  or 
two.  The  puncture  must  be  repeated  at  each  occasion  of  feeding, 
obviously  a  risky  proceeding. 

Dilatation  of  Strictures  of  the  (Esophagus  from  below  through 
an  Opening  in  the  Stomach. — Where  non-malignant  strictures  low 
down  in  the  oesophagus  resist  dilatation  from  above,  and  the  patient  is 
losing  ground,  the  stricture  may  be  attacked  from  below  in  one  of  the 
following  ways  : — 

(i.)  By  Gastrotomy,  the  opening  being  closed  at  the  same  time. 
Prof.  Loreta,  of  Bologna,  operated  on  the  first  case  in  1885.1' 

The  patient,  aged  24,  had  swallowed  caustic  alkali.  Attempts  to  dilate  the  stricture 
by  bougies  were  unsuccessful,  and  at  last  it  became  impossible  to  pass  any  instrument. 
The  point  at  which  the-  sound  was  arrested  seemed  to  correspond  with  the  fourth 
dorsal    vertebra.        The   patient   was   entirely   unable   to   swallow,  and   emaciation   had 

*  Thus,  Mr.  Durham  (Syst.  of  Sun/.,  vol.  i.  p.  S03  ;  Loud.  Med.  Bee.,  March,  1878), 
mentions  a  patient  of  Trendelenburg's  who,  after  masticating  his  food,  spat  it  into  a 
funnel,  and  then  forced  it  on  through  a  tube  into  his  stomach.  Two  of  my  later  patients 
have  fed  themselves  after  this  fashion  through  a  tube. 

t  An  excellent  summary  of  Prof.  Loreta's  cases  is  given  by  Mr.  Holmes  (Brit.  Med. 
Journ.,  Feb.  21,  1885). 


456         OPERATIONS  ON  THE  ABDOMEN. 

become  extren  ••     Eleven  months  after  the  injury  an  incision  abonl  five  inches  long  was 

made  It the  xiphoid  cartilage  downwards  and  to  the  left.    Borne  difficult} 

with  in  finding  the  Btomach,  owing  i<>  its  contraction  and  tin-  way  in  which  the  liver 
overlapped  it ;  bnt  at  Length  the  operator  succeeded  in  drawii  itei  pari  oi 

Btomach  onl  of  the  wound,  and  a  Longitudinal  incision  was  made  through  its  wall 
the  two  curvatures,  having  its  upper  end  as  near  the  cardia  as  possible.  The 
was  to  find  the  orifice  <>!'  the  oesophagus,  in  order  to  introduce  the  dilator;  bul  this 
derable  difficulty,*  and  the  Bearch  was  interrupted  l<y  a  considerable 
quantity  of  bile,  which  regurgitated  from  the  duodenum  into  the  Btomach.  At  length  by 
thing  with  the  left  index  between  the  under-surface  of  the  Liver  and  the  small  curva- 
ture of  the  stomach,  the  end  of  the  oesophagus  was  found.  Then  the  distended  stomach 
was  kept  drawn  down  by  an  aesistanl  while  the  operator  introduced  a  dilator  (something 
like  that  of  Dupuytren  for  lithotomy).  The  wound  was  then  Bewn  up  and  the  stomach 
returned.  The  patient  rallied  well,  and  in  six  hours  swallowed  some  soup,  with  the  yolk 
of  an  egg,  to  his  great  joy,  as  for  twelve  months  i  e  had  been  unable  to  do  more  than 
swallow  mouthful-.     Recovery  is  Btated  to  have  been  complete. 

Mr.  Kendal  Pranks  has  related  an  instructive  case  of  the  same  kind 
{Ann.  of  Surg.,  vol.  i.  1894,  p.  385)  : — 

Here  the  whole  of  the  right  hand  was  introduced  into  the  abdomen,  and  the  index 
finger  into  the  stomach  through  an  opening  an  inch  long  situated  about  midway  between 
the  curvatures  and  the  orifices.  As  the  finger  could  only  just  reach  but  not  dilate  the 
stricture,  an  Otis'e  dilating  urethrotome  (the  blade  having  been  removed)  was  guided  by 
the  linger  into  the  stricture,  screwed  up,  and  withdrawn  fully  expanded.  After  this  had 
been  done  both  laterally  and  antero-posteriorly,  an  oesophagus  bougie  could  be  easily 
1  through  the  Btricture  from  above.  The  wound  in  the  stomach  was  united  with  two 
continuous  sutures,  one  uniting  the  mucous  membrane,  the  other,  by  Lembert's  method, 
the  peritonaea!  coat.  The  patient  made  a  good  recovery.  Large-sized  bougies  could  be 
without  difficulty  or  pain. 

It  is  clear  that  the  above  method  may  he  resorted  to  with  great 
benefit  in  non-malignant  strictures  low  down  in  the  oesophagus,  where 
the  dilated  condition  above  the  contraction  makes  it  very  difficult  to  hit 
this  off  with  a  bougie. 

(ii.)  By  Gastrostomy. — This,  while  rendering  manipulations  safer  in 
a  measure,  cripples  the  surgeon's  movements,  as  it  will  be  impossible, 
however  much  the  fistula  be  dilated,  to  get  the  finger  passed  through  it 
anywhere  near  the  stricture  in  the  oesophagus. 

Instrumental  dilatation  can  alone  l>e  made  use  of  through  a  gastric 
fistula,  and  tor  this  reason  the  method  by  two  Btages  is  inferior  to 
the  other.  It  has  been  most  ingeniously  used  under  the  following 
circumstances : — 

In   i  bach  (Correspondenzblatt  Sehtoeizer  Aerzte,  No.  5)  directed  a  patient 

with  a  non-malignant  Btricture  of  the  oesophagus  to  swallow  a  small  shot  attached  to  a 
Long  thread.  This  was  drawn  onl  of  the  stomach  through  the  fistula,  and  a  strong  Bilk 
thread  fasti  ned  to  it  and  drawn  up  through  the  month.     To  the  lower  end  a  bougie  was 

sing  sizes  were  daily  drawn  through  the  fistula. 

Dr.  It.  Abbe,  of  Newport  [Ann.  of  Surg.,  vol.  i.  1893,  p.  489),  advises 

what  lie  calls  the  "  string  "  method  in  the  treatmenl  of  dense  fibrous 
strictures.      A  gastrostomy  having  been  previously  performed, i  a  small 

directions  given  ai  p.  459. 
t   In  this  and  the  preceding  instance   the  gastrostomy  opening  should  be  placed  as 
high  up  .In  his  case  Dr.  Abbe  opened  the  'esophagus  near  the  root  of  the 

neck  as  well  as  performing  a  gastrostomy. 


GASTROSTOMY.  457 

gum  ^elastic  bougie  is  guided  through  the  stricture  from  below  up  into 
the  mouth,  and  a  stout  silk  ligature  passed  in  the  Bame  way.  This 
silk  being  Bee-sawed  backwards  and  forwards,  the  stricture  is  felt  to 
yield,  and  larger  bougies  can  then  be  passed. 

Dr.  Dunham  (.1////.  0/ Surg.,  vol.  xxxvii.  1903)  has  devised  a  simple  and  ingenious 
wav  0  a  thread  through  a  stricture  of  the  oesophagus.     Ee  uses  "an  ordinary 

drinking  tube,  a  glass  of  water,  and  a  piece  of  black  silk  thread.  The  tube  is  threaded  bo 
thai  one  end  of  the  thread  is  at  the  mouth  end  of  the  tube.  The  patient  then  drinks 
through  the  tube.  The  thread  is  carried  up  the  tube  and  on  into  the  oesophagus  by  the 
current  of  water.  More  thread  is  fed  into  the  water  as  it  disappears  up  the  tube,  care 
always  being  taken  1  hat.  it  is  not  fed  in  too  rapidly.  When  several  feet  of  thread  have 
been  thus  washed  down  the  lower  portion  of  the  thread  may  be  fished  ou1  of  the  stomach 
by  means  of  a  bent  probe,  passed  in  at  the  gastrostomy  opening."  In  some  cases  t  hi. ^ 
method  may  fail  from  want  of  co-operation  on  the  part  of  the  patient,  and  the  thread 
may  then  be  introduced  through  a  funnel  and  rubber  tube,  the  latter  being  passed  into  the 
pharynx  or  oesophagus.  Once  the  thread  has  been  introduced,  larger  ones  will  follow,  and 
these  can  be  used  as  suggested  by  Abbe.  Soon  rubber  tubing,  kept  upon  the  stretch  by 
traction  upon  a  string  attached  to  each  end  of  it,  can  be  introduced,  as  suggested  by 
Curtis  (Ann.  of  Surg.,  vol.  xxxi.  p.  358).  This  effects  dilatation  very  rapidly,  and  larger 
ones  can  be  introduced  until  biconical  French  bougies  can  be  used  with  ease,  and  the 
gastrostomy  wound  closed. 

Dr.  Dowd  [Ann.  0/  Surg.,  vol.  xxxix.  1904,  p.  272)  records  a  very  interesting  and 
successful  case  of  simple  stricture  near  the  cardiac  end  of  the  oesophagus,  which  was 
impermeable  from  above,  and  also  from  the  stomach.  Dunham's  method  of  introducing  a 
thread  was  tried,  and  failed.  Kelly's  cystoscope  tube  was  used  to  locate  the  cardiac  orifice 
from  below,  and  to  conduct  bougies  to  the  orifice,  but  the  bougies  would  not  pass. 
Dunham's  plan  was  tried  again,  and  proved  successful.  The  stricture  was  dilated  by  the 
methods  of  Abbe  and  Carter,  and  within  two  months  large  (No.  28)  bougies  could  be 
passed  with  ease,  and  ordinary  food  partaken  of.  The  gastrostomy  wound  had  been  dilated 
for  the  introduction  of  the  cystoscope,  and  leakage  therefore  occurred,  so  that  it  became 
necessary  to  close  the  fistula  by  an  operation. 

Difficulties  in  and  after  Gastrostomy. 

i.  The  very  prominent  angle  formed  between  the  ribs  and  the  sunken 
umbilical  region  (p.  449).  ii.  Haemorrhage.  This  will  be  almost  nil 
if  the  rectus  fibres  are  separated  with  a  director,  and  the  veins  on  the 
stomach  carefully  avoided.  iii.  Finding  the  stomach,  iv.  Drawing 
this  up  into  the  wound  if  itself  affected  by  disease,  as  when  the  primary 
disease  is  situated  very  low  down  in  the  oesophagus,  or  if  it  is  adherent 
by  reason  of  secondary  deposits,  v.  Jerking  breathing  due  to  the 
anaesthetic,  vi.  Completing  the  second  stage  of  the  operation,  vii. 
Intense  pain  on  introducing  food  into  the  stomach. 

In  a  patient  of  Mr.  Butlin's  {Brit.  Med.  Journ.,  April  14,  1883)  this  was  found  to  be 
the  case,  the  patient  dying  nearly  a  month  after  the  operation.  Mr.  Butlin  attributes 
this  pain  to  his  opening  having  been  close  to  the  pylorus. 

If  it  is  thought  that  the  opening  is  made  too  near  either  extremity 
of  the  stomach,  it  would  be  well  after  feeding  to  keep  the  patient 
turned  on  to  the  opposite  side.  viii.  Leakage  of  gastric  juice  and 
regurgitation  of  food.  This  is  an  extremely  troublesome  complication, 
leading,  as  it  does,  to  most  rebellious  dermatitis  ;  it  is  fortunately 
quite  rare  with  modern  methods. 

Causes  of  Death  after  Gastrostomy. 

1.  Inanition    and    exhaustion,  the  operation    being   performed    too 


458  OPERATIONS  ON  THE  ABDOMEN. 

late.  2.  Peritonitis.  3.  Extension  of  the  disease  to  surrounding 
parts — e.g.,  trachea,  bronchi,  iVc.  4.  Lung  affections — e.g.,  pneumonia, 
due  in  part  to  the  operation  viz.,  the  anaesthetic  and  enforced  recum- 
bency— and  ill  part  possibly  to  the  saliva,  which  cannot  pass  down  the 
oesophagus,  being  drawn  into  the  air-passages,  either  before  or  during 
the  operation.  5.  Hemorrhage — e.g.,  from  ulceration  into  aorta  or 
lung.  6.  Acute  gastritis.  7.  Suppuration  between  stomach  and  liver. 
S.  Phthisis. 


GASTROTOMY. 

Indications. — The  operation  may  be  required  for  the  removal  ot 
foreign  bodies  which  will  not  pass  through  the  pylorus,  such,  for 
instance,  as  forks,  as  in  MM.  Labbe's  and  Peau's  cases,  and  masses  of 
hair,  as  in  Thornton's  {Lancet,  Jan.  9,  1886)  patient.  Increasing  pain, 
vomiting,  emaciation,  and  sufficient  time  having  elapsed  to  allow  of  the 
body  passing,  will  be  the  chief  indications.  In  a  very  few  cases 
gastrotoiny  will  be  required  also  for  the  removal  of  foreign  bodies 
impacted  iow  down  in  the  cesophagus.  It  is  also  indicated  in  certain 
cases  of  severe  gastric  haemorrhage,  and  for  the  dilatation  of  fibrous 
strictures  of  the  cesophagus  (vide  supra,  p.  455). 

Operation. — A.  Fob  Removal  of  Foreign  Bodies  from  the 
Stomach. — Such  cases  as  Mr.  Thornton's  show  that  this  operation 
can  be  safely  performed  at  one  stage. 

The  parts  being  cleansed  and  the  abdomen  relaxed,  one  of  the 
following  incisions  is  made  : — (1)  Over  the  body  itself,  when  this  can 
be  felt.  (2)  In  the  case  of  a  large  body,  through  the  left  rectus  sheath 
or  in  some  cases  through  the  right.  (3)  One  of  the  incisions  given 
for  gastrostomy — e.g.,  one  parallel  with  the  left  costal  margin  and 
about  an  inch  below  it,  reaching  from  a  point  near  the  xiphoid  cartilage 
obliquely  downwards  and  outwards  to  a  point  opposite  to  the  ninth 
rib.  One  of  the  first  two  will  probably  be  the  best.  The  abdominal 
wall  having  been  divided,  and  the  peritonaeum  opened,  the  exact  site  of 
the  foreign  body  is  made  out.  If  this  be  pointed,  great  care  must  be 
taken  not  to  let  it  damage  the  stomach  during  the  needful  manipula- 
tions. In  such  cases  the  external  opening  must  be  free,  that  the 
surgeon  may  see  what  he  is  about.  In  the  case  of  such  a  body  as  a 
fork  the  blunt  end  must  first  be  found. 

When  the  surgeon  has  decided  where  to  open  the  stomach,  he  brings 
tins  part  out  of  the  wound  and  packs  sterile  gauze  all  around  it,  so  as 
to  steady  it,  and  also  to  shut  off  the  peritonaea!  sac. 

The  stomach  is  now  opened  with  scissors  by  an  incision  transverse 
to  its  long  axis,  and  of  length  adapted  to  the  case.  As  far  as  possible, 
any  vessels  must  be  avoided,  but  any  that  bleed  will  at  once  be  com- 
manded by  Spencer  Wells's  forceps.  The  body  is  next  extracted  with 
suitable  forceps  or  a  scoop,  care  being  now  taken  not  to  damage  the 
stomach,  especially  it'  the  foreign  body  has  set  up  inflammation  or 
ulceration,  and  to  allow  no  blood  or  mucus  to  escape  into  the 
peritoneal  sac. 

After  the  removal  of  the  foreign  body,  if  the  stomach  contains  much 
mucus    or    blood,    this    may   be    removed    by   gentle    sponging.     The 


CASTKOTOMY. 


45'J 


aperture  in  the  stomach  is  then  closed  with  a  continuous  suture  which 
pierces  all  the  coats,  care  being  taken  not  to  evert  the  mucous  mem- 
brane. This  is  reinforced  by  a  continuous  Leinbert  suture.  The 
parietal  wound  is  closed. 

13.  For  Removal  of  Bodies — e.g.,  Tooth-plates — impacted  in 
the  Lower  Part  of  the  (Esophagus. — These  cases,  though  rare, 
are  so  difficult  as  to  call  for  some  remarks  here.  Prof.  Richardson,  of 
Harvard  University,  first  brought  forward  a  very  successful  case  of 
this  operation  (Lancet,  1887,  vol.  ii.  p.  707).  A  plate  carrying  four 
teeth  had  been  impacted  eleven  months  in  a  patient  aged  37. 
Numerous  attempts  had  been  made  to  remove  it  from  the  mouth.  The 
plate  was  successfully  removed  by  gastrotomy,  by  an  incision  six  inches 
long  parallel  to  the  lower  margin  of  the  left  ribs.  The  following 
interesting  details  are  given  : — 

Determination  of  the  Site  of  the  Foreign  Body. — In  an  individual  of 
average  height,  and  with  a  neck  of  ordinary  length,  the  distance  from 
the  incisors  to  the  diaphragm  is  fourteen  and  a  half  inches.  All  parts 
of  the  oesophagus  are  accessible  to  the  finger  either  by  gastrotomy  or 
external  cesophagotomy.  With  the  right  forefinger  introduced  by 
cesophagotomy  and  the  left  by  gastrotomy  it  was  found  possible,  not 
only  to  make  the  fingers  touch,  but  in  many  cases  overlap.  But  these 
results  are  only  approximate,  as  it  would  not  always  be  possible  to  do 
both  operations  on  a  patient.  It  is  possible  to  reach  with  the  left  hand 
three  inches  above  the  cardiac  opening — i.e.,  the  length  of  the  left 
middle  finger.  From  above,  through  the  wound  in  the  neck,  one 
cannot  reach  quite  so  far  on  account  of  the  sternum  and  clavicle. 
Allowing  in  the  average  neck  one  and  a  half  to  two  inches  from  the 
cricoid  cartilage  to  the  lowest  point  of  the  wound  in  the  oesophagus, 
we  have  the  average  distance  from  that  incision  to  the  cardiac  opening 
of  five  and  a  half  or  six  inches.  If  the  obstruction  be  less  than  six 
inches  from  the  cricoid,  an  attempt  should  be  made  to  remove  it  from 
above  ;*  if  more  than  this,  or  thirteen  inches  from  the  teeth,  gastrotomy 
should  be  performed.  The  incision  that,  on  the  whole,  is  recommended 
is  an  oblique  one  below  the  margin  of  the  left  ribs.  The  stomach  being 
drawn  up  into  the  wound,  it  is  most  essential  to  put  the  lesser  curva- 
ture on  the  stretch,  so  that  it  makes  a  straight  line  to  the  diaphragmatic 
opening.  The  cut  through  the  stomach  wall  must  be  far  enough  to 
the  right  to  allow  the  passage  of  instruments  along  the  sulcus  between 
the  anterior  and  posterior  walls  of  the  stomach,  made  tense  as  above. 
If  the  instrument  is  brought  obliquely  to  this  groove  and  passed  up- 
wards, all  the  time  being  pressed  gently  against  the  straightened  lesser 
curvature,  it  will  glide  into  the  oesophagus  every  time  with  the  greatest 
ease.  The  opening  in  the  stomach  should  be  first  large  enough  to 
admit  instruments  ;  if  these  fail,  it  must  be  enlarged,  and  the  whole 
hand  introduced. 

In  the  following  case  I  was  much  less  fortunate,   owing  to   the  way 
in  which  the  tooth-plate  was  jammed  above  the  cardiac  orifice.     While 

Mr.  Fullerton  (Brit.  Med.  Journ.,  May  7,  1904)  performed  oesophagotomy  and 
removed  a  halfpenny  which  had  been  impacted  for  seven  months  opposite  the  third  and 
fourth  dorsal  vertebra?,  and  four  and  a  half  inches  below  the  wound.  The  wound  was 
closed  by  deep  and  superficial  sutures  of  catgut,  and  the  child,  set.  7,  recovered. 


460  OPERATIONS   ON   THE   ABDOMKN. 

such  cases  are  rare,  they  are  most  important,    011    account   of   the 
numerous  difficulties  which  they  present. 

E.  \\\.  aged  44,  was  sent  to  meal  Gay's  in  lia;  iving  swallowed  a  vulcanite 

tooth-plate,  which  "stack  in  his  throat."  The  plate  originally  carried  seven,  bal  now 
only  two  teeth,  a  medical  man  whom  he  sawal  once  poshed  the  plate  down  with  a 
boogie.  An  emetic  which  had  been  given  then  acted  and  brought  ap  some  blood.  Tlic 
patienl  complained  of  constaol  pain  in  the  epigastric  region  jasl  below  the  xiphoid 
lage,  and  in  bis  dorsal  vertebras.    Swallowing  was  painful,  and  so  was  eructation  of 

though  this  lmvc  relief.     Patient  was  able  to  swallow  1 1  unite  well.     He  was  not 

troubled  by  vomiting.    A  boogie  could  be  passed   into  the  Btomach,  but  just  before  it 
entered  it  rubbed  01  gu  body.    The  body  did  not  yield  in  the  least  to  any  force 

which  I  thought  it  justifiable  to  ose  with  the  boogie.  On  .June  11  I  operated  as  folio 
The  stomach  having  been  washed  out  with  dilute  boracic  acid,  an  incision  three  inches 
and  a  half  Long  was  made,  parallel  with  the  linea  alba,  commencing  on  the  level  of  the 
xiphoid,  and  about  an  inch  to  the  left  of  it.  The  rectus,  the  sheath  being  opened,  was 
Bplil  with  a  steel  director.  The  Btomach  was  very  Bmall  and  pale.  Sponges  having  been 
packed  around,  it  was  opened,  with  scissors,  just  to  the  right  of  the  cardiac  end,  and  as 
up  as  possible.  The  opening  was  about  a  quarter  of  an  inch  long.  Three  small 
vessels  Bprang,  and  were  tied.  The  exploring  linger  detected  the  body  imbedded  just 
abov<  liac  orifice.     I  us  membrane  around  felt  pulpy  and  swollen.    N'ume- 

ion-  curved  forceps  were  introduced  by  the  opening,  and  then  along  the  le-ser  curvature, 
but,  though  the  body  was  repeatedly  seized,  I  was  quite  unable  even  to  loosen  it.  This 
was  due  to  its  not  presenting  any  projecting  points  and  to  the  swelling  of  the  mucous 
membrane  around.  J  nexl  enlarged  the  opening  in  the  stomach  so  as  to  introduce  my 
hand,  but,  though  with  the  tip  of  the  middle  finger  I  was  able  to  reach  the  pi 
unable  to  dislodge  it.  Mr.  Durham  and  .Mr.  Davies-Oollej  also  tried,  with  a  like  result. 
Moreover,  to  steady  it,  Mr.  Tubby  was  good  enough  to  keep  the  end  of  an  oesophageal  bougie 
pressed  against  it  from  above.  1  closed  the  lower  two-thirds  of  the  wound  in  the  stomach 
with  Lembert's sutures  of  fine  silk,  and  stitched  the  remaining  pari  to  the  upper  part  of 
the  parietal  incision,  so  that  other  forceps  might  be  tried  later  on.     The  patient,  how- 

oever  rallied  completely,  and  sank  about  forty-eight  hour-  afterwards.  At  the  i 
mortem  examination  the  coronary  arteries  were  found  in  an  advanced  stage  of  atheroma. 
1  here  was  no  peritonitis  or  escape  of  gastric  contents.  The  mucous  membrane  near  the 
cardiac  orifice  of  the  stomach  presented  a  ragged  appearance  dating  to  the  prolonged 
manipulations.  The  plate  was  very  firmly  fixed  in  the  oesophagus,  one  inch  ami  a  half 
tic  cardiac  opening. 

M.  Bluysen  (Lancet,  1906,  vol.  i.  p.  192)  performed  gastrotomy  and 
removed  a  denture  which  had  been  Bwallowed  a  fortnight  earlier,  and 
had  become  impacted  near  the  cardiac  orifice.  Forceps  having  tailed, 
the  index  finger  was  introduced  into  the  lower  end  of  the  oesophagus, 
and  served  to  hook  and  remove  the  plate. 

C.  Fob  Certain  Casks  of  Severe  and  Recurrent  ELemobrhagb 
from  a  Gastric  Ulcer. — A  considerable  number  of  these  cases  have 
been  operated  on  with  a  lair  amount  of  success,  although  the  exact 
indications  for  operation  and  the  best  methods  of  dealing  with  the 
bleeding  cannot  he  said  to  he  finally  settled. 

It  is  not  easy  to  estimate  the  percentage  of  deaths  that  occur  from 
haemorrhage  in  cases  of  gastric  ulcer  under  medical  treatment,  for  the 
fatalities  will  vary  almost  inversely  with  the  duration  and  thoroughness 
of  the  medical  treatment,  which  should  always  be  tried. 

Mayo  Robson,  and  Moynihan  in  their  work  on  The  Diseases  of  the 
Stomach  (1904)  conclude  from  published  records  that  the  mortality 
from  haemorrhage  may  vary  from  3  to  11  per  cent.  1  >r.  Bulstrode  (Clin. 
80c.  Trans.,  1903,  p.  86)  collected  the  records  of  the  500  cases  of 
gastric  ulcer  which  were  admitted  into  the  London  Hospital  between 


GASTROTOMY.  46] 

1897  and  1903.  He  found  that  2*5  per  cent,  of  tlie.se  patients  died 
from  haemorrhage,  10  per  cent,  from  perforation  peritonitis,  and 
altogether  c8  per  cent,  of  the  patients  died.     In  42  per  cent,  of  the 

cases,  from  one  to  four  or  more  relapses  occurred. 

Dr.  Hawkins  and  Mr.  Nitch  (Royal  Med.-Chir.  Soc,  Nov.  13, 
1906)  found  that  less  than  I  per  cent,  of  419  consecutive  cases  of 
gastric  ulcer  collected  from  the  records  of  St.  Thomas's  Hospital 
died  of  bleeding.  It  is  clear  that  many  of  these  cases  relapse, 
and  that  not  all  of  these  will  seek  admission  again  into  the  same 
institution,  so  that  the  figures  are  clearly  too  favourable  as  they 
stand.  The  total  mortality  of  the  556  cases  at  St.  Thomas's  Hos- 
pital was  13*3  per  cent.  ;  8*5  died  from  perforation,  and  i'g  from 
sequelae. 

These  figures  serve  to  show  how  efficient  medical  treatment  for 
bleeding  may  he  if  carefully  carried  out,  but  unfortunately  it  is  not 
practicable  under  existing  circumstances  to  ti'eat  the  poor  subjects  of 
gastric  ulcer  by  rest  and  dieting  for  the  long  time  that  is  necessary  for 
cure.  Too  often  they  have  to  return  to  work  when  only  beginning  to 
recover,  and  it  is  not  surprising  that  relapses  are  so  frequent. 

It  should  be  remembered  also  that  a  timely  operation  for  the  relief 
of  recurrent  haemorrhage  may  not  only  arrest  the  bleeding,  but  may 
lead  to  healing  of  the  ulcer,  and  prevention  of  perforation  and  other 
complications  and  sequelae,  which,  although  they  may  not  always  be 
immediately  fatal,  yet  shorten  and  spoil  many  lives. 

That  haemorrhage  is  an  important  cause  of  death  is  shown  by  the 
following  facts.  Dr.  Wall  (Clin.  Soc.  Trans.,  1903,  p.  90)  found  that 
of  the  cases  of  gastric  ulcer  with  bleeding  as  a  symptom  6  per  cent, 
of  the  women  and  I2"5  per  cent,  of  the  men  over  30  years  of  age 
died  from  haemorrhage  alone.  MacNevin  and  Herrick  (quoted  by  Hale 
White,  loc.  infra  cit.)  state  that  of  55  cases  of  undoubted  gastric 
ulcer,  shown  at  a  post-mortem  examination,  which  died  from  either 
perforation  or  haemorrhage,  25  died  from  haemorrhage.  Of  these 
19  were  males  and  6  were  females,  of  the  30  dying  from  peritonitis 
8  were  males  and  22  were  females,  and  of  the  25  of  both  sexes 
dying  from  haemorrhage  all  except  one  female  were  30  years  of  age 
or  over  11. 

It  is  rarely,  if  ever,  wise  to  operate  during  the  occurrence  of  acute 
haemorrhage,  for  only  a  few  patients  die  from  a  single  haemorrhage, 
and  the  tendency  to  a  natural  arrest  of  the  bleeding  is  very  great  in 
acute  ulcers  under  proper  medical  treatment,  whereas  the  results  of 
operations  which  have  been  performed  during  the  progress  of  bleeding 
have  been  very  bad.  Mr.  Paterson  estimates  that  the  mortality  of 
operations  performed  during  haemorrhage  is  about  80  per  cent., 
whereas  only  about  5  per  cent,  die  under  medical  treatment.  The 
operation  will  only  increase  the  collapse  and  profound  anaemia,  from 
which  the  patients  may  recover  without  an  operation  under  medical 
treatment.  When  large  vessels  have  been  opened,  death  occurs  so 
speedily  that  an  operation  is  rarely  practicable  in  time  to  save  life  even 
if  the  bleeding  vessel  can  be  found  and  secured. 

Although  a  few  successful  operations  have  been  undertaken  during 
recurrent  attacks  of  severe  haemorrhage,  there  is  but  little  doubt  that 
it   is  far  better  to  defer  surgical  interference  until  the  bleeding  has 


462  OPERATIONS  ON  THE  ABDOMEN. 

ceased  and  time  has  been  granted  for  reaction  from  collapse  to  take 
place. 

Dr.  Hale  White  (Lancet,  1906,  vol.  ii.  p.  1189)  has  collected  29 
cases  of  "  gastrostaxis,"  or  the  oozing  of  blood  from  the  mucous 
membrane  of  the  stomach.  Only  two  of  these  patients  were  males,  and 
most  of  them  were  women  well  under  40  years  of  age.  Although  this 
disease  is  rarely  fatal  under  medical  treatment,  8  deaths  occurred  in 
24  cases  treated  by  operation,  a  niortalitj"  of  27*5  per  cent. 

The  ulcers  which  give  rise  to  serious  haemorrhage  are  usually 
situated  on  the  posterior  wall  of  the  stomach,  and  nearer  to  the  lesser 
curvature  than  the  greater.  The  character  of  the  ulcers  is  very 
variable.  They  may  be  small  and  quite  superficial,  when  the  bleeding 
commonly  arises  from  vessels  in  the  submucous  layer ;  or  they  may  be 
deep  and  adherent  to  structures  outside  the  stomach,  leading  to 
ulceration  of  large  vessels,  such  as  the  aorta,  or  the  hepatic,  coronary, 
splenic,  or  pancreatico-duodenal  arteries.  It  should  also  be  borne  in 
mind  that  in  a  number  of  cases  more  than  one  ulcer  or  erosion  was 
present,  and  that  in  others  the  ulceration  may  be  in  the  duodenum, 
or  that  no  ulcer  may  be  discovered,  or  even  exist.  Leube  and  Kocher 
give  as  indications  for  operation  recurrent  severe  haemorrhages  when 
careful  dieting,  rest,  and  other  medical  measures  have  failed.  A  single 
profuse  bleeding  is  not  necessarily  an  indication  for  operation,  because 
a  second  haemorrhage  may  never  occur. 

Mr.  H.  J.  Paterson,  in  his  Hunterian  Lectures  (Lancet,  vol.  i.  1906, 
p.  502),  gave  the  following  excellent  summary  of  his  views  upon  this 
subject: — 

"In  haemorrhage  from  an  acute  ulcer,  erosion,  or  exulceratio  simplex, 
that  is,  when  the  onset  of  bleeding  is  sudden  and  previous  history  of 
gastric  ulcer  is  absent,  first  give  a  thorough  trial  to  absolute  rest  in 
bed,  Trippier's  hot  water  injections  by  the  rectum,  and  avoidance  of 
food  by  the  mouth  for  at  least  four  or  five  days.  If  a  second  profuse 
haemorrhage  occurs  perform  gastrojejunostomy,  provided  it  is  quite 
clear  that  the  second  haemorrhage  has  not  been  brought  oil  by  want  of 
absolute  rest,  by  too  early  stimulation,  or  by  too  early  administration 
of  food.  It  is  advisable  to  delay  operation  until  the  patient  has 
recovered  from  the  collapse  induced  by  the  haemorrhage.  In  haemor- 
rhage from  a  chronic  ulcer,  that  is  in  cases  with  a  definite  histoiy  of 
pain  after  food,  vomiting,  and  possibly  previous  slighter  attacks  of 
lmmatemesis,  perform  gastrojejunostomy  after  one  severe  attack  or 
after  several  slighter  attacks  of  haematemesis  if  the  loss  of  blood  is 
causing  serious  anaemia." 

With  these  views  I  agree  in  the  main,  but  it  is  certain  that  gastro- 
jejunostomy will  not  be  found  to  be  sufficient  in  all  cases ;  and  it  is 
probable  that  many  cases  of  subacute  gastric  ulcer  with  haemorrhage 
will  get  well  without  operation,  if  only  the  treatment  be  carried 
out  thoroughly  and  for  a  sufficient  length  of  time.  When  this  is 
impracticable  for  various  reasons,  or  the  hemorrhage  recurs  even  under 
careful  medical  treatment,  an  operation  should  be  undertaken,  although 
it  carries  with  it  a  considerable  risk.  The  danger  is  worth  running, 
especially  when  the  ulcer  is  at  or  near  the  pylorus,  for  gastro- 
jejunostomy may  provide  rest  for  the  stomach,  induce  the  ulcer  to  heal, 
and  thus  prevent  troublesome  and  dangerous  complications, 


CASTUOTo.MY. 


463 


The  following  are  a  few  of  the  cases  that  have  heen  reported  ;  they 
give  some  idea  of  the  various  means  that  have  been  adopted  :  — 

Roux  (Revue  <tr  Qynecologie,  1S97,  !'■  113)  reported  two  successful  cases.  In  the  first 
lie   Ligatured   the   bleeding  vessel  ami    then    excised    t he   ulcer  ;  and  in  the  second  he 

Ligatured    the   artery  at   the  two  ends  <>f  the  lesser  curvature  without   re val  of  the 

ulcer.  Guniard  [These  Trognon,  Paris,  1893)  performed  gastroenterostomy  for  a  bleeding 
pyloric  ulcer,  with  recovery.  Kuster  (Ann.  of  Surg.,  August,  1894)  cauterised  theulct 
two  cases,  and  in  ench  also  performed  gastroenterostomy,  with  recovery.  Korte*  Proceed- 
ings of  the  German  Surgical  Congress,  1S97)  cauterised  an  ulcer  which  could  not  be 
extirpated,  the  patient  dying  eight  days  later,  a  perforation  of  the  splenic  artery  being 
found  at  the  necropsy.  Mikulicz  ( These  de  Marion,  Paris,  1S97)  reported  two  cases.  In 
the  first  he  excised  the  ulcer,  and  the  patient  recovered  ;  in  the  second  he  used  the 
cautery,  the  patient  dying  the  same  evening.  Cazin  (Prex.se  MiAicale,  1899,  p.  31)  reports 
a  case  in  which  he  found  four  erosions.  These  were  sutured  with  catgut,  and  the  patient 
recovered  without  further  haemorrhage.  In  a  number  of  cases  the  operation  failed  owing 
to  inability  to  discover  the  ulcer.  Finally,  in  an  exhaustive  paper  by  Drs.  Andrews 
and  Eisendrath  (Ann.  of  Surg.,  October,  1S99)  from  which  the  greater  part  of  the  following 
is  gathered,  two  brilliantly  successful  cases  operated  upon  by  Dr.  Andrews  are 
described,  the  plan  adopted  here  being  ligation  of  the  ulcer  en  masse  within  the  cavity  of 
the  stomach. 

Mansell  Moullin  (Clin.  Soc.  Trans.,  1903,  p.  85)  refers  to  eleven 
operations  for  gastric  haemorrhage,  with  only  two  deaths,  although  six 
of  the  patients  were  so  collapsed  that  infusion  had  to  be  resorted  to 
either  during  or  soon  after  the  operation. 

One  patient  died  of  haemorrhage,  and  another  of  peritonitis,  due  to 
leakage  from  want  of  union  of  the  gastric  incision  which  was  made  for 
exploration. 

In  two  cases  silk  sutures  were  used  to  underrun  and  compress  the 
ulcers  from  the  mucous  surface;  in  three  the  ulcer  was  excised  without 
trespassing  on  the  muscular  wall,  and  the  edges  of  the  mucous 
membrane  were  sutured.  In  one  a  portion  of  the  whole  thickness  of 
the  stomach  wall  was  removed.  The  ulcer  and  all  the  coats  of  the 
stomach  were  invaginated  and  ligatured  from  within  in  two  cases, 
serous  sutures  being  used  to  protect  the  site  of  the  invagination. 

Sutures  were  passed  through  all  the  coats  from  the  mucous  membrane 
to  include  and  secure  the  ulcer.  In  one  case,  Lembert  sutures  being 
employed  to  bury  the  deep  stitches,  no  leak  occurred  at  the  ulcer, 
but  fatal  peritonitis  followed  failure  of  union  of  the  exploratory 
wound. 

In  one  case  a  gastric  exploration  failed  to  reveal  any  ulceration,  but, 
after  remaining  well  for  a  year,  the  man  became  suddenly  collapsed, 
and  this  condition  was  followed  by  profuse  melaena,  probably  due  to 
duodenal  ulcer.  In  another  case  a  negative  gastrotomy  was  not 
followed  by  any  recurrence  of  haemorrhage  for  over  two  years  and  a 
half.  Such  cases  are  very  exceptional  (Brit.  Med.  Journ.,  vol.  i. 
1904,  p.  420). 

Operation. — The  incision  must  be  free,  and  should  in  the  first 
instance  be  median.  If  this  does  not  give  sufficient  room,  the  left 
rectus  may  be  subsequently  divided.  The  chief  difficulty  is  the  finding 
of  the  ulcer.  The  anterior  surface  and  the  two  curvatures  of  the 
stomach  should  be  first  systematically  examined  for  any  indurated 
spot ;  then  the  posterior  surface  is  reached  and   examined  by  passing 


464  OPERATIONS   ON   THE   ABDOMEN 

the  hand  through  a  hole  in  the  great  omentum.  If  no  external  guide 
to  the  position  of  the  ulcer  is  found  in  this  way,  Andrews  and  Kisendrath 
recommend  the  examination  of  the  interior  of  the  stomach  through  a 
vertical  incision  in  the  anterior  wall,  this  incision  being  so  placed  a^  to 
avoid  as  far  as  possible  any  large  vessels  which  are  visible.  Before 
this  incision  is  made,  the  stomach  must  be  withdrawn  from  the 
abdomen  as  far  as  possible,  and  carefully  isolated  with  sterile  gauze. 
The  whole  interior  of  the  stomach  is  then  carefully  and  systematically 
inspected,  a  strong  electric  light  being  essential.  Andrews  and  Bisen- 
drath  carry  this  out  in  the  following  manner: — "The  hand  is  passed 
behind  the  organ  through  the  opening  in  the  omentum  already  men- 
tioned. The  posterior  wall  is  now  pushed  forward  into  the  opening 
and  passed  portion  by  portion  into  plain  view.  This  may  be  continued 
until  the  whole  posterior  wall  to  the  cardiac  end  has  been  gone  over. 
The  greater  and  lesser  curvatures  and  the  remainder  of  the  anterior 
wall  may  in  the  same  manner  be  caused  to  invert  and  pass  in  review 
beneath  the  opening,  the  latter  being  caused  by  traction  to  assume 
various  positions  to  assist  in  this  invagination.  Should  the  posterior 
wall  be  adherent  to  the  pancreas,  as  in  Case  T.,  and  somewhat  immovable, 
that  particular  part  of  the  viscus  should  be  inspected  b}r  reflected  light. 
In  such  a  case  the  lesser  peritonaeum  should  be  opened,  which  will 
give  additional  access  to  the  posterior  wall.  We  now  come  to  a  portion 
of  the  stomach  interior  which  cannot  be  drawn  down  or  forward — 
namely,  the  cardiac  end,  where  it  is  covered  by  the  left  lobe  of  the  liver 
and  attached  to  the  diaphragm.  To  inspect  these  parts  it  is  necessary 
to  illuminate  the  cavity,  and  retract  the  liver  and  costal  arch.  The 
Trendelenberg  position  would  probably  be  of  assistance  at  this  stage 
both  in  gaining  access  and  in  the  matter  of  illumination.  With  care  a 
good  view7  can  be  obtained  of  the  whole  cardiac  end  and  opening."  The 
treatment  of  the  ulcer  or  ulcers  when  found  must  vary  according  to  the 
conditions  present.  If  the  ulcer  is  quite  small  and  superficial,  it 
should,  if  possible,  be  excised  without  invading  the  muscular  coats,  and 
the  edges  of  the  mucous  membrane  should  be  sutured.  Failing  this, 
the  ulcer  may  be  ligatured  en  masse,  or  underrun  with  sutures. 
The  cautery  has  been  successfully  used  in  some  cases.  Excision  offers 
the  best  chance  of  healing,  but  this  will  not  be  possible  when  the  base 
of  the  ulcer  is  adherent  to  parts  outside  the  stomach,  and  when  it  is 
large  and  situated  at  the  pylorus.  Some  small  pyloric  ulcers  may 
be  treated  by  excision,  followed  by  pyloroplasty. 

Some  deep  ulcers  unsuitable  for  excision  may  be  ligatured  en 
masse,  as  Andrews  (loc.  supra  cit.),  did  in  his  two  successful  caE 
or  invaginated  and  protected  by  serous  sutures,  as  adopted  by  Mansell 
Moullin.  Failing  these  methods,  gastroenterostomy  must  be  per- 
formed, and  it  is  improbable  that  any  treatment  will  be  completely  and 
permanently  successful  without,  the  drainage  provided  by  gastro- 
enterostomy. It  is  even  probable  that  this  operation  should  be 
resorted  to  at  once  in  the  majority  of  cases  without  a  preliminary  and 
perhaps  fruitless  exploration  of  the  interior  of  the  stomach. 

Mr.  Moynihan  {Royal  Med.-Chir.  Soc,  Nov.  13,  1906)  has 
operated  33  times  for  recurrent  hemorrhage  from  gastric  and  duodenal 
ulcers.  "  Posterior  gastrojejunostomy  was  performed  in  every  case 
save  one.     In  this  case  the  ulcer  was  excised  ;  the  patient  died.     In 


DIGITAL    DILATATION    OF   THE   STOMACH.  465 

21  gastrojejunostomy  was  the  only  treatment  adopted ;  two  of  th< 
died.  Gastrojejunostomy  was  combined  with  excision  of  the  ulcer  in 
two  patients,  one  of  whom  died.  Gastrojejunostomy  with  infolding  of 
the  ulcer  was  done  eight  times,  with  two  deaths.  Gastrojejunostomy 
with  infolding  of  the  pylorus  and  of  the  ulcer  was  performed  once;  the 
patient  recovered." 

Six  of  these  33  patients  died.  One  of  them  had  cirrhosis  of  the  liver, 
and  no  ulcer  could  he  found.  One  died  collapsed  at  the  end  of  a  week, 
but  the  cause  of  death  is  not  known.  One  died  of  pneumonia,  one  of 
exhaustion  after  eleven  days,  another  after  three  weeks.  One  died  from 
shock  a  few  hours  after  the  operation.  It  will  be  noticed  that 
the  mortality  of  the  operation  has  been  8  per  cent,  in  spite  of  Mr. 
Moynihan's  skill  in  gastric  surgery  ;  but  the  cases  were  mostly  grave 
ones,  and  no  recurrence  of  bleeding  took  place  in  any  of  them.  Mr. 
Moynihan  now  combines  infolding  of  the  ulcer  with  gastro-jejuostomy, 
and  considers  this  to  be  the  safest  and  best  procedure. 

Paterson  (loc.  supra  cit.)  recommends  gastrojejunostomy  without 
local  treatment  of  the  ulcer  in  all  cases,  because  he  believes  the 
operation  to  be  sufficient,  and  to  be  less  dangerous  than  local  treatment. 

If  gastrojejunostomy  could  be  relied  upon  to  secure  the  arrest  of 
gastric  haemorrhage,  and  to  prevent  its  recurrence,  gastrotomy  would 
be  no  longer  necessary  in  these  cases. 

The  direct  treatment  of  the  bleeding  spot  is  beset  with  difficulties 
for  the  surgeon  and  dangers  for  the  patient.  The  bleeding  ulcer  may 
not  be  in  the  stomach,  but  in  the  duodenum,  or  it  may  be  difficult  or 
impossible  to  find  the  source  of  bleeding,  or  the  wrong  ulcer  may  be 
excised.  Still  gastrojejunostomy  has  not  been  proved  to  do  away 
with  the  need  of  local  treatment  of  the  ulcer  in  all  cases,  for  Mansell 
Moullin  and  others  have  recorded  cases  in  which  haemorrhage  recurred 
in  spite  of  this  operation.  Dr.  F.  G.  Connell  (Ann.  of  Surg.,  1904, 
vol.  xl.  p.  500)  has  collected  10  cases  where  gastrojejunostomy  failed 
in  its  object.  Seven  of  these  ended  fatally.  Dr.  Ticehurst  also  records 
two  cases  in  which  gastrojejunostomy  was  of  no  avail,  and  in  one  of 
these  patients  no  definite  source  of  haemorrhage  was  found  either  at 
the  operation  or  after  death.  The  other  patient,  a  young  man,  died  of 
recurrent  haemorrhage  from  multiple  erosions  in  spite  of  gastrojejunos- 
tomy and  ligation  of  many  bleeding  points.  Paterson  contends  that 
the  recurrence  maj^  be  due  to  malignant  disease,  to  inefficient  drainage, 
or  to  the  use  of  mechanical  contrivances  in  making  the  fistula.  It  may 
be  concluded  that  a  gastrojejunostomy  is  indicated  in  all  cases,  and 
that  in  a  few  an  accessible  ulcer  may  be  infolded  with  Lemhert's 
sutures  at  the  same  time. 

DIGITAL   DILATATION  OP    THE   ORIFICES   OP  THE 

STOMACH. 

We  owe  this  operation  to  Prof.  Loreta,*  of  Bologna,  whose  two  first 
cases  Mr.  Holmes  was,  I  believe,  the  first  to  bring  prominently  under 
the  notice  of  English  surgeons. 

*  Prof.  Loreta's  first  case  is  reported  in  the  Lancet,  Aug.  18,  1883.     The  ninth  opera- 
tion, one  of  dilatation  of  the  cardiac  orifice,  is  briefly  given  in  the  same  journal  April  26, 
S. — VOL.  II.  30 


466  OPERATIONS   ON    Tin:   ai;i>m\ii.v 

Dilatation  "l"  Bimple  stricture  of  the  oesophagus  has  been  already 
discussed  (p.  455).  Digital  or  instrumental  dilatation  of  the  cardiac 
orifice  may  be  performed  from  the  stomach,  and  subsequent  contraction 

may  be  prevented  by  means  of  bougies. 

Pylorodiosis,  or  digital  dilatation  of  the   pylorus,  lias  been  almost 

entirely  replaced  by  some  form  of  gastro-enterostomy  or  pyloroplasty. 
The  contracted  pylorus  lias  been  Btretched  by  means  of  one  or  more 

fingers  introduced  through  an  incision  in  the  anterior  wall  of  the 
stomach.  Forceps  or  various  dilators  Lave  been  found  necessary  to  start 
the  dilatation  and  to  allow  the  introduction  of  a  finger,  and  much  force 
has  been  required  to  produce  the  necessary  amount  of  dilatation  or 
tearing. 

Jlalm  introduced  a  finger  into  the  pylorus  by  invaginating  the 
anterior  wall  of  the  stomach,  thus  avoiding  the  need  of  an  incision 
and  the  risks  of  it,  hut  it  is  clear  that  the  amount  of  force  which  is 
often  required  to  dilate  the  pylorus  could  not  he  exerted  in  this  way 
without  seriously  damaging  the  wall  of  the  stomach.  Moreover,  the 
contraction  may  he  so  tight,  that  the  finger  cannot  he  passed  into  it. 

Although  the  operation  has  heen  of  use  in  some  cases  of  fibrous 
stricture  of  the  pylorus  without  ulceration,  and  in  some  cases  of 
congenital  hypertrophic  stenosis,  it  is  not  surprising  that  it  has  fallen 
into  disfavour,  hecause  it  is  not  founded  upon  sound  principles.  The 
laceration  of  the  deeper  tissues,  and  even  of  the  mucous  membrane, 
that  must  occur  during  the  forcihle  dilatation,  would  he  expected  to  he 
followed  hy  interstitial  haemorrhage,  inflammation,  and  a  great  tendency 
to  recontraction.  Such  a  narrowing,  often  worse  than  the  original,  does 
in  fact  usually  occur,  and  there  is  no  means  of  preventing  it.  No 
instrument  can  he  tied  in  during  the  contractile  stage,  as,  after  forcihle 
dilatation  of  urethral  stricture,  ulceration  and  haemorrhage  also  have 
followed  pylorodiosis. 

]\Iayo  Kobson  collected  the  records  of  seventy-eight  of  these  operations 
for  his  Hunterian  lecture  in  1899,  and  found  the  mortality  to  he  39*7  per 
cent.  Of  course  it  is  hardly  fair  to  compare  this  high  death  rate  with 
that  of  gastro-enterostomy  (3  to  5  per  cent.)  at  the  presenl  day. 

Paterson  (Hunterian  Lectures,  1906;  Lancet,  vol.  i.  1906,  p.  577) 
found  that  this  operation  has  been  performed  twenty-one  times  for 
infantile  hypertrophic  stenosis  of  the  pylorus.  Fifteen  of  the  patients 
recovered  from  the  operation.  In  three  cases  the  pylorus  or  duodenum 
was  ruptured,  and  death  resulted  in  two  of  these;  in  the  other  the  rent 
was  recognised  and  sutured  during  the  operation. 

Kelapse  occurred  in  several  of  those  patients  who  survived  the 
operation,  and  in  at  least  two  of  these  death  followed  the  recurrence 
of  the  obstruction;  a  third  patient  recovered  after  a  secondary  gastro- 
enterostomy. There  is  little  doubt  but  that  gastrojejunostomy  and 
pyloroplasty  are  preferable  to  pylorodiosis,  although  the  immediate 
mortality  of  these  operations  has  been  greater  in  the  past. 

1884.  Mr.  Holmes'  summary,  a  very  full  one,  of  two  papers  by  Prof.  Loreta,  will  be  found 
in  the  Brit.  Med.  .loiim.,  Feb.  21,  1885.  Any  BurgeoD  about  to  perform  these  operations 
should  refer  to  tins.  .Mr.  Eaggard's  case — the  firel  successful  one  performed  by  an  English 
surgeon — was  published  in  the  Jirit.  Med.  Joum.,  Feb.  19,  1887.     In  the  same  journal  for 

March  17,  i8SS,  is  a  note  that  the  patient  continues  perfectly  well. 


PYLOROPLASTY.  467 

PYLOROPLASTY. 

This  is  ;i  scientific  advance  od  Prof.  Loreta's  operation  for  the  relief 
of  non-malignanl  strictures  of  the  pylorus,  e.g.,  those  due  to  congenital 
Btenoais,  corrosive  poisoning,  injury,  cicatrised  ulcers,  and  chronic  gas- 
tritis. We  «>we  the  operation  to  Heineke  and  Mikulicz,  who  performed 
it  independently  in  e886  and  1887. 

In  pyloroplasty  a  definite  plastic  operation  replaces  ;i  divulaion  per- 
formed more  or  less  in  the  dark.  The  two  operations  are  very  well 
contrasted  hy  Mr.  Pearce  Gould  in  an  instructive  paper  (Lancet,  1893, 
vol.  i.  p.  1 183)  : — "  Of  the  two  methods  of  obtaining  a  wider  pylorus, 
pyloroplasty  was  chosen  as  safer  and  more  likely  to  he  permanently 
successful  than  Loreta's  operation  of  divulsion.  Both  operations  entail 
incision  into  the  stomach  and  subsequent  suture  of  the  wound  ;  so  far 
their  perils  are  the  same.  But  whilst  pyloroplasty  consists  of  a  clean 
cut  through  the  anterior  wall  of  the  pylorus,  where  it  is  most  free  from 
large  vessels  and  under  the  operator's  eye,  the  effects  of  divulsion  are 
not  seen,  and  may  be  more  or  less  than  the  surgeon  intends,  and  may 
be  inflicted  upon  important  vessels.  The  statistics  of  Loreta's  operation 
show  cases  of  death  from  complete  rupture  of  the  pylorus  on  its  posterior 
aspect,  and  also  from  haemorrhage  ;  the  plastic  operation  is  entirely  free 
from  these  dangers.*  A  further  most  important  consideration  is  the 
question  of  relapse.  Divulsion  has  been  followed  by  recurrence  of  the 
stricture,  and  in  many  cases  the  operation  has  been  repeated ;  and, 
looking  to  analogous  cases,  this  is  what  one  would  expect.  A  sudden 
dilatation  of  the  strictured  urethra  or  rectum  is  well  known  to  be 
followed  by  relapse  unless  special  means  are  used  to  maintain  the 
enlargement.  All  such  special  means  are  inapplicable  in  the  case  of 
the  stomach.  Stretching  the  pylorus  may  consist  of  over-stretching 
the  muscular  ring,  analogous  to  stretching  the  sphincter  ani.  This  may 
be  entirely  satisfactory  in  its  result ;  on  the  other  hand,  it  may  effect  a 
tearing  and  stretching  of  fibroid  or  cicatricial  tissue — a  process  known 
to  be  very  unsatisfactory  in  mairy  cases.  Pyloroplasty,  on  the  other 
hand,  introduces  new  and  presumably  health}'  tissues  into  the  pyloric 
ring,  tissues  with  no  tendency  to  contract." 

The  stomach  should  be  washed  out  thoroughly  on  the  day  before  the 
operation.  The  lavage  should  be  repeated  about  two  hours  before  the 
operation,  and  a  saline  enema  given.  To  lessen  the  risk  of  pulmonary 
complications,  the  teeth  and  mouth  should  be  well  cleansed  for  a  day 
or  two,  and  an  antiseptic  mouth  wash  used.  Only  boiled  milk  should 
be  given  by  the  mouth  for  two  days  before  the  operation. 

Operation  (Figs.  172  and  173). — The  abdomen  having  been  opened 
by  a  free  incision  through  the  sheath  of  the  right  rectus,  the  muscle 
drawn  well  outwards,  and  all  haemorrhage  stopped,  the  pylorus  is  found, 
brought  out  of  the  wound  if  possible,  and  in  any  case  well  packed 
around  with  tampons  of  sterile  gauze.  Adhesions  between  the 
pylorus    and  omentum,    or    between  the    pylorus    and  the  liver,  may 

*  Mr.  P.  Swain,  of  Plymouth,  whose  operative  experience  is  well  known,  has  candidly- 
published  {Lancet,  1892,  vol.  i.  p.  87)  two  cases  of  digital  dilatation  of  the  pylorus  which 
ended  fatally.  Both  patients  were  in  very  weak  condition  ;  one  died  of  continued  vomit- 
ing. In  the  other,  the  duodenum,  which  was  very  thin,  was  torn  cpaite  through  behind, 
at  its  junction  with  the  pylorus. 

30—2 


468 


OPERATIONS   ON    THE   ABDOMEN. 


need  separating.  A  transverse  incision  is  then  made  into  the  anterior 
wall  of  the  stomach,  just  internal  to  the  pylorus,  by  which  the  stricture 
is  examined  from  within.  The  incision  is  next  prolonged  transversely 
through  the  strictured  pylorus  into  the  duodenum,  making  it  about  two 
inches  long.     Any  vessels  which  spirt  must  he  clamped.     Any  contents 

Fig.  172. 


Pyloroplasty,  first  stage,  showing  the  longitudinal  incision.     (Pearce  Gould.) 


Fig.  173. 


Pyloroplasty,  second  stage,  showing  the  longitudinal  wound  converted  into 
a  transverse  by  retraction.  (Pearce  Gould.)  It  is  far  better  to  make  the 
deep  suture  pierce  all  the  coats. 

of  the  stomach  which  may  escape  are  carefully  removed  on  gauze.  The 
transverse  incision  is  then  widely  opened  out  by  two  blunt  hooks, 
placed  in  the  centre  of  each  side;  this  produces  a  wound  of  lozenge 
shape,  which  is  united  so  as  to  form  a  vertical  one.  Any  soiled  sponges 
or  tampons  heing  renewed,  the  sutures  are  inserted  in  a  douhle  row. 
There  are  several  ways  of  doing  this.  A  continuous  suture  uniting 
the  mucous  membrane  and  a  row  of  Lembert's  sutures,  carried  well 
into  the  muscular  coat,  have  heen  used  successfully  (Fig.  173).  Con- 
sidering the  tension,  I  prefer  to  make  the  deep  stitch  pierce  all  the 


PYLOROPLASTY. 


■\r>9 


coats,  to  secure  a  firmer  hold.  The  knots  of  this  should  be  upon  the 
mucous  surface  {vide  Figs.  ro6,  107  and  166).  This  stitch  should  be 
reinforced  and  buried  by  a  continuous  Bero-muscular  suture.  Fine  silk 
should  be  used  on  ordinary  round  sewing-needles.  To  strengthen  the 
line  of  suture  any  tags  of  jxritoineal  adhesions  which  have  been  sepa- 
rated and  left  attached  near  the  incision  may  he  brought  together  and 
fixed  over  it  by  a  few  points  of  suture.  The  after-treatment  will  be 
that  given  at  p.  522. 

Successful  cases  will  be  found  recorded  by  Mr.  Page,  of  Newcastle 
(Lancet,  1892,  vol.  ii.  p.  84)  ;  Mr.  Gould,  loc.  supra  cit.  ;  Mr.  Morison 
(Lancet,  1895,  vol.  i.  p.  396).  Mr.  Gould  quotes  several  foreign 
operators,  and,  having  collected  23  cases,  finds  the  mortality 
to  be  about  25  per  cent.  Mr.  M.  Robson  (Brit.  Med.  Journ.,  1900, 
vol.  i.  p.  627)  makes  use  of  his  decalcified  bone  bobbin.  This,  besides 
steadying  the  line  of  sutures  for  twenty-four  or  forty-eight  hours, 
secures  an  immediately  and  thoroughly  patent  channel.  The  same 
author  (loc.  supra  cit.)  also  remarks  as  follows  on  the  limitations 
of  this  operation  : — "  If,  owing  to  cicatrisation  of  the  ulcer,  there  is 
extensive  hypertrophy  of  the  pylorus  with  a  large  amount  of  thickening, 
pyloroplasty  is  insufficient,  as  in  such  cases  contraction  will  be  likely 
to  recur.  Here  pylorectomy  may  be  performed,  as  in  two  cases  of  my 
own,  or,  better  still,  gastro-enterostonvy,  which  is  a  simpler,  quicker, 
and  safer  operation.  Numerous  and  firm  adhesions,  active  ulceration, 
and  the  presence  of  new  growth,  are  also  contra-indications  for 
pyloroplasty.  Pyloroplasty  with  partial  excision  seems  the  right 
practice  in  bad  organic  stricture.  The  dense  tissue  being  cut  away, 
the  lozenge-shaped  incision  can  be  readily  sutured  so  as  to  become 
transverse  ;  whilst,  if  a  simple  longitudinal  incision  is  made  through 
the  tissues  of  a  dense  stricture,  it  is  impossible  to  convert  it  safely 
into  a  transverse  line  of  sutured  wound,  owing  to  the  great  tension 
if  the  two  ends  be  made  to  meet  in  the  middle." 

Mr.  Robson  collected  the  records  of  thirty-eight  operations  for  his 
Hunterian  Lectures,  and  found  the  mortality  to  have  been  I5'4  per 
cent.  Since  then  the  results  have  improved  greatly.  Thus  in  Robson 
and  Moynihan's  last  twenty-seven  pyloroplasties  only  one  death  occurred. 

Pyloroplasty  does  not  drain  a  dilated  stomach  nearly  so  well  as 
gastrojejunostomy,  nor  does  it  provide  rest  for  the  diseased  pylorus, 
but  vomiting  from  the  so-called  vicious  circle  cannot  follow  the  ordinary 
pyloroplasty.  Recurrence  of  the  contraction,  or  even  ulceration,  may 
slowly  develop,  and  give  rise  to  serious  symptoms  even  after  several 
years.  Paterson  (Lancet,  vol.  i.  1906,  p.  498),  from  an  analysis  of  the 
published  cases,  concludes  that  relapse  occurs  in  at  least  27  per  cent, 
of  the  patients.  Out  of  22  cases  followed  up  by  Paterson  himself, 
relapse  occurred  in  12.  Secondary  gastrojejunostomy  has  not 
uncommonly  been  required  and  performed.  The  operation  has  been 
more  successful  in  cases  of  congenital  hypertrophic  stenosis,  the 
immediate  mortality  being  less  than  that  of  gastro-jejunostom}r  in 
these  usually  marasmic  patients,  and  the  after-results  being  excellent 
in  the  5  cases  that  survived  (Paterson,  loc.  cit.,  p.  578). 

Finney's  Operation  (Bull.  Johns  Hopkins  Hosp.,  July,  1902). — 
Dr.  Finney  described  his  ingenious  operation  as  a  new  method  of 
pyloroplasty,   but    it    is    also    a    form   of  gastro-duodenostomy.     The 


470 


OPERATIONS  ON  THE  APDOMKN. 


pylorus,  llio  pyloric  end  of  the  stomach,  and  the  first  part  of  the 
duodenum  are  thoroughly  freed  from  adhesions,  so  that  the  subsequent 
steps  may  be  made  easy  and  all  tension  prevented.  Finney  lays  stress 
on  the  need  of  dividing  the  adhesions  very  thoroughly,  and  considers 
this  to  be  one  of  the  most  essential  points  of  the  operation. 

Retractor  sutures  are  inserted  at  the  upper  border  of  the  pylorus, 
and  low  down  on  the  anterior  walls  of  the  stomach  and  duodenum 
(vide  Fig.  176).      Traction  is  made  upon  these  threads  for  the  double 

Fig.  174. 


Strictured  pylorus 


Finney's  operation.     Strictured  pylorus. 
Fig.  175. 


Incision  in   stomach 
b,  duodenum 

Finney's  operal  ion. 

purpose  of  bringing  the  stomach  and  duodenum  together  and  holding 
their  walls  taut,  to  facilitate  the  insertion  of  sutures.  A  continuous 
sero-muscular  suture  is  first  used  to  join  the  stomach  and  duodenum 
as  far  back  as  possible  (ride  Fig.  177)  ;  anterior  mattress  sutures  are 
then  placed  to  complete  the  circle  of  sero-muscular  stitches  (vide 
Fig.  176).  The  anterior  sutures  are  retracted  as  shown  in  Fig.  177, 
and  a  horseshoe-shaped  incision  is  made  within  the  line  of  sutures 
(Figs.  175,  177).  The  incision  divides  the  stricture  near  its  lower 
border  and  extends  well  into  the  stomach  and  duodenum.  To  limit  sub- 
sequent contraction,  as  much  of  the  scar  tissue  as  possible  is  removed 


PYLOROPLASTY. 
Fig.  176. 


Retractor  suture 


Anterior  mattress 
sutures  of  silk 


Retractor  sutures 


471 


The  posterior  continuous  sero-muscular  suture  is  shown.     Finney's  operation. 
(After  Finney,  Bull,  Johns  Hopkins  Hosp.") 


Fig.  177. 


Hook  pulling  anterior 
sutures  aside 


Posterior  continuous 
suture  of  silk 


Hook 


The  horseshoe-shaped  incision  is  shown.    Finney's  operatioD.    (After  Finney, 
Bull.  John*  Hopkins  Hosp.") 


47^ 


nlT.UATIONS    ON    THE    ABDnMI'.N. 


from  either  Bide  of  the  incision,  especially  if  the  walls  of  the  pylorus  are 
much  thickened.  To  prevenl  the  formation  of  obstructing  valves,  and 
to  make  suturing  easier,  redundant  edges  of  mucous  membrane  are 
removed.  Haemorrhage  is  arrested,  and  the  posterior  edges  of  the 
incision  are  joined  together  by  means  of  a  continuous  catgut  suture, 
which  pierces  all  the  coats  of  the  stomach  and  intestines  (Fig.  178). 
This  suture  reinforces  the  posterior  sero-muscular  stitch,  si  cures  better 
contact  of  the  edges,  and  prevents  the  reunion  of  the  anterior  to  pos- 
terior edges  of  the  opening.  The  anterior  sutures  are  then  tied  and 
the  operation  completed  (Fig.  179).  Scudder  uses  continuous  instead 
of  interrupted  sutures,  and  Gould  employs  clamps  for  the  control  of 
haemorrhage  (Finney,  Lancet,  1905,  vol.  ii.  p.  327).  Both  these  modi- 
fications are  of  value,  for  they  make  the  operation  easier,  simpler,  and 

Fig.  178. 


Posterior  continuous 
catgut  deep  suture    \i 


Finney's  operation.    (After  Finney,  Bull.  Johns  Hopkins  Hosjj.,  July,  1902.) 


safer.  The  clamps  are  used  in  just  the  same  way  as  for  gastro- 
jejunostomy, and  the  advantages  of  using  them  are  discussed  at  p.  501. 

The  advantages  claimed  for  this  operation  are — that  it  is  easy  and 
simple  to  perform;  that  the  risk  of  infection  is  very  slight,  owing  to  the 
minimum  exposure  of  infective  surfaces;  that  the  size  and  position  of 
the  new  orifice  are  such  as  to  provide  free  drainage  of  the  stomach, 
unless  the  latter  is  greatly  dilated  ;  that  spur  formation  and  the  develop- 
ment of  a  vicious  circle  are  impossihle;  and  that  there  is  a  peculiar  free- 
dom from  post-operative  nausea  and  vomiting  [regurgitation  of  bile  does 
occur  in  some  cases,  however]  ;  and  further  even  a  Large  ulcer  may  be 
removed  from  the  anterior  aspect  of  the  pylorus  or  stomach  without  fear 
of  subsequent  cicatricial  contraction.  It  does  not  interfere  with  digestion 
in  the  duodenum  and  with  the  refiex  secretion  of  bile  and  pancreatic 
juice  ;  hence  absorption  should  be  better  than  after  short-circuiting. 

Disadvantages. — Although   the    operation   is  a   great   improvement 


PYLOROPLASTY. 


473 


on  pyloroplasty,  the  separation  of  adhesions  is  troublesome,  and  may 
be  dangerous.  The  after-results  are  no1  bo  good  us  those  of  gastro- 
jejunostomy. It  is  contra-indicated  in  most  cases  of  active  ulceration,  or 
with  ileus. •  adhesions,  and  its  mortality  is  higher  than  thai  of  gastro- 
jejunostomy. The  mesogastrium  may  be  too  short  orthe  duodenum  may 
be  too  fixed  to  allow  easy  approximation  of  the  parts  that  may  then  have 
to  be  joined  in  the  depth  of  the  wound.  Finney  {Lancet,  1905,  vol.  ii. 
p.  327)  states  that  he  has  performed  the  operation  twenty-five  times, 
and  that  he  has  collected  the  results  of  112  operations  performed  by 
twelve  surgeons  ;  the  death  rate  was  just  under  9  percent.  In  fifty-eight 
of  these  operations  Dr.  W.  J.  Mayo  had  a  mortality  of  a  little  less 
than  7  per  cent.  {Ann.  of  Sun/.,  1905,  vol.  xlii.). 

It  may  be  concluded  that  Finney's  operation  is  neither  so  safe  nor 

Fig.  179. 


Anterior  sutures 
tied 


Finney's  operation.     (After  Finney,  Bull.  Johns  Ilojrfiins  Hosp.') 


so  generally  applicable  as  gastrojejunostomy,  but  that  in  slight  cases, 
with  few  adhesions,  and  in  the  absence  of  an  irremovable  ulcer,  it  may  be 
the  operation  of  choice  occasionally. 

GASTRO-DUODENOSTOMY. 

This  operation  was  designed  by  Jaboulay  with  the  object  of  overcom- 
ing pyloric  stenosis,  and  yet  to  allow  the  food  to  enter  the  duodenum 
for  digestive  purposes,  and  particularly  with  the  view  of  preventing  the 
development  of  a  vicious  circle  or  regurgitant  vomiting.  Theoretically 
gastro-duodenostomy  is,  on  these  two  accounts,  better  than  gastro- 
jejunostomy, but,  as  a  matter  of  fact,  some  bile  regurgitation  may  follow 
gastro-duodenostomy,  if  the  opening  be  made  as  large  as  in  Finney's 
operation  and  others.  At  the  present  time  regurgitant  vomiting  after 
a  proper  gastrojejunostomy  has  ceased  to  be  the  terror  of  surgeons, 
although  it  still  occurs  occasionally,  especially  with  loop  operations  and 
an  open  pylorus. 

It  remains  to  be  proved  that  a  posterior  gastrojejunostomy  without 
a  loop  does  really  and  seriously  interfere  with  normal  digestion  and 
absorption    in  non-malignant  cases,    and    abundant    clinical   evidence 


474  OPKKATIOXS    ON    TIIK    AliDOMKX. 

points  strongly  the  other  way.  Dr.  Cameron  tells  me  that  in  one  of 
my  cases,  which  he  has  kindly  investigated,  the  absorption  of  hit  was 
less  than  normal  during  the  second  week-  ;  hut  the  man  is  rapidly 
putting  on  weight.  There  is  no  risk  of  peptic  jejunal  ulcer  following 
gastro-duodenostomy,  and  even  a  duodenal  one  is  extremely  unlikely  to 
develop,  lor  the  acid  chyme  now  enters  quite  near  the  biliary  papilla, 
and  is  soon  neutralised  by  the  bile  and  pancreatic  juice. 

This  operation  is  either  impracticable  or  unsuitable  for  malignant 
disease,  for  if  the  growth  is  too  extensive  lor  resection,  it  is  also  too 
extensive  for  gastro-duodenostomy,  and  if  there  is  some  reason  against 
resection,  while  the  growth  is  small  enough  to  allow  gastro-duodenostomy 
the  new  opening  will  soon  be  invaded  and  obstructed  by  extension  of 
the  growth.     In  rare  cases  of  extensive  adhesions  of  all  the  stomach 
except    near   the    pylorus    in    front,    gastro-duodenostomy  may  be    of 
great  value,  but  the  adhesions  are  usually  limited  to  the  pyloric  region. 
When  an  active  ulcer  at  or  near  the  pylorus  can  be  excised,  a  gastro- 
duodenostomy  may  be  so  designed  as 
FlG-  l80,  to  do  this  and   drain  the  stomach  at 

the  same  time  as  in  Finney's  operation 
(vide  p.  472).     When  the  stomach  is 
considerably  or  greatly  dilated,  gastro- 
jejunostomy is  undoubtedly  to  be  pre- 
ferred over  gastro-duodenostomy,  and, 
as  far  as  the   available  evidence  goes, 
this     operation    is    both   simpler    and 
safer  in    the    great  majority  of  cases. 
As  compared  with  such  unsatisfactory 
operations  as  pylorodiosis  and  pyloro- 
Jaboulay's  method  of  gastro-duodc-     plasty,    gastro-duodenostomy    has   the 
nostomy.  (Mayo Robson and  Moynihan.)     grea{   a(lvantage    of    avoiding   diseased 
a.  Incision  into  the  stomach.    It  would      fiooiips 
he   better  to  place  this   much   lower  '     ^ '       }       Kocher     ]m(]  iously 

down.    b.  Ihe  wound  in  the  uuodenum.      .    .        ,  , ,  i      /•  .1         1       j 

joined  the  open   end  or  the  duodenum 

to  the  posterior  surface  of  the  stomach  after  resection  of  the  pylorus, 
Jaboulay  was  the  first  to  suggest  gastro-duodenostomy  as  a  lateral 
anastomosis.  He  joined  the  duodenum  to  the  anterior  surface  of  the 
stomach  by  making  a  vertical  incision  in  each,  and  folding  the  duodenum 
over  and  to  the  left.  This  is  only  possible  with  a  very  movable 
duodenum,  or  after  making  it  mobile  by  Kocher's  method.  Villard 
made  a  fistula  between  the  neighbouring  surfaces  of  the  duodenum 
and  dilated  stomach  below  and  quite  near  the  pylorus,  which  is  a 
difficult  procedure.  Prof.  Kocher  mobilises  the  duodenum  so  that  it 
can  be  more  easily  and  safely  joined  to  the  stomach.  He  gives  the 
following  description  of  his  method.* 

"The  most  suitable  incision  is  one  similar  to  that  which  we  recom- 
mended for  exposing  the  gall-bladder,  viz.,  an  oblique  incision  two 
fingers'  breadth  below  and  parallel  to  the  right  costal  margin,  beginning 
at  the  middle  line  (vide  Fig.  211,  p.  531).  After  dividing  the  skin  and 
fascia,  the  rectus  muscle  is  cut  through  as  far  as  the  broad  abdominal 
muscles.       The    posterior    layer    of    the    rectal    sheath,    the    fascia 


*  Operative  Surgery,  translation  by  Stiles,  1903,  Appendix,  p.  433. 


GASTIIO-hUODENOSToMY.  475 

transversalis,  and  the  peritonaeum  arc  divided.  In  muscular  Bubjects,  the 
transversalis  muscle  is  split  parallel  to  its  fibres,  which  are  then  firmly 
drawn  apart.  Should  anyadhesions  exist  between  the  gall-bladder  and 
the  colon,  they  must  be  divided.  The  liver  is  drawn  upwards,  and  the 
stomach  to  the  left,  and  the  transverse  colon  and  the  descending  limb 
of  the  hepatic  flexure  downwards.  The  duodenum  is  then  brought  into 
view,  and  its  outer  border  (dearly  defined.  A  pad  of  gauze  is  placed 
against  the  under  surface  of  the  liver,  and  the  latter  is  then  drawn 
well  upwards  with  a  suitable  retractor.  Gauze  compresses  are  also 
employed  to  push  aside  the  stomach  and  the  colon. 

"  The  delicate  layer  of  the  parietal  peritonaeum  covering  the  kidney  is 
divided  vertically  one  and  a  half  inches  external  to  the  second  part  of 
the  duodenum,  and  the  incision  is  then  continued  vertically  downwards 
through  the  upper  layer  of  the  transverse  mesocolon  (which  is  held  on 
the  stretch)  as  far  as  the  larger  branches  of  the  vessels.  The  fingers 
are  then  introduced  behind  the  left  edge  of  the  incision  through  the 
peritonaeum,  and  the  duodenum  is  separated  from  the  vertebral  column, 
the  vena  cava,  and  the  aorta,  until  it  can  be  brought  forward  and 
pressed  against  the  pyloric  portion  of  the  stomach,  which,  in  its  turn, 
is  compressed  against  the  left  edge  of  the  wound  in  the  abdominal 
wall,  so  as  to  shut  off  the  general  cavity  of  the  stomach  and  prevent 
escape  of  its  contents.  Both  stomach  and  duodenum  are  now  com- 
pressed above  and  below  between  the  fingers  of  an  assistant,  and  the 
lateral  anastomosis  is  effected  in  the  usual  manner  by  two  rows  of 
sutures.  To  one  who  has  convinced  himself  how  easily  and  securely 
this  lateral  gastro-duodenostomy  can  be  performed,  provided  the 
duodenum  can  be  rendered  sufficiently  movable,  it  will  be  evident  how 
admirably  the  operation  fulfils  the  indications  for  treatment  of  stenosis 
of  the  pylorus.  Unlike  other  surgeons  who  have  performed  gastro- 
duodenostomy,  we  do  not  limit  the  operation  to  special  cases ;  on  the 
contrary,  we  regard  it  as  the  normal  procedure,  and  we  are  of  opinion 
that  it  will  take  precedence  over  all  previous  methods  of  gastro- 
enterostomy and  pyloroplasty. 

"  The  method  is  subject  to  only  one  contra-indication,  viz.,  the 
presence  of  such  extensive  adhesions  to  the  under  surface  of  the  liver, 
that  the  duodenum  cannot  be  sufficiently  freed.  This  difficulty  of 
adhesion  can,  however,  often  be  overcome,  as  we  have  proved  in  three 
of  our  cases ;  but  the  fact  of  having  to  perform  the  suturing  inside  the 
abdomen  is  apt  to  interfere  with  the  security  of  stitching,  especially  in 
difficult  cases.  It  is  on  this  account  that  subpyloric  gastro-duodenos- 
tomy did  not  meet  with  universal  acceptance.  The  subpyloric  portion 
of  the  duodenum  cannot  be  drawn  out  of  the  wound,  on  account  of  its 
connection  with  the  gastro-hepatic  omentum  and  the  important 
structures  contained  within  it.  This  fixation  to  the  under  surface  of 
the  liver  may  be  so  firm  that  only  the  lower  two-thirds  or  only  the 
lower  part  of  the  vertical  portion  of  the  duodenum,  together  with  the 
inferior  flexure,  can  be  brought  in  contact  with  the  stomach. 

"  We  therefore  propose  that,  instead  of  Villard's  subpyloric  gastro- 
duodenostomy,  the  name  lateral  gastro-duodenostomy  be  given  to 
this  operation  to  distinguish  it  from  our  method  of  inserting  the 
divided  duodenum  into  the  posterior  wall  of  the  stomach  after  resection 
of  the  pylorus.     The    great    difference    between  Villard's   subpyloric 


476         OPERATIONS  ON  THE  ABDOMEN. 

gastro-duodenostomy  :ui<l  our  procedure  is,  thai  we  render  the  descending 
portion  of  the    duodenum,   the    inferior   flexure,  and    a  considerable 

portion  of  thf  third  (transverse)  part  so  movable  that  tin-  parts  to  be 
sutured  can  readily  be  raised  up  and  surrounded  with  gauze,  so  that  the 
sutures  can  he  introduced  extra-peritoneeally  with  comfort  and  security. 

••  We  intend  in  future  to  perform  lateral  gastro-duodenostomy  in  all 
cases  of  stricture  of  the  pylorus,  and  only  to  perform  gastrojeju- 
nostomy in  cases  rendered  unusually  difficult  h}'  firm  adhesions.  We 
have  performed  the  operation  on  five  occasions,  four  tines  for 
cicatricial  stenosis  and  once  for  malignant  stricture.  The  results 
have  been  convincing.  "  Regurgitation  of  hile  either  does  not  occur  at 
all,  or  only  at  first,  when  a  large  gaping  opening  has  been  made.  It 
is  advisable  to  make  the  anastomotic  opening  as  high  as  possible  in 
the  duodenum  and  not  too  large.  The  patient  with  carcinoma  was  at 
once  relieved  of  all  her  discomfort.  Only  one  patient  complained 
subsequently  of  very  severe  pain,  and  he  had  a  simultaneous  chole- 
cystostomy  performed  for  gall-stones.  That  a  dilated  and  sacculated 
stomach  is  not  so  well  emptied  as  by  our  inferior  gastrojejunostomy  is 
obvious.  If  gastro-duodenostomy  be  performed  in  such  a  case,  it  is 
advisable  to  occasionally  wash  out  the  stomach." 

It  is  to  be  noted  that  even  Prof.  Kocher  found  adhesions 
troublesome  in  three  out  of  his  five  cases.  Although  operation 
may  appear  easy  to  him,  it  is  certain  that  for  those  of  less 
experience  gastrojejunostomy  is  easier  and  safer  to  adopt  in  the 
large    majority   of  cases. 

.PYLORECTOMY ;    PARTIAL    GASTRECTOMY. 

This  operation,  which  we  owe  especially  to  German  surgeons — e.g., 
Billroth,  Wolfler,  Gussenbauer,  and  v.  Winiwarter — has  not  hitherto 
been  so  largely  practised  in  England  as  elsewhere.  The  principal 
indication  is  malignant  disease,  although  the  operation  has  occasionally 
been  performed  for  non-malignant  stenosis  of  the  pylorus  (vide  supra). 
The  original  method  of  end  to  end  direct  suture  has  been  largely 
replaced  by  the  more  expeditious  methods,  in  which  the  divided  ends 
of  the  stomach  and  duodenum  are  closed  by  suture,  and  a  gastro- 
duodenostomy  or  gastroenterostomy  then  performed.  On  several 
occasions  also  the  operation  has  been  performed  in  two  stages,  the 
eastro-enterostomy  being  first  performed ;  then,  after  the  general 
condition  of  the  patient  has  improved  as  a  result  of  the  relief  from 
pyloric  stenosis,  the  removal  of  the  pylorus  is  carried  out.  This  has 
been  done  by  Tupolske,  Ilahn,  Franke,  Barker,  and  others.  Mr.  Mayo 
Robson  {Brit.  Med.  Journ.,  vol.  i.  1900,  p.  696)  objects,  however,  to 
this  plan  on  the  ground  that  the  patient  may  derive  so  much  benefit 
from  the  first  operation  that  he  cannot  be  always  brought  to  see  the 
necessity  of  a  second  operation  until  it  is  too  late  to  be  successful.  The 
resection  may  alter  the  anatomical  relations  so  much,  that  kinking  and 
obstruction  of  the  opening  into  jejunum  takes  place.  Paterson  lost 
one  patient  from  this  cause. 

The  improvements  in  technique  have  led  to  a  considerable  diminu- 
tion in  the  mortality,  as  may  be  gathered  by  a  comparison  of  the 
following  sets  of  cases  collected  in  1885  and  1900  : — 

Mr.    Butlin  quotes  Bramer  {Cent.  f.  Chir.,  1885,  p.  54S)  as  having 


I'YLOKKCTOMY. 


•177 


collected  72  cases  of  pylorectomy  for  cancer,  of  which  55  died  from 
the  operation,  a  mortality  of  76  per  cent. 

Mr.  Mayo  Robson  (loc.  supra  cit.)  uives  a  table  containing  572 
with  174  deaths,  a  mortality  of  3C4  per  cent.     Some  operators  have, 
moreover,  published  recent  lists  showing  even  far  better  results  than 
these.      For  instance,  Maydl  had  only  4  deaths  in  J5  cases,  and   Kocher 
only  5  deaths  in  57  cases. 

Mr.  Paterson  in  his  Hunterian  Lectures  on  Gastric  Surgery  {Lancet, 
1906,  vol.  i.  p.  580)  gives  a  number  of  valuable  and  recenl  statistics. 
Thus  Kocher  had  performed  no  resections  lor  carcinoma  oi  the 
stomach  up  to  the  end  of  1905,  with  a  mortality  of  24  per  cent.,  but 
since  1898  the  death  rate  of  58  cases  has  been  only  15  per  cent.  Urs. 
W.  J.  Mayo  and  C.  Mayo  had  performed  100  resections  up  to  the  end 
end  of  1905,  with  a  mortality  of  only  14  per  cent. 

Such  results  are  not  attainable  without  special  experience,  and  it 
is  probable  that  a  mortality  of  from  20  to  25  per  cent,  would  be  con- 
sidered to  be  a  low  one  by  most  surgeons,  who  do  not  get  their  cases 
so  early  as  those  who  are  known  to  have  unusual  experience  of  gastric 
surgery.  Mr.  Moynihan  (Clin.  Soc.  Trans.,  1906,  p.  87)  lost  three  of 
his  ten  cases,  a  mortality  of  30  per  cent.,  but  these  figures  include  one 
case  of  total  gastrectomy. 

As  regards  the  question  of  pylorectomy  compared  with  gastrojeju- 
nostomy only,  the  following  words  of  Dr.  Macdonald's  (Ann.  of  San/., 
February,  1901,  p.  160),  referring  to  the  results  of  pylorectomy,  may  be 
quoted  : — "  I  have  taken  occasion  recently  to  make  a  cursory  investiga- 
tion of  the  literature  with  relation  to  this  subject,  and  have  been  able 
to  find  43  cases  for  which  pylorectomy  was  done  for  carcinoma 
of  the  stomach,  and  that  the  patients  were  living  without  recurrence 
three  years  after  the  operation,  and  that  there  were  patients  in  this 
group  who  were  alive  ten  years  after  the  primary  operation,  without 
symptoms  of  recurrence.  I  may  also  say  that  this  group  of  43 
cases  is  collected  from  among  527  operations  done  for  the  relief  of 
pyloric  carcinoma,  with  an  immediate  mortality  of  31  per  cent.  In 
other  words,  we  have  from  the  work  already  done  rather  more  than 
8  per  cent,  of  final  recoveries  as  judged  by  ordinary  standards.  This 
will  compare  very  favourably  with  the  ultimate  success  which  we 
enjoyed  a  few  years  ago  in  the  treatment  of  cancer  of  the  breast." 

From  an  analysis  of  the  recorded  cases  of  total  and  subtotal  gastrec- 
tomy and  a  number  of  partial  gastrectomies  Paterson  concludes 
that  over  8  per  cent,  of  the  patients  remain  well  for  over  five  years, 
and  may  be  considered  to  be  probably  cured.  In  Kocher's  series  of 
"  97  consecutive  cases  8  per  cent,  of  the  patients  are  alive  and  well 
over  five  years  after  the  operation,  and  of  the  42  patients  who  have 
died  only  2  died  later  than  three  years  and  a  half  after  the 
operation." 

Before  deciding  between  a  pylorectomy  on  the  one  hand  and  a 
gastrojejunostomy  only  on  the  other,  the  following  conditions  must 
be  most  carefully  considered  : 

i.  The  size,  site,  and  degree  of  fixation  of  the  growth.  Is  the 
mass  small,  circumscribed,  and  localised  to  the  pylorus  ? — i.e., 
how  far  is  it  (a)  without  any  secondary  deposits  ?  (/3)  free  from 
adhesions  ?     It  is  probably  quite  impossible  to  be  certain  as  to  these 


478         OPERATIONS  ON  THE  ABDOMEN. 

points.     While  in  many  cases  cancer  of  the  pylorus  may  remain  long 

limited  to  the  pylorus  itself,  it  is  very  liable  to  infect  the  omenta  and 
the  lymphatic  glands  around  the  head  of  the  pancreas,  and  to  cause 
secondary  growths  in  the  liver  and  other  parts.'     Adhesions,  too,  are 
very  frequentlyl  met  with  between  the  stomach  and  the  colon,  pancn 
and  liver. 

When  adhesions  are  present  the  immediate  mortality  of  the  operation 
is  greatly  increased,  and  this  is  especially  true  of  adhesions  involving 
the  pancreas ;  in  these  cases  Mikulicz  had  a  mortality  of  70  per  cent. 
The  prospects  of  permanent  relief  are  of  course  much  diminished,  for 
the  growth  follows  closely  in  the  wake  of  inflammatory  adhesions. 
The  more  the  growth  has  extended  towards  the  cardiac  orifice  along 
the  lesser  curvature,  the  less  the  chance  of  successful  resection. 

Slight  enlargement  of  the  lymphatic  glands  is  not  a  contra-indication 
to  resection,  for  the  glands  are  very  frequently  found  to  be  merely 
inflammatory,  and  they  may  be  seen  near  a  simple  ulcer. 

When  the  glands  are  of  large  size  and  adherent,  it  is  generally  too 
late  to  attempt  the  removal  of  the  growth.  In  the  great  majority  of 
cases,  an  exploration  should  be  undertaken  before  any  tumour  can  be 
felt,  but  it  is  certainly  not  true  that  resection  may  be  considered  to 
be  impracticable  because  a  tumour  is  evident,  for  even  the  induration 
around  a  simple  pyloric  ulcer  may  be  felt  in  thin  patients.  It  must 
not  be  concluded  from  the  apparent  mobility  of  a  growth  felt  through 
the  abdominal  wall  that  a  resection  is  practicable,  or  vice  versa. 

The  following  cases  show  how  easily  the  surgeon  may  be  mistaken 
in  regard  to  these  points.  In  Mr.  Southam's  patient  (Brit.  Med. 
Journ.,  July  29,  1882 — an  instructive  paper,  from  which  I  shall  again 
quote  later),  aged  43,  though  the  hard  nodular  mass  in  the  situation 
of  the  pylorus  moved  with  respiration,  and  shifted  as  the  patient 
moved  from  side  to  side,  though  the  symptoms  were  only  of  four 
months'  duration,  and  the  disease  appeared  to  be  limited  to  the  pylorus, 
there  were  a  mass  of  enlarged  glands  surrounding  the  head  of  the 
pancreas,  and  some  slight  adhesions  of  the  stomach  to  these. 
Mr.  Morris  mentions  a  patient  of  Prof.  Lietherin  in  whom,  though 
the  growth  could  be  easily  moved  in  different  directions,  it  was  found 
so  firmly  adherent  that  the  operation  had  to  be  abandoned. 

From  a  careful  consideration  of  the  symptoms,  and  the  results  of 
chemical  and  microscopical  examinations  of  the  gastric  findings,  Ac, 
the  diagnosis  should  be  more  frequently  made  before  the  growth 
becomes  irremovable  ;  and  with  this  object  an  early  exploration  should 
be  undertaken,  when  the  symptoms  do  not  yield  to  treatment  and 
strongly  suggest  the  probability  of  the  existence  of  carcinoma  of  the 
stomach.  The  danger  of  an  early  exploration  is  very  small,  although 
a  simple  exploration  in  late  and  inoperable  cases  carries  with  it  a  very 
considerable  risk  of  death,  as  shown  by  the  experience  of  Kronlein 
and  Mikulicz,  who  had  a  mortality  of  about  9  per  cent,  in  such  late 
explorations. 

*  McArdle  {Dublin  Journ.  Med.  8cL,  vol.  lxxxiii.  p.  511).  having  collected  from  the 
statistics  of  different  writers  1,342  cases,  states  that  the  pylorus  alone  was  involved  in  802, 
or  over  half  the  cases. 

f  The  of  Gnssenbauer  and  Winiwarter  (Langenbeck's  Ar,h..  BA  xix.  p.  372, 

1876)  show  that,  of  542  cases  of  cancer  of  the  pylorus,  adhesions  were  present  in  370 


PYLORECTOMY.  47Q 

Moynihan  (Clin.  Hoc  Trans.,  1906,  p.  89)  has  recently  drawn  attention 

to  this  point.      One  of  his  six  cases  died. 

ii.  The  strength  and  age  of  the  patient.  The  general  condition, 
power  of  repair,  &c,  must  be  sufficient  to  justify  the  patient  being 
submitted  to  an  operation  on  very  vital  parts,  which  will  certainly  take 
more  than  an  hour,  and  may  take  an  hour  and  a  half  or  two  hours. 

iii.  The  rate  at  which  vomiting,  pain,  and  emaciation  are  increasing. 
Where  this  is  marked,  resection  should  be  abandoned. 

Where  the  surgeon  remains  in  doubt  as  to  the  advisability  of 
resection  up  to  the  time  that  the  abdomen  is  opened,  the  presence  of 
extensive  adhesions  between  the  stomach  and  adjacent  parts,  liver, 
pancreas,  &c,  the  existence  of  secondary  deposits,  the  extension  of 
the  disease  into  the  omenta,  if  any  of  these  are  present,  resection 
should  be  abandoned. 

Partial  gastrectomy  is  now  more  frequently  undertaken  than  a  few 
years  ago,  for  in  suitable  cases  it  is  far  preferable  to  gastrojejunostomy. 
The  mortality  of  resection  in  skilled  hands  is  not  much  greater  than 
that  of  gastroenterostomy.  Mikulicz,  Carle  and  Fantino,  have  even 
had  a  lower  mortality  from  resection  than  from  gastroenterostomy  in 
cancerous  cases.  In  the  three  years  ending  in  1901,  Mikulicz  had  a 
death-rate  of  26*5  per  cent,  for  gastroenterostomy  and  25  per  cent,  for 
resection  of  the  growth. 

The  comfort  and  relief  of  the  patient  is  far  greater  after  resection, 
and  the  prolongation  of  life  even  when  recurrence  follows  is  longer  by 
nearly  a  year.  Moreover,  resection  does  give  an  appreciable  chance  of 
freedom  from  relapse,  whereas  the  only  hope  of  permanent  recovery 
after  gastrojejunostomy  is  that  a  mistaken  diagnosis  has  been  made. 
The  high  mortality  and  the  comparative  discomfort  of  patients  after 
gastroenterostomy  for  carcinoma  are  due  chiefly  to  toxaemia  and 
hemorrhage  from  the  breaking  down  growth.  Septic  pulmonary  com- 
plications are  also  very  frequent. 

If  resection  be  decided  upon  one  of  the  following  methods  may  be 
adopted  : — 

i.  Rocker's  method,  or  Hartmann,s  modification  of  this  method. 

ii.  Resection  with  direct  suture  of  the  divided  ends,  without  or  with  the 
aid  of  a  mechanical  contrivance  (Billroths'  first  method). 

iii.  Resection  combined  with  gastrojejunostomy  (Billroth' s  second 
method). 

The  researches  of  Cuneo,  Lindner,  and  others  have  shown  us  that 
carcinoma  spreads  (a)  early  and  widely  in  the  submucosa,  (b)  towards 
and  along  the  lesser  curvature  towards  the  cardiac  orifice,  and  (c)  to  the 
glands  in  the  lesser  and  greater  omenta,  and  those  lying  near  the 
head  of  the  pancreas ;  but  real  dissemination  is  a  comparatively  late 
occurrence  in  gastric  carcinoma. 

There  is  very  little  tendency  for  the  disease  to  spread  along  the 
greater  curvature  towards  the  left  into  the  fundus,  which  can  be  safely 
left  in  pyloric  and  prepyloric  growths,  which  form  the  large  majority 
of  gastric  cancers. 

It  is  clear,  therefore,  that  resections  must  be  wider  than  hitherto, 
especially  as  regards  the  lesser  curvature  and  the  lymphatic  vessels 
and  glands.  It  is  also  evident  from  modern  results  that  wide  resections 
can  be  undertaken  without  much,  if  any,  more  risk  than  pylorectomy, 


480 


OPERATIONS   ON   Till'.    ABDOMEN. 


and  that  resections  can  be  hopefully  undertaken  later  than  we  used  to 
Ihink. 

Preparation. — For  some  days  before  the  operation  the  stomach 
should  he  washed  out  with  tepid  water,  syphon  fashion,  by  an  india- 
rubber  tube  and  funnel,  till  the  contents  come  out  clear,  this  being 
done  more  frequently  according  to  the  degree  of  dilatation  of  the  viscus. 

The  stomach  should  he  gently  washed  out  again  about  three  hours 
before  the  operation,  care  being  taken  not  to  exhaust  the  patient  by 


Fig.  iSr. 


Pneumogastric 
left 

Gland 

Pneumogastric 
rigftt 

Coronary 
artery 

Coronary 
vein 

Ganglion 

Hepatic 
artery 

Gastro- 
epiploic 
artery 


Gland 

Gastro- 
epiploic 

vein 


The  anatomy  of  the  stomach  after  Hart  maun  and  Cunco.     (Mayo.  Ann.  of  Surg.') 
Mote  the  distribution  of  the  lymphatics  and  the  blood-vessels. 

needless  prolongation  of  the  lavage,  and  undue  exposure.  The  teeth 
and  mouth  should  be  thoroughly  cleansed  for  several  days,  and  an 
antiseptic  mouth  wash  used,  with  the  object  of  preventing  septic 
pulmonary  complications  as  far  as  possible.  No  food  should  he  given 
by  the  mouth  on  the  day  of  the  operation,  but  liquids  and  jelly  may 
be  given  on  the  preceding  day.  Nutrient  enemata  may  be  commenced 
twenty-four  hours  before  the  operation,  and  a  pint  of  normal  saline 
solution  may  be  administered  an  hour  before  the  operation. 

llectal    or    subcutaneous    saline    infusion    may    also    be    given    in 


I'YLOKKCTO.MY. 


481 


exhausted  and  weakly  patients,  and  this  is  generally  necessary  to  combal 
shock  after  t lie  operation.  Continuous  or  repeated  small  infusions  are 
better  than  one  large  one.  Every  precaution  at  the  time  of  the 
operation  should  be  taken  againsl  shock — viz.,  wrapping  up  the  patient 
well,  a  hot-water  bed,  hot  bottles,  bandaging  the  limbs  in  flannel, 
keeping  the  head  low,  the  administration  of  ether  if  possible,  or  A.C.E., 
for  tin1  greater  part  of  the  operation,  and  subcutaneous  injections  of 
strychnine  or  brandy. 

Mayo  recommends  the  subcutaneous  injection  of  morphia  before  the 
operation,  so  that  only  a  small  amount  of  ether  need  be  given,  and 
shock  thus  lessened. 

Fig.  182. 


Liver 


Line  of  separa- 
tion of  lesser 
omentum. 


Transverse 

colon. 


Kesection  of  pylorus,  first  stage.     (After  Kocher.) 

At  the  present  time  the  omenta  are  divided  well  away  from  the  growth  and 
beyond  the  lymphatic  glands  (compare  Figs.  186  and  192).  Instead  of  the  fungi  srs, 
Kocher  now  uses  large  curved  crushing  forceps,  which  hold  the  stomach  more 
securely  and  prevent  leakage  more  effectually.  The  line  of  gastric  section  is 
shown  further  to  the  left  than  in  Kocher's  original  figure,  but  it  does  not  extend 
high  enough  on  the  lesser  curvature. 


I.  Kocher's  Method. — Pylorectomy  combined  with  gastro-duode- 
nostomy. 

This  operation  as  originally  described  is  too  limited  in  extent  for 
gastric  carcinoma,  but  it  may  be  suitable  for  some  cases  of  simple 
ulceration,  although  gastro-enterostomy  will  be  preferable  in  nearly  all 
these  cases.  Kocher  himself  recommends  Hartmann's  modification  of 
his  method.     Kocher's   operation  will  not  be  described  in  detail,  but 

s. — vol.  H.  31 


482 


OPERATIONS    ON    TIIK    AP,I><»MKN. 


the  three  stages  of  it  are  illustrated  in  the  figures,  which  are  preserved 
for  historical  interest,  and  to  emphasise  the  progress  that  has  occurred 
in  gastric  surgery  during  recent  years. 

Hartmann's  Modification  of  Kocher's  Method. — The  following 
account  is  largely  taken  from  Kocher  [Operativi  Surgery  translation  by 
Stiles,  1903,  p.  2:4).  A  central  incision  is  made  from  the  tip  of  the 
ensiform  cartilage  to  the  umbilicus,  and  a  transverse  incision  is  carried 
from  this  across  the  rectus  abdominis  if  more  room  is  required.  The 
growth  and  its  connections  are  thoroughly  examined,  to  determine 
whether  the  tumour  is  removable  or  not.  It  is  lifted  out  if  possible, 
and  the  lesser  omentum  and  gastro-colic  ligament  are  perforated  w<  11  to 
the  left  of  the  growth.     Two  large  pressure  or  crushing  forceps  are  then 

Fig.  183. 


Duodenum. 


Transverse 
colon. 


Eesection  of  pylorus,  second  stage.     (After  Kocher.) 


applied  close  together,  with  their  points  above  the  lesser  curvature, 
close  to  the  oesophagus,  so  that  all  the  lesser  curvature  may  be 
removed.  Gauze  is  packed  beneath  the  forceps,  and  the  stomach 
is  then  divided  between  the  (lamps.  The  gastric  artery  is  served 
between  two  ligatures,  and  the  gastro-hepatic  omentum  is  divided  well 
above  the  glands.  This  makes  the  stomach  much  more  movable,  and 
allows  it  to  be  turned  over  towards  the  right.  The  lymphatic  tissues 
and  fat  are  removed  as  far  as  the  pyloric  artery,  which  is  ligatured  and 
divided.  Any  lymphatic  glands  upon  the  gastro-duodenal  artery  and 
the  head  of  the  pancreas  are  removed,  and  the  right  gastro  epiploic 
artery  tied  near  its  origin.  The  hepatic  artery  should  be  carefully  avoided. 
By  turning  the  stomach  over  to  the  right  the  posterior  surface  of 
the  duodenum  becomes  accessible,  so  that  the  extent  of  the  growth  in 
this  direction   can   be   ascertained.     The  length   and    mobility  of  the 


PYLORECTOMY. 


483 


duodenum  can  also  be  determined,  so  thai  the  Burgeon  may  now  decide 
if  it  is  practicable  to  perform  gastro-duodenostomy  without  exerting 
undue  tension  upon  the  anastomosis.  Gauze  is  packed  under  the 
duodenum,  which  is  then  divided  between  two  small  crushing 
forceps.  The  cut  edges  are  cleansed.  The  duodenal  end  can  be  joined 
to  the  stomach  either  before  or  after  the  large  wound  in  the  stomach 
is  closed. 

This  wound  is  closed  by  passing  a  continuous  mattress  suture  through 
the  stomach  just  to  the  left  of  the  crushing  forceps,  which  are  then 
removed.  Traction  is  made  upon  the  ends  of  the  suture  so  that  no 
leakage  can  occur.  Any  projecting  mucous  membrane  or  muscle  which 
may  have  escaped  crushing  by  the  powerful  forceps  is  clipped  away 


Fig.  184. 


Continuous  serous 
suture  closing 
stomach 

Post-serous  suture 
between  stomach 
ami  duodenum. 
Duodenum 


Assistant's  thumb 
in,'  stomach 
d  duodenum 
pressure. 

Opening  in  the 

Lor  wall  of 
the  stomach. 


Kesection  of  pylorus,  third  stage.     (After  Kocher.)     Gastro-duodenostomy 


with  scissors.  A.  continuous  over-stitch  is  then  passed  through  all 
the  coats  of  the  stomach,  so  as  to  approximate  the  edges,  and  also  fix 
each  loop  of  the  mattress  suture,  and  finally  the  two  rows  are  buried 
by  means  of  a  continuous  Lembert  suture. 

The  stomach  and  duodenum  are  then  gently  clamped  at  a  con- 
venient distance  from  the  site  of  the  anastomosis  that  is  to  be  made, 
and  the  crushing  forceps  are  removed  from  the  duodenal  extremity. 
This  end  is  joined  to  the  posterior  surface  of  the  stomach  near  the 
greater  curvature  and  about  one  and  a  half  inches  from  the  occluded 
right  extremity  of  the  stomach. 

An  incision  is  made  through  the  serous  coat  of  the  stomach ;  its 
length  should  be  equal  to  the  breadth  of  the  flattened  duodenum,  and 
its  direction  parallel  to  the  right  border  of  the  stomach. 

A  posterior  serous  suture  is  applied  (vide  Fig.  188).     "  The   wall 

31—2 


484         OPERATIONS  ON  THE  ABDOMEN. 

of  the  stomach  is  then  completely  cut  through,  and  a  continuous  suture 
passing  through  all  the  coats  is  applied  so  as  to  unite  the  posterior 
edges  of  the  opening  in  the  stomach  and  duodenum.  A  third  continuous 
suture  is  applied  so  as  to  unite  the  two  mucous  edges.  The  anterior 
edges  are  now  united  by  a  continuous  suture  which  passes  through  all 
the  coats,  and  is  knotted  to  the  posterior  suture.  The  clamp  forceps, 
if  such  have  been  employed,  are  removed,  and,  lastly,  the  anterior  serous 
suture  is  applied  and  knotted  at  each  end  with  the  posterior  serous 
suture."  To  secure  a  patent  opening  it  is  well  to  excise  some  of  the 
bulging  mucosa  of  the  stomach,  and  the  usual  deep  and  superficial 
continuous  sutures  are  simple  and  satisfactory.  The  suture  line  is 
well  swabbed  with  warm  saline  solution,  and  the  gauze  packs  are 
removed.  The  abdominal  wound  is  closed  in  layers  and  covered  with 
a  sealed  dressing. 

When  the  duodenum  is  not  movable  enough  to  be  joined  to  the 
remains  of  the  stomach,  it  may  be  mobilised  by  Kocher's  method 
(p.  474),  or  its  end  may  be  occluded,  and  a  gastrojejunostomy  performed 

(p.  486). 

Kocher  emphasises  the  following  points  as  essential  to  success : 
(1)  The  operation  must  be  performed  ascptically,  and  the  greatest  care 
must  be  taken  to  avoid  the  entrance  of  disinfectants  into  the  abdomen. 
Sublimate  and  its  substitutes  must  only  be  used  to  disinfect  the  lines 
of  suture  and  those  areas  of  peritonaeum  which  have  been  directly 
contaminated  by  the  gastro-intestinal  contents.  Kocher  thinks  that 
collapse  is  often  due  to  the  too  free  use  of  such  disinfectants.  Even 
during  a  very  prolonged  operation  salt  solution  should  be  employed 
exclusively  for  the  swabs,  and  all  the  gauze  placed  around  the  wound. 
To  prevent  the  entrance  of  gastro-intestinal  contents,  it  is  essential 
to  use  plenty  of  soft  gauze.  (2)  As  advocated  by  Rydygier  and 
Lauenstein,  all  the  sutures,  the  superficial  serous  and  the  deeper 
which  take  up  the  whole  thickness  of  the  wall,  must  be  continuous 
and  without  the  least  interruption  from  one  end  of  the  wound  to  the 
other ;  this  is  why  Kocher  so  strongly  urges  leaving  the  ends  of  the 
posterior  sutures  long  after  knotting  them,  so  that  they  may  be  again 
reliably  knotted  with  the  anterior  sutures.  A  perfectly  secure  closure 
is  thus  attained,  and  there  is  not  the  slightest  necessity  to  prove  that 
the  suture  is  water-tight  by  distending  the  intestine.  Another  reason 
for  carrying  the  continuous  suture  through  the  entire  thickness  of  both 
gastric  and  intestinal  walls  is  that  only  by  this  means  can  reactionary 
hemorrhage,  which  has  been  the  cause  of  a  certain  number  of  fatal 
cases,  be  prevented  with  certainty.  Fine  strong  silk  must  be  used  for 
the  sutures,  not  the  less  reliable  catgut.  Kocher  has  not  seen  any  of 
the  disadvantages  ascribed  to  silk.  He  considers  that  Senn's  method 
is  more  complicated  than  his  own,  and  that  its  results  have  not 
quite  fulfilled  expectations.  (3)  The  employment  of  clumps.  Kocher 
considers  these  absolutely  necessary  for  the  closure  of  the  cancerous 
portion,  both  on  the  duodenal  and  the  gastric  side.  It  is  only  in 
this  way,  as  he  has  pointed  out  (Centr.  f.  Cliir.,  18S3,  No.  45),  that 
the  dangerous  escape  of  cancer  juice  can  be  prevented  with  certainty. 
The  clamps  have  the  following  additional  advantages  :  viz.,  that  the 
intestine,  and  more  especially  the  stomach,  can  be  cut  across  along 
an  exact  line  at  the  place  desired,  a  matter  which  is  otherwise  not 


PYLORECTOMY.  ,s5 

always  easy.  Further,  the  use  of  clamps  greatly  shortens  the  operation. 
They  produce  complete  closure,  and  serve  as  convenient  handles  for 
drawing  up  and  manipulating  the  parts.  Theyincrease  the  possibility 
of  completely  disinfecting  thecut  edges  immediately  after  the  section 
by  preventing  their  slipping  back.  Lauenstein's  objection  thai  they 
necessitate  removal  of  additional  sound  tissue  is  hardly  a  disadvantage, 
as  a  prospect  of  a  permanent  cure  is  thereby  increased.  As  to  other 
disadvantages,  Kocher  is  convinced  that  they  cause  no  necrosis  it"  the 
operation  be  properly  and  aseptically  performed.  He  has  no  hesitation 
in  applying  a  clamp  to  the  healthy  part  of  the  duodenum  where  it  is 
afterwards  to  be  stitched.  In  his  use  of  clamps,  Kocber  applies  no 
elastic  covering  after  the  manner  of  Gussenbauer,  nor  does  be  use 
the  elastic  bands  of  Rydygier.  He  merely  clamps  them  firmly  enough 
to  thoroughly  close  the  intestine  and  stomach,  and  has  observed  that 
the  edges  of  both  bleed  actively  as  soon  as  the  clamps  are  removed. 
Finally,  Kocber  denies  that  the  clamps,  by  requiring  unnecessary 
room,  necessitate  a  needless  separation  of  the  mesentery,  as  stated  by 
Lauenstein. 

The  results  which  Kocher  and  others  have  obtained  with  his  method 
are  very  good  as  regards  the  low  immediate  mortality,  the  restoration 
of  function,  and  the  prolongation  of  life  ;  but  this  operation  is  not 
applicable  for  all  cases,  especially  now  that  it  has  become  generally  recog- 
nised to  be  necessary  to  resect  more  freely  towards  the  cardiac  orifice. 
As  in  all  intestinal  surgery,  there  must  be  no  tension  upon  the  suture 
line,  but  if  the  duodenum  be  mobilised  as  described  by  Kocher  (p.  474), 
it  can  be  joined  to  the  remainder  of  the  stomach  after  a  fairly  wide 
resection  ;  but  the  surgeon's  primary  duty  is  to  resect  freely  enough, 
and  the  method  of  anastomosis  is  a  matter  of  comparatively  slight 
importance,  which  must  not  be  allowed  to  have  any  influence  on  the 
extent  of  the  resection  to  be  adopted  in  any  given  case.  A  surgeon 
who  slavishly  attempts  to  apply  Kocher's  method  of  joining  the  duodenum 
to  the  stomach  in  all  cases  will  sometimes  either  remove  too  little  of 
the  stomach,  or  court  disaster  by  joining  parts  under  tension. 

II.  Pylorectomy  with  Suture  of  the  Divided  Ends  (the  first 
method  of  Billroth).  Direct  union  of  the  divided  ends  has  little  to 
recommend  it,  and  it  is  only  mentioned  here  for  its  historical  interest. 

When  it  is  possible  to  bring  the  parts  together  without  tension,  it 
is  better  to  adopt  Kocher's  method  of  gastro-duodenostomv,  for  the 
mortality  of  the  latter  operation  is  much  lower.  Guinard  (quoted  by 
Kocher  loc.  cit.,  p.  211)  analysed  the  result  of  291  resections  performed 
between  1891  and  189S,  and  found  the  mortality  of  14S  operations 
performed  by  Billroth's  first  method  to  be  37*8  per  cent.,  whereas 
only  I5'64  per  cent,  of  deaths  resulted  from  64  operations  after  Kocher's 
method.  Maydl,  however,  only  had  a  mortality  of  16  per  cent,  in  25 
resections  by  Billroth's  first  method.  The  operation  takes  a  long  time 
on  account  of  the  difficulty  of  the  suturing.  Leakage  very  frequently 
occurred  at  the  angle  of  junction  of  the  anastomosis  and  the  gastric 
wound — "  the  fatal  suture  angle  "  of  Billroth.  Paterson  (loc.  cit.) 
found  that  leakage  had  occurred  in  35  per  cent,  of  59  cases  collected 
by  him  ;  whereas  the  catastrophe  only  happened  in  3  out  of  79  cases 
of  lateral  anastomosis,  and  Kocher  in  84  resections  by  his  method 
"  lost  only  one  patient  from  leakage  at  the  line  of  union."     This  grave 


OPEK  mONS    ON    THE    ABDOMEN. 


risk  may  be  partly  avoided,  and  time  saved,  by  using  a  bone  bobbin, 
as  recommended  by  Mr.  May,.  Etobson,  but  in  many  cases  of  wide  re- 
section the   divided  ends  cannot  be   brought  together  without    undue 
tension.    Ulceration  and  obstruction  has  occurred  at  the  line  of  union 
in  a  case  under  the  care  <>t  Mr.  Bruce  Clarke,  quoted  by  Mr.  Pat--:  - 

III.  Combined     Resection     and     Gastrojejunostomy     (Billroth's 
second  method).     This  method,  the   adoption   of  which  is  becoming 

Fig.  1S5. 


Kesection  of  the  pylorus.  (After  Billroth.)  The  luwer  end  of  the  line  of 
section.  &,  should  be  a  little  more  to  the  left.  In  Billroth"s  original  operation  both 
the  stomach  and  the  duodenum  were  divided  nearer  to  the  growth. 


Fig.  186. 


1 


Duodenum  united  to  the  greater  curvature.     'After  Billroth.)     This  m« 
of  union  is  so  apt  to  be  followed  by  leakage  at  the  angle  of  the  suture  line  that  it 
has  been  almost  universally  discarded. 


more  and  more  general,  bids  fair  t<>  become  the  n  ^  I  method  of 
removing  growths  of  the  pyloric  third  of  the  stomach.  The  chief 
advantages  are  : — 

(1)  Great  rapidity  and  simplicity,  especially  if  the  anastomosis  be 
made  with  a  Murphy's  button,  but  this  ingenious  contrivance  should 
not  be  resorted  to  except  when  there  is  great  need  for  hurry,  for  the 
anastomosis  is  neither  so  safe  nor  so  likely  to  remain  patent  as  the 
one  made  by  the  direct  suture  method. 


PYLORECTOMY. 


487 


(2)  It  is  as  easy  to  remove  ;i  considerable  portion  of  the  stomach  as 
to  excise  the  pylorus  only  ;  hence  the  surgeon  need  run  no  risk  of 
not   removing  the  growth   widely  enough. 

(])  The  anastomosis  is  made  between  healthy  uninjured  parts,  which 
are  under  no  tension.     It  should  be  remembered,  however,  that  this 


Fig.  187. 

Lesser  omentum  tied 


C .  Hepati 
artery 


Mikulicz-Hartmann 

liae 

Showing  the  lesser  omentum  tied  well  above  the  stomach  and  lymphatic 
glands,  and  the  lines  of  division  of  the  stomach  and  duodenum.     (After  Mayo, 
Ann.  of  Surg.") 
method  has  some   of  the  possible,  if    diminishing,   disadvantages  of 
gastrojejunostomy  for  other  causes;    and  these  have  to  be  guarded 
against   (p.    502)- 

The  following  description  of  the  operation  is  largely  taken  from 
Dr.  W.  J.  Mayo's  valuable  contribution  upon  this  subject  (Ann.  of  Surg., 
1904,  vol.  xxxix.  p.  321).  Dr.  Mayo  does  not  claim  that  the  operation, 
as  he  performs  it,  is  in  any  sense  original.  It  is  a  composite  opera- 
tion, based  upon  the  labours  of  Billroth,  Kronlein,  Mikulicz,  and 
Hartmann,  and  upon  the  researches  of  Cuneo  into  the  lymphatics  of  the 
stomach  (vide  Fig.  185,  p.  480). 

Operation.—"  A  small  incision  is  made  in  the  median  line,  halt-way 
between  the  ensiform  cartilage  and  the  umbilicus;  through  this  two 
fingers  are  introduced  for  exploration.     If  the  condition  is  inoperable, 


488 


OPERATIONS   ON    Till:   ABDOMEN. 


the  incision  is  closed,  and  a  Bufficienl  oumber  of  buried  non-absorbable 
mattress  sutures  of  silk,  linen,  <>r  wire  introduced  into  the  aponeurotic 
structures  of  the  linea  alba  to  enable  the  patient  to  get  about  a<  once 
and  to  return  to  his  friends  within  a  few  days.  It' sutured  in  the  usual 
manner,  and  the  patients  placed  in  bed  for  two  or  three  weeks,  many 
of  them  will   develop  hypostatic  pulmonary  lesions,  loss    of   appetite, 


Fi<;.  i 


Deep  suture 


Gastro- colic 
omentum,  tied 


Showing  the  clamps  in  position,  the  gastro-colic  omentum  tied  below  the 
lympl  The  duodenum  has  been  severed,  and  i--  being  occluded  by 

means  of  two  sutures.    (After  Mayo,  Ann.  of  Surg.") 

swelling  of  the  feet,  and  general  debility,  and  may  be  unable  to  spend 
their  lew  remaining  days  at  home.  When  an  advanced  cancer  case  goes  to 
bed  for  a  week  or  two,  the  chances  of  his  getting  about  again  are  small." 

If  the  growth  is  removable,  the  incision  is  enlarged  to  four  or  live 
inches,  and  the  gastro-hepatic  omentum  is  at  once  tied  and  divided  to 
the  extent  shown  in  Fig.  191. 

This  at  once  increases  the  mobility  of  the  growth,  and  allows  gauze 
packs  to  be  introduced  behind  it  for  the  isolation  of  the  field  of 
operation,  and  prevention  of  any  soiling  of  the  peritonaeum.    The  gastric 


PYLORECTOMY. 


489 


artery  is  Bevered  between  two  ligatures,  where  it  joins  the  Lesser  curva- 
ture, about  an  inch  below  the  cardiac  orifice.  The  gastro-duodenal 
artery  or  the  right  gastroepiploic  is  tied  near  the  pylorus,  and  the  left 
gastroepiploic  is  Becured  opposite  the  line  of  section  0f  the  Btomach  ; 
the  pyloric  artery  is  also  tied  and  divided  between  two  ligatures.  By 
securing  these  vessels  quite  early  the  operation  is  rendered  almost 
bloodless,  and  collapse  is  very  considerably  diminished.     The  gastro- 


FlG.    I 


Deep 
uture 


Showing  the  occluded  end  of  the  duodenum  and  the  introduction  of  the  first  row 
of  gastric  sutures.     (After  Mayo.  A  run.  of  Surg.) 

colic  omentum  is  tied  and  severed  to  the  necessary  extent.  "  It  is 
important  that,  in  ligating  the  gastro-duodenal  vessel  and  the  gastro- 
colic omentum,  the  fingers  should  raise  the  structures  away  from  the 
middle  colic  artery,  which  runs  immediately  beneath  in  the  transverse 
mesocolon."  Failure  to  take  this  precaution  may  lead  to  gangrene  of 
the  transverse  colon,  which  has  happened  many  times,  as  pointed  out 
by  Kronlein. 

'  The  duodenum  is  doubly  clamped  and  divided  between  with  the 
actual  cautery  to  prevent  inoculation  of  the  cut  surface  with  cancer. 


490 


OPERATIONS  ON  THE  ABDOMEN. 


The  duodena]  slum])  should  be  lefl  one-fourth  of  an  inch  long,  and, 
before  removing  the  clamp,  a  running  suture  of  catgut  is  introduced 
through  the  seared  Btump  and  tied  as  the  clamp  is  removed.  A  purse- 
string  suture  of  silk  or  Linen  three-quarters  of  an  inch  below  the  slum]) 
enables  inversion  in  a  similar  manner  to  the  stump  of  the  appendix 
(Figs.  192,  193). 

"A  long  Kocher's  holding  clamp  is  now  placed  from  the  tied  gastric 

Fie  190. 


Loop  of 

jejunum 

Tlie  operation  is  completed.     (After  Mayo,  Ann.  of  Surg.") 

artery  at  Mikulicz's  point  of  election  in  an  oblique  direction,  so  as 
to  save  as  much  as  possible  of  the  greater  curvature,  to  Hartmann'a 
point  of  election  in  the  greater  curvature  (Fig.)  192. 

"  The  blades  of  this  clamp  should  be  covered  with  rubber  tubing,  and 
the  compression  should  be  just  sufficient  to  hold  the  tissues  in  its  grasp. 
A  second  (damp  is  applied  on  the  tumour  side  to  prevent  leakage. 
The  tissues  between  are  severed  with  the  Paquelin  cautery  one  quarter 
of  an  inch  from  the  holding  clamp;  and  as  the  tissues  are  divided 
several  catch  forceps  are  caught  on  the  projecting  Btump  to  prevent 
retraction  of  some  part  of  the  gastric  wall  from  the  grasp  of  the  Kocher 


PYLORECTOMY.  49] 

clamp.  The  pyloric  end  of  the  stomach,  with  the  tumour  guarded  against 
Leakage  by  the  clamp  at  each  end,  is  removed.  The  cauterised  stump 
projecting  beyond  the  Kocher  clamp  is  rapidly  sutured  with  a  catgut 
buttonhole  suture  from  the  greater  to  the  lesser  curvature  through  all 
the  coats  of  the  Btomach,  and  in  the  same  maimer  directly  back,  and 
tied  at  the  starting  point ;  this  prevents  hemorrhage  as  well  as  Leakaj 
"  The  doubling  of  this  form  of  suture  holds  the  approximated  edgi 
evenly  in  line.  The  Kocher  clamp  is  now  removed,  and  any  bleeding 
point  caught  and  tied.  The  final  suture  is  now  introduced,  of  silk  or 
linen,  and  made  after  the  right-angled  plan  of  Gushing.  It  is  taken 
sufficiently  far  from  the  catgut-suture  line  to  enable  easy  approximation 
of  the  sero-muscular  layers  without  tension. 

"  Some  of  these  steps  can  be  varied  sometimes  with  advantage. 
"  We  have  frequently  tied  off  the  gastro-hepatic  ligament  and  the 
superior  vessels,  and  at  once  double-clamped  and  divided  the  duo- 
denum. By  pulling  upward  on  the  stomach  side  the  gastro-duodenal 
artery  is  easily  caught,  tied,  and  divided,  and  the  operation  proceeded 
with  as  before.  In  a  few  cases  we  have  begun  on  the  stomach  side, 
ligating  and  dividing  the  gastric  and  left  gastro-epiploic  vessels  first, 
then  clamping,  dividing,  and  suturing  the  stomach  as  before.  This  is 
favoured  by  Hartmann.  If  there  are  adhesions,  however,  the  first  plan 
mobilises  the  stomach  much  better,  and  enables  more  accurate  work 
and  greater  exposure  of  that  part  of  the  stomach  which  at  the  line  of 
section  lies  naturally  deep  under  the  costal  arch." 

Gastrojejunostomy  is  then  performed  b}T  one  of  the  posterior  suture 
methods  (vide  pp.  506  and  512). 

Mayo  performs  the  anterior  button  operation  to  save  time  in  bad 
cases,  but  I  should  not  expect  the  button  to  be  quite  safe  in  such  cases. 
The  gauze  packs  are  removed  and  all  bleeding  points  ligated. 
Drainage  is  only  occasionally  used,  on  account  of  some  accidental 
soiling ;  a  cigarette  drain  is  then  passed  just  above  the  transverse 
colon,  but  not  near  the  suture  lines.  The  other  end  of  the  tube  is 
fixed  at  the  lower  angle  of  the  wound.  Generally  the  abdominal 
"wound  is  completely  closed. 

Drs.  W.  J.  Mayo  and  C.  H.  Mayo  have  performed  100  resections, 
with  a  mortality  of  only  14  per  cent.  The  duodenal  orifice  can  be 
more  quickly  closed  by  ligaturing  its  extremity  after  crushing  it  with 
Doyen's  angiotribe,  and  then  inverting  the  tied  end  by  means  of  a 
pursestring  suture. 

Paterson  (loc.  supra  cit.)  performs  gastrojejunostomy  at  the 
beginning  instead  of  at  the  end  of  the  operation,  so  that  the 
anastomosis  may  not  be  done  hurriedly,  and  in  order  to  allow  time  for 
freezing  and  examining  a  small  piece  of  the  supposed  growth.  Should 
the  mass  prove  to  be  innocent,  resection  may  be  avoided.  The  micro- 
scopical examination  need  only  take  about  five  minutes.  It  may  be 
objected  that  posterior  gastrojejunostomy  limits  the  mobility  of  the 
stomach  so  much  that  resection  becomes  more  difficult,  and  that 
hurried  examinations  of  peripheral  parts  of  the  growth  or  of  the 
lymph  glands  would  be  unreliable,  for  the  section  may  only  show 
inflammatory  changes  that  surround  a  growth.  Moreover,  the  resection 
may  disturb  the  anastomosis,  although  any  fault  in  this  may  perhaps 
be  recognised  before  closing  the  abdomen. 


492  OPERATIONS   ON   Till-]    ABDOMEN. 

The  After-treatment.  —  Shock  is  treated  by  warm  rectal  or 
subcutaneous  saline  infusions,  warmth,  subcutaneous  injections  of 
strychnine  or  aseptic  ergot.     Morphia  should  be  given  if  pain  is  so 

severe  as  to  prevent  rest  and  sleep.  The  patient  should  he  placed  in 
the  semi-sitting  attitude  of  Fowler,  for  this  diminishes  the  risk  of 
pulmonary  complications  and  facilitates  drainage  of  the  stomach, 
thus  lessening  vomiting.  It  also  aids  drainage  of  the  lesser  peritoneal 
sac  in  those  eases  which  require  it. 

Rectal  feeding  should  be  adopted  from  the  beginning,  and  continued 
until  sufficient  nourishment  can  be  taken  by  the  mouth.  Soon  after 
the  patient  has  come  round  from  the  anesthetic,  tablespoonfuls  of  hot 
water  may  be  given  by  the  mouth  to  quench  the  thirst ;  after  about  twelve 
hours'  small  feeds  of  peptonised  milk,  and  other  liquids  may  be  given 
every  hour  if  they  are  retained.  A  small  amount  of  food  given  by  the 
mouth  is  worth  a  great  deal  more  than  nutrient  enemata.  In  some 
cases,  where  vomiting  is  troublesome  and  persistent,  continuous  or 
repeated  subcutaneous  infusion  should  be  adopted,  and  half  an  ounce 
of  olive  oil  may  be  given  subcutaneously  night  and  morning,  as  recom- 
mended by  Dr.  Hale  White. 

TOTAL    GASTRECTOMY. 

Removal  of  the  whole  or  very  nearly  the  whole  of  the  stomach  has 
now  been  successfully  practised  a  number  of  times  by  different  surgeons. 

The  operation  is  indicated  when  it  is  found,  on  abdominal  explora- 
tion, that  the  stomach  is  infiltrated  with  cancer,  but  that  extensive 
adhesions  and  secondary  deposits,  either  in  other  organs  or  in  the 
lymphatic  glands,  are  absent. 

Connor,  of  Cincinnati,  was  the  first  to  perform  this  heroic  operation 
in  1883,  but  his  courage  was  not  rewarded,  for  the  patient  died  upon 
the  table. 

Schlatter,  of  Zurich,  was  the  first  to  perform  the  operation  successfully 
in  1897. 

Paterson  (Hunterian  Lectures,  1906),  has  "  collected  27  cases  of 
total  gastrectomy  for  malignant  disease.  Of  the  27  patients  10  died  and 
17  recovered,  a  result  surprisingly  good  considering  the  extent  and 
severity  of  the  operation." 

Mr.  Paterson  has  ascertained  the  subsequent  history  of  all  except 
two  of  the  17  patients  who  survived  the  operation.  Five  of  the  patients 
have  died,  but  the  average  duration  of  their  lives  after  the  operation  was 
nineteen  months.  "Dr.  Brookes  Brigham's  patient,  is  at  the  present 
time  in  perfect  health,  eight  years  after  the  operation.  Dr.  Macdonald's 
patient  is  also  alive  and  at  work  as  a  farm  labourer,  although  seven 
years  have  gone  by  since  his  operation." 

Six  of  the  patients  are  still  living  and  well  six  years  after  the 
operation,  and  three  are  well  five  years  after  it. 

Paterson  collected  20  cases  of  subtotal  gastrectomy,  with  14  recoveries. 
Of  those  patients  who  recovered  from  the  operation  7  are  now  dead, 
the  average  duration  of  their  survival  being  twenty-two  and  a  half 
months,  5  died  from  recurrence,  I  from  heart  disease  eleven  years  after 
the  operation,  and  1  from  intestinal  obstruction,  without  any  recurrence. 
"  Of  the    remaining    6    patients    1    was  alive    five  and    a   half  years 


GASTROJEJUNOSTOMY. 


493 


after  the  operation,  I  four  years,  and  i  three  and  a  half  years,  after  the 
operation." 

It  must  be  remembered  that  these  results  have  been  attained  by 
Burgeons  of  unusual  experience,  and  that  the  mortality  of  36  per  cent. 
for  total  gastrectomy  and  30  per  cent,  for  subtotal  gastrectomy  does 
not  represent  the  risk  of  these  operations,  many  of  which,  being 
unsuccessful,  have  not  been  published. 

As  regards  the  method  of  operating,  the  plan  most  usually  adopted 
is  to  remove  the  diseased  area,  as  described  above,  and  then  to  join  a 
loop  of  jejunum  to  the  oesophagus  or  remnant  of  stomach.  The 
oesophagus  has  also  been  joined  to  the  duodenum,  but  this  is  neither 
so  easy  nor  so  safe,  owing  to  the  difficulty  of  mobilising  the  latter 
sufficiently  without  interfering  seriously  with  its  nutrition;  the  jejunum 
can  be  joined  without  tension. 

Mr.  Mayo  Robson  (Diseases  of  the  Stomach,  1904)  found  flexion  of 
the  head  valuable  in  making  the  oesophagus  more  accessible,  and  he 
derived  much  help  and  guidance  from  an  oesophageal  tube.  The 
patient  died  of  shock.  Simple  suture  is  to  be  preferred  in  making  the 
anastomosis,  but  if  this  is  not  practicable  at  the  great  depth  of  the 
wound,  Murphy's  button  or  Mayo  Robson's  bobbin  may  be  adopted. 

In  a  very  successful  case  operated  upon  by  Dr.  Harvie  of  New  York 
(Ann.  of  Surg.,  March,  1900,  p.  344),  the  duodenum  and  oesophagus 
were  united  by  direct  suture. 

The  patient  was  a  woman,  aged  46,  who  had  had  gastric  symptoms  for  eighteen 
months  before  operation.  On  examination  a  rounded  tumour  could  both  be  seen  and 
felt.  The  operation  was  rendered  difficult  by  adhesions  both  in  front  and  behind  the 
stomach,  practically  the  whole  of  which  was  infiltrated  and  thickened.  The  entire 
stomach  was  removed,  and  the  cut  surfaces  of  the  oesophagus  and  duodenum  united  by 
means  of  sutures.  "  The  entire  time  consumed,  from  the  first  incision  until  the 
abdomen  was  closed,  was  one  hour  and  five  minutes.  There  was  little  or  no  loss  of 
blood."  The  subsequent  progress  was  most  satisfactory,  nourishment  being  first  given  by 
the  mouth  on  the  eighth  day.  The  patient  left  the  hospital  sis  weeks  after  the  operation, 
"after  taking  a  dinner  consisting  of  roast  beef,  mashed  potatoes,  ice-cream,  cup  of  coffee, 
and  one  glass  of  milk." 


GASTROJEJUNOSTOMY.* 

The  object  of  this  operation  is  to  make  an  opening  between  the 
obstructed  stomach  and  the  small  intestine  as  high  up  in  the  latter  as 
possible,  so  that  the  food  may  still  find  its  way  into  the  intestine  and 
there  meet  with  the  other  digestive  fluids. 

Although  this  operation  is  a  very  valuable  one  in  suitable  cases,  it  is 
necessary  to  protest  against  its  indiscriminate  use  and  abuse.  There 
are  some  who  seem  to  think  that  gastrojejunostomy  cures  all  the  ills 
that  the  stomach  is  heir  to ;  and  from  the  writings  of  others  we  may 


*  To  be  accurate,  the  term  gastrojejunostomy  should  be  used  for  union  of  jejunum  to 
stomach,  gastro-duodenostomy  for  union  of  duodenum  and  stomach  (pp.  473  and  481). 
The  term  gastro-enterostomy,  which  has  been  carelessly  used  for  either  of  the  above 
operations,  should  be  dropped.  In  future,  writers  should  specify  which  operation  they 
refer  to. 


494 


OPERATIONS   ON    THE   ABDOMEN. 


indeed    wonder,  with    Porter,*  that  we  arc   not   horn   with   b   gastro- 
jejunostomy. 

Lei  us  nol  forget  that  the  stomach  and  duodenum  have  their  uses  in 
digestion  and  absorption,  and  that  we  ought  not  to  endeavour  to 
prematurely  empty  the  one  or  to  occlude  the  other  without  due  con- 
sideration, unless  there  is  definite  pyloric  obstruction,  for  which  short- 
circuiting  is  of  undoubted  value.  There  are  other  indications  which 
will  be  discussed  in  detail.  It  has  been  frequently  stated  of  late  that 
gastrojejunostomy  is  almost  devoid  of  danger;  but  this  is  far  from 
true,  although  it  may  he  almost  safe  in  the  hands  of  a  few  experts,  if 
the  patients  arc  almost  normal  in  their  general  health,  but  the  opera- 
tion lias  often  to  be  performed  under  very  different  circumstances  from 
these.  It  is  certain  that  many  gastrojejunostomies  are  now  performed 
unnecessarily,  and  it  is  just  as  certain  that  many  others  are  deferred 
until  it  is  too  late.  The  statistics  of  the  former  are  too  favourable, 
and  those  of  the  latter  are  too  unfavourable  ;  the  truth  lies  between 
them.  Further,  the  late  results  of  gastrojejunostomy  are  not  so 
very  good  as  some  would  have  us  believe,  although  they  should 
certainly  improve  in  future. 

It  is  necessary  to  refuse  the  operation  in  late  cases  of  growth,  and 
particularly  in  all  cases  of  gastric  neurosis,  and  to  perform  the  gastro- 
jejunostomy, for  the  crises  of  locomotor  ataxy  can  only  be  due  to 
gross  carelessness  in  diagnosis.  That  this  and  similar  mistakes 
should  have  been  made  only  emphasises  the  fact  that  this  valuable 
operation  is  in  considerable  danger  of  being  too  frequently  and  lightly 
undertaken. 

Indications. — It  may  be  made  use  of  (A)  in  malignant  disease  of  the 
stomach  or  duodenum  under  the  two  following  conditions  chiefly: 
i.  Together  with  pylorectomy  or  partial  gastrectomy  (p.  486). — Thi 
always  to  he  preferred  to  an  end  to  end  union.  This  combination  of 
operations  has  given  good  results  (p.  495)  ;  it  enables  us  to  attempt 
the  removal  of  the  disease,  and  at  the  same  time  greatly  shortens  the 
operation.  A  very  thorough  examination  should  precede  the  operation, 
ii.  Alone. — This  is  clearly  a  very  inferior  operation  to  those  of 
pylorectomy  or  resection  and  gastrojejunostomy  combined.  If  all  the 
cases  of  gastrojejunostomy  which  have  been  performed  had  been 
published,  it  is  practically  certain  that  the  results  both  as  regards  the 
immediate  mortality  and  the  duration  of  life  would  be  most  disappoint- 
ing. This  is  no  doubt  due  to  the  fact  that  the  operation  has  been  far 
too  often  performed  in  very  emaciated  patient-,  quite  unfit  to  bear  a 
prolonged  operation  and  to  supply  the  necessary  plastic  repair.  For 
the  future  gastroenterostomy,  or,  as  it  should  be  here  more  correctly 
called,  gastrojejunostomy,  should  he  reserved  for  the  following  cases 
of  pyloric  cancer:  (1)  where  the  malignant  disease  extends  too  far 
into  the  stomach,  especially  along  the  lesser  curvature,  or  where  it  is 
too  fixed — e.g.,  to  liver  or  pancreas — to  make  either  a  pylorectomy,  or 
a  partial  or  complete  gastrectomy,  justifiable,  or  where  secondary 
deposits  and  fixed  enlarged  glands  can  be  felt;   (2)  where  the  cachexia 

*  Ann.  of  Surg.,  vol.  xliv.  p.  901.     Dr.  Porter  gives  many  reasons  for  believing  that 
gastroenterostomy  is  not  a  harmless  u,  and  bis  article  i>  well  worthy  of  careful 

-deration. 


GASTROJEJUNOSTOMY.  495 

;iik1  emaciation4  of  the  patients  arc  not  so  marked  that  it  is  very 
doubtful  whether  they  will  survive  an  operation  that  necessitates  the 
handling  of  very  vital  parts,  and  for  its  success  entails  a  certain 
adequate  amount  of  plastic  repair.  The  risks  of  pulmonary  and  other 
complications  in  these  late  cases  must  also  be  remembered. 

These  marasmic  patients  also  suffer  much  more  severely  from  Bhock 
than  those  with  non-malignant  disease,  although  the  operation  may 
be  very  quickly  performed. 

[f  the  operation  be  carefully  reserved  for  the  above  cases  it  will  be 
called  for  less  frequently  than  of  late  years,  but  will  be  found  in  these 
to  give  great  relief  and  to  prolong  life  for  some  months.  If  surgeons 
continue  to  perform  it,  as  gastrostomy  has  been  too  often  performed 
for  malignant  diseases  of  the  oesophagus,  in  cases  where  the  operation 
comes  too  late,  their  patients,  if  they  survive,  will  do  so  for  a  very 
short  time,  succumbing  to  the  effects  of  a  marasmus  so  established  as 
to  be  unalterable. 

Gastrojejunostomy  is  worse  than  useless  when  the  growth  does  not 
cause  obstruction  of  the  pylorics  and  stasis  of  the  gastric  contents. 

Recent  improvements  in  the  technique  of  the  operation  have  greatly 
reduced  its  mortality  even  in  malignant  disease. 

Dr.  W.  J.  Mayo  {Ann.  of  Surg.,  1905,  vol.  xlii.,  p.  642)  states  that 
he  and  his  brother,  Dr.  C.  H.  Mayo,  had  performed  in  all  114  gastro- 
jejunostomies for  malignant  disease,  with  21  deaths,  a  mortality  of 
18  per  cent.  Of  these  114  cases  63  were  in  connection  with  pylorec- 
tomy  or  partial  gastrectomy,  with  8  deaths  (13  per  cent.).  The  very 
unfavourable  cases  of  cancer  obstruction  were  subjected  to  gastro- 
enterostomy, so  that  this  operation  gives  a  higher  mortality  than 
radical  excision.  In  the  last  40  gastrojejunostomies  for  malignant 
disease  the  mortality  was  8  per  cent. 

Mr.  Moynihan  (Clin.  Soc.  Trans.,  1901,  vol.  xxxix.  p.  84)  had 
performed  gastro-jejunostom}'  for  malignant  disease  35  times  between 
1897  and  July,  1905,  with  5  deaths,  or  a  little  over  14  per  cent.  The 
first  7  operations  were  anterior,  and  the  Murphy  button  was  used,  with 
2  deaths.  The  last  28  were  posterior  suture  operations,  with  only  3 
deaths. 

The  average  mortality  for  all  cases  by  all  operators  is  certainly  a 
great  deal  higher  than  is  indicated  by  the  figures  given  by  these 
brilliant  surgeons,  of  unusual  experience  in  this  branch  of  surgery.  It 
is  probably  nearer  30  per  cent.  This  is  largely  due  to  too  much  delay 
in  operating  and  want  of  courage  to  refuse  to  perform  the  operation 
in  hopelessly  late  cases,  and  to  the  too  frequent  use  of  the  Murphy 
button. 

It  is  to  be  hoped  that  with  earlier  exploration  and  diagnosis  gastro- 
jejunostomy will  be  replaced  to  a  greater  extent  by  resection,  although 
many  patients    will    always    present    themselves  so  late  that  only  a 


*  Instances  which  do  and  which  do  not  justify  gastrojejunostomy  would  be  cases 
where,  on  the  one  hand,  the  loss  has  been  only  two  pounds  in  several  mouths,  and,  on  the 
other,  that  of  a  stone  in  a  week  or  two.  In  12  out  of  98  cases  collected  by  Dr.  Tice- 
lmi'st  (loc.  Infra  cit.),  the  patients  had  lost  more  than  a  stone  a  month,  and  7  of  these 
died  from  the  operation,  and  out  of  23  others,  in  which  the  wasting  was  very  considerable, 
10  died. 


496         OPERATIONS  ON  THE  ABDOMEN. 

palliative   gastrojejunostomy    can    be   performed.     At  present   many 
come  too  late  even  for  this. 

(B.)  In  certain  non-malignant  discuses  of  the  Btomach  and 
duodenum. 

I.  In  most  cases  of  pyloric  stenosis,  especially  when  there  is  great 
dilatation  of  the  stomach,  much  thickening  of  the  pylorus,  extensive 
adhesions  or  active  ulceration.  When  the  stomach  is  greatly  dilated, 
posterior  gastrojejunostomy  with  a  large  opening  provides  far  better 
drainage  than  any  pyloric  operation. 

II.  In  chronic  ulcer  of  the  stomach  or  duodenum,  causing  severe 
and  recurrent  haemorrhage,  in  spite  of  careful  and  thorough  medical 
treatment.  For  the  large  majority  of  surgeons,  if  not  for  all,  it  is  never 
wise  to  perform  gastrojejunostomy  during  the  progress  of  severe 
gastric  haemorrhage  (vide  p.  460). 

III.  For  chronic  or  relapsing  ulceration  of  the  stomach  or  of 
duodenum  after  medical  treatment  has  been  thoroughly  tried  and 
has  failed. 

Mr.  Paterson  in  his  valuable  Hunterian  Lectures  (Lancet,  1906, 
vol.  i.  p.  500)  concludes  that  "the  mortality  from  gastric  ulcer  treated 
medically  is  at  least  20  per  cent.,  and  further  that  at  least  50  per 
cent,  of  the  so-called  cures  relapse,  while  probably  not  more  than 
25  per  cent,  of  the  patients  treated  medically  are  really  cured.  On  the 
other  hand,  gastrojejunostomy  holds  out  an  almost  certain  prospect 
of  cure,  the  proportion  of  relapses  being  probably  no  more  than  10  per 
cent.  The  immediate  risk  of  the  operation  is  about  3  per  cent.,  to 
which  may  be  added  the  risk  from  septic  jejunal  ulcer,  under  2  per 
cent." 

Paterson  formulates  the  principles  on  which  to  act  as  follows  : — "  If 
after  six  weeks'  complete  rest  on  a  milk  diet,  a  further  period  of  six 
weeks  on  a  milk  diet  with  comparative  rest,  followed  by  three  months' 
careful  dieting,  the  patient  is  not  free  from  definite  symptoms,  or  if, 
after  apparent  cure,  the  patient  has  a  relapse,  operation  is  probably  in 
the  best  interest  of  the  patient.  The  symptoms,  however,  must  be 
clear  and  definite." 

Dr.  Hawkins  and  Mr.  Nitch  (Trans.  Royal  Med.  and  Ghir.  Soc.,  Nov.  2, 
1906),  in  a  review  of  556  cases  of  gastric  ulcer  and  its  sequelae  admitted 
consecutively  into  St.  Thomas's  Hospital,  found  the  mortality  to  be 
13  per  cent.  These  figures  include  419  cases  of  simple  ulcer,  with 
5  deaths,  1*2  per  cent.,  4  from  haemorrhage  and  1  from  exhaus- 
tion. The  remaining  137  patients  were  admitted  for  complica- 
tions and  sequelae,  and  69  of  these  died.  Dr.  Hawkins  and  Mr.  Nitch 
point  out  that  75  of  these  137  patients  were  admitted  "  suffering  from 
a  perforation  of  a  chronic  ulcer,  or  the  results  of  long-standing  ulcera- 
tion, such  as  gastric  adhesions  and  pyloric  stenosis,  with  long  histories 
of  gastric  disease,  often  amounting  to  several  years.  The  aim  of  treat- 
ment is  to  abolish  this  class  of  chronic  ulcer."  Forty-seven  gastro- 
jejunostomies were  performed,  with  11  deaths. 

I  venture  to  quote  the  following  important  and  fair  remarks  which 
were  made  by  Dr.  Hawkins  at  the  meeting  of  the  Royal  Medico- 
Chirurgical  Society  on  Nov.  27,  1906: — 

"  If  the  plan  of  medical  treatment  is  good,  its  duration  is  quite  insuffi- 
cient.    There  are  difficulties,  however,  in  its  extension  when  we  are 


GASTROJEJUNOSTOMY.  497 

dealing  with  patients  who  have  to  work  for  a  Living,  but  there  is  n  fair 
probability  that  the  number  of  patients  who  enter  into  the  chronic 
ulcer  group  might  l>e  reduced  if  the  duration  of  medical  treatment  and 
dieting  could  be  extended  to  a  minimum  of  six  months. 

As  regards  surgical  treatment,  as  a  measure  aimed  at  preventing  the 
chronic  ulcer,  gastroenterostomy  is  to  be  recommended.  The  question 
of  gastroenterostomy  as  a  routine  mutter  in  all  cases  which  either  do 
not  make  a  good  recovery  after  medical  treatment  or,  having  made  a 
good  recovery,  quickly  relapse,  turns  entirely  on  the  mortality  rate 
which  is  to  be  expected  from  the  operation  itself,  and  on  the  efficiency 
of  the  anastomotic  opening.  There  are  thus  two  sides  to  the  question. 
In  the  first  place,  we  have  the  balancing  of  the  risks  to  life.  It  is 
among  these  chronic  ulcer  cases  (roughly  25  in  every  100  patients)  that 
the  chief  mortality  of  gastric  ulcer  arises.  I  think  it  may  be  accepted 
that  at  least  nine  of  the  twenty-five  ultimately  die  from  perforation  or 
from  sequelas,  and  the  remainder  are  crippled  for  some  years.  I 
believe  that,  though  the  mortality  rate  from  the  operation  of  gastroenter- 
ostomy itself  must  be  reckoned  with,  it  is  so  low  (and  is  likely  to  become 
lower)  that  on  the  score  of  risk  to  life  the  balance  is  greatly  in  favour  of 
the  operation.  Our  figures  at  St.  Thomas's  Hospital  are  too  small  to 
bear  a  conclusion.  In  forty-seven  instances  of  gastroenterostomy  there 
were  eleven  deaths.  Of  these  eight  must  be  credited  to  disease,  and 
three  to  the  operation.  But  these  cases  are  not  wholly  to  the  point, 
for  they  were  mostly  instances  of  cicatricial  effects  of  chronic  ulcer,  in 
other  words  instances  of  the  very  conditions  which  the  operation  as 
here  recommended  is  intended  to  prevent,  and  it  must  be  remembered 
that  in  the  cases  under  consideration  the  operation  would  be  under- 
taken, as  it  were,  in  a  quiescent  interval  as  a  preventive,  and  not  as  a 
curative,  measure,  under  the  best  conditions,  and  at  a  selected  time. 

In  the  second  place,  there  is  the  question  how  far  gastroenterostomy 
may  be  considered  as  truly  preventive  of  subsequent  trouble  and  as  a 
really  scientific  method  of  treatment.  In  this  respect  I  think  the 
figures  from  St.  Thomas's  Hospital  are  satisfactory,  the  more  so,  in  fact, 
because,  as  is  stated  above,  they  are  not  strictly  applicable,  the 
operations  being  designed  mainly  to  relieve  sequelae  rather  than  to 
forestall  them.  Of  33  cases  of  gastroenterostomy  I  think  17  may  be 
described  as  giving  a  good  result  after  one  to  four  years,  five  derived 
slight  benefit,  two  no  benefit,  and  nine  were  discharged  apparently  well, 
but  the  operation  was  too  recent  to  justify  a  verdict. 

Certainly  in  two  points,  the  comparative  rest  to  the  stomach 
afforded  by  its  early  emptying  and  the  shortening  of  the  period  of  high 
acidity,  the  operation  lias  everything  to  commend  it,  and  I  believe 
that  this  advantage  comes  equally  into  play  both  as  regards  the  speedy 
healing  of  a  chronic  ulcer,  and  as  regards  the  prevention  of  fresh 
ulceration." 

When  the  profession  realises  how  bad  the  results  of  the  medical 
treatment  of  gastric  ulcer  are  at  the  present  time,  and  adopts  more 
thorough  and  prolonged  treatment  along  the  lines  laid  down  by  Dr. 
Hawkins,  Dr.  Spriggs,  and  others  at  the  discussion  before  the  Royal 
Medical  and  Chirurgical  Society  in  November  and  December,  1906,  the 
mortality  of  this  grave  condition  will  be  very  considerably  diminished. 
The  results  will  improve  still  more,  when  medical  men  realise  the 
s. — vol.  11.  32 


I<iN  OPERATIONS   ON    THE    ABDOMEN. 

possibility  and  the  importance  of  preventing  the  development  of  the 
sequelae  and  mosl  of  the  complications  of  gastric  ulcer  by  advising  early 
operation  when  medical  treatment  1ms  been  thoroughly  tried  and  1ms 
failed  to  cure. 

The  average  mortality  of  gastrojejunostomy  for  gastric  ulcer  and 
its  sequelae  is  unfortunately  still  higher  than  3  per  cent.,  us  given  by 
Mr.  Paterson.  In  the  practice  of  a  few  surgeons  of  unusual  experience 
of  gastric  surgery  the  death  rate  may  he  even  under  1  per  cent.  Mr. 
Moynihan  has  had  no  deaths  in  the  last  151  operations  {Lancet,  1906. 
vol.  ii.  p.  1440),  Drs.  W.  J.  Mayo  and  C.  II.  Mayo  {Ann.  of  Surg., 

1905,  vol.  41,  p.  641)  had  four  deaths  in  their  last  140  gastrojejunos- 
tomies, and  only  one  in  the  last  80.  It  must  not  be  forgotten,  however, 
that  these  surgeons  have  gradually  acquired  special  skill  and  judgment, 
and  especially  that  their  fame  enables  them  to  get  their  cases  earlier* 
than  the  average  surgeon,  who  is  very  often  not  asked  to  operate  until 
it  is  too  late  to  hope  for  the  excellent  immediate  and  remote  results 
that  may  be  obtained  by  operating  in  time  to  prevent  the  late  results 
and  complications  of  gastric  ulceration.  The  general  health  of  these 
neglected  patients  has  been  undermined  by  years  of  malnutrition,  and 
the  local  conditions  are  often  too  serious  for  complete  recovery  to  be 
expected. 

It  is  partly  for  these  reasons  that  hospital  statistics  extending  back 
for  about  ten  years,  and  showing  a  mortality  rate  of  about  25  per  cent., 
should  not  be  allowed  to  influence  us  too  much  when  we  are  estimating 
the  death-rate  of  gastrojejunostomy  as  it  should  be  performed  for 
simple  ulcer.  These  figures  also  include  the  early  failures  from  errors 
and  imperfections  of  technique.  Many  of  the  operations  were  performed 
for  sequelae  that  should  become  more  and  more  uncommon  in  the 
future.  On  the  other  hand,  the  low  death-rate  given  in  the  statistics 
of  individual  and  brilliant  operators  gives  a  false  idea  of  the  safety  of  the 
operation,  and  operations  performed  without  sufficient  reasons  give 
even  a  more  erroneous  impression,  that  gastrojejunostomy  is  free  of 
danger  and  can  be  undertaken  lightly. 

As  at  present  performed  for  simple  ulcer,  its  complications  and  its 
sequehc,  gastrojejunostomy  certainly  has  a  higher  mortality  than  3  per 
cent. ;  and  in  hospital  patients  derived  from  the  poverty-stricken 
districts  of  London  the  death-rate  is  far  greater.     Mr.  Gask  {Lancet, 

1906,  vol.  ii.  p.  1662)  gives  the  following  statistics  from  St.  Bartholo- 
mew's Hospital :  "  From  1903  to  1905  16  cases  were  operated  upon  by 
gastrojejunostomy  for  gastric  ulcer,  and  two  died,  giving  a  mortality  of 
18  per  cent."  During  the  same  period  "  19  cases  were  operated  upon 
for  fibrous  stenosis  of  the  pylorus.  Of  these  four  died  as  the  result  of 
the  operation,  giving  a  mortality  of  21*05  per  cent." 

In  private  practice  the  results  are  much  better,  for  the  patients 
generally  seek  relief  earlier,  and  are  in  better  condition  to  undergo  the 
operation. 

It  is  probably  true  that  the  average  mortality  of  gastrojejunostomy 
for  non-malignant  disease,  as  now  performed  by  surgeons  of  average 
skill    upon    hospital    and    private    patients,    is    nearer  6  than    3  per 

*  This  can  be  seen  very  clearly  by  studying  the  statistics  which  were  brought  before 
the  Medico-l'hirurgieal  Society  in  November,  1906. 


GASTROJEJUNOSTOMY. 


eent.  ;  bul  when  the  operation  is  undertaken  for  simple  gastric  ulcer, 
and  nol  for  recurrent  Bevere  haemorrhage,  or  for  pyloric  stenosis  or 
other  sequelae,  the  mortality  should  certainly  be  under  3  per  cent. 
in  the  hands  of  aseptic  surgeons  of  average  skill  and  thorough 
practical  knowledge  of  all  the  necessary  details  of  technique  which  are 
utial  to  success. 

Dr.  Norman  Moore  and  Dr.  Hale  White  {Royal  Med.  and  I  'I'm.  Trans., 
November,  1906)  have  laid  stress  upon  the  fact  that  gastric  ulcer  is 
more  serious  in  patients  over  30  years  of  age  and  in  men  than  in 
women;  therefore  an  operation  should  he  advised  earlier  in  these  than 
in  young  women. 

In  conclusion  it  may  he  stated  that  if  definite  symptoms  of  gastric 
ulcer  do  not  disappear  under  a  six  month's  course  of  thorough  medical 
treatment,  or  if  they  soon  reappear  after  the  cessation  of  this  treatment, 
gastrojejunostomy  is  strongly  indicated  in  order  to  prevent  the  develop- 
ment of  a  chronic  ulcer,  with  its  dangerous  and  crippling  complications 
and  sequela?.  In  addition,  an  accessible  and  removable  chronic  ulcer 
may  be  excised  in  order  to  hasten  the  recovery  and  make  it  more 
certain,  as  well  as  to  lessen  the  risk  of  the  development  of  carcinoma. 

It  is  often  wise  to  operate  earlier  in  poor  patients,  because  of  the 
great  difficulties  in  the  way  of  continuing  medical  treatment  long  enough 
to  effect  a  cure.  The  older  the  patient,  the  more  important  is  it  to 
operate  without  avoidable  delay.  It  should  be  added,  however,  that 
the  operation  should  be  performed  by  a  good  surgeon,  otherwise  the 
danger  may  he  greater  than  by  leaving  well  alone. 

IV.  Infantile  Hypertrophic  Stenosis  of  the  Pylorus. — It  is  not 
yet  certain  whether  pyloroplasty  or  gastrojejunostomy  is  the  best  opera- 
tion for  this  condition.  The  mortality  of  the  former  has  been  less  in 
published  cases;  14  deaths  have  occurred  in  25  gastrojejunostomies, 
and  3  fatalities  in  9  pyloroplasties  (Paterson,  Hunterian  Lectures, 
loc.  cit.).  The  late  results  are  probably  better  after  gastrojejunostomy 
than  after  pyloroplasty,  and  infinitely  better  than  after  pylorodiosis, 
which  has  a  comparatively  low  immediate  mortality.  Most  of  these 
patients  are  in  a  grave  condition  at  the  time  of  the  operation,  and  this 
accounts  for  the  high  death-rate  from  all  three  operations ;  it  may  be 
hoped  that  earlier  recognition  and  resort  to  surgery  in  suitable  cases 
will  do  much  to  improve  the  results.  And  the  recent  improvements 
in  the  technique  of  gastrojejunostomy  ought  to  improve  the  results  of 
this  operation  very  considerably  even  when  due  allowance  is  made  for 
the  marasmic  condition  of  these  infants. 

It  has  been  maintained  by  Mr.  Clinton  Dent*  in  his  Hunterian 
Lectures  that  pyloroplasty  is  simpler,  less  severe,  and  safer  than 
gastrojejunostomy,  and  also  that  it  is  quite  as  efficient. 

Mr.  Paterson  agrees  "  with  Mr.  Stiles  that  in  principle  gastro- 
jejunostomy is  the  better  operation  for  the  following  reasons :  (1)  It 
is  preferable  to  operate  on  normal  than  on  morbid  tissues.  (2)  Feeding 
can  be  commenced  at  once  after  gastrojejunostomy,  no  small  advantage 
in  these  cases,  whereas  in  several  of  the  cases  of  pyloroplasty  the 
feeding  has  caused  no  little  anxiety.  (3)  If  the  anterior  operation  be 
performed,  it  can  be  completed  within  twenty-five  minutes,  which  is  a  little 

*    Traiia.  Roy.  Med.  and  Chir.  Soc,  vol.  lxxxvi.  p.  481. 

32—2 


500         OPERATIONS  ON  THE  ABDOMEN. 

longer  than  the  time  required  for  pyloroplasty.  (4)  The  incision  need 
be  no  Longer  than  that  required  for  pyloroplasty  ;  two  and  a  half  inches 
is  quite  sufficient.  If  the  patient's  shoulders  be  slightly  raised  there 
is  no  tear  of  the  protrusion  of  intestine.  (5)  The  remote  results  are 
highly  satisfactory.  We  do  not  yet  know  that  those  of  pyloroplasty 
are  so  good." 

A'.  Dilatation  of  the  stomach  from  obstruction   of  the  pylorus  ot 

duodenum  due  to  the  contraction  of  adhesions  or  to  the  pressure  of 

irremovable   new    growths    of  the  pancreas,    kidney,  or  gall  bladder. 

The  results  of  the  operation  for  atonic  dilatation,  for  gastroptosis,  and 

for  gastric  neuroses  have  been  very  unsatisfactory. 

VI.  Hour-glass  Contraction  due  to  Contraction  of  a  Simple  Ulcer. 
— The  jejunum  may  be  joined  to  the  cardiac  pouch,  which  is  generally 
the  largest.  This  will  be  sufficient  unless  pyloric  stenosis  coexists, 
which  is  not  uncommon. 

If  the  pylorus  is  constricted,  the  jejunum  may  be  joined  separately 
to  both  pouches  of  the  stomach,  as  suggested  by  Weir  and  Foote,  or 
gastrojejunostomy  may  be  combined  with  gastroplasty  or  gastro- 
gastrostomy.  This  combination  is  attended  with  excellent  remote  as 
well  as  good  immediate  results. 

On  the  other  hand,  gastroplasty  and  gastro-gastrostomy  by  them- 
selves are  very  apt  to  be  followed  by  recurrence.  Paterson  in  an  able 
analysis  of  92  cases  of  hour-glass  stomach  (Lancet,  1906,  vol.  ii.  p.  503) 
found  that  25  per  cent,  of  the  patients  who  had  submitted  to  gastro- 
plasty either  obtained  no  relief  or  suffered  from  relapse,  and  the  same 
results  had  followed  30  per  cent,  of  the  gastro-gastrotomies. 

In  at  least  3  cases  the  true  nature  of  the  condition  has  not  been 
discovered  at  the  operation,  and  the  jejunum  has  been  uselessly  joined 
to  the  pyloric  pouch.  Kammerer has  adapted  Finney's  operation  to  hour- 
glass contraction  of  the  stomach  (vide  p.  469).  In  the  rare  cases 
of  carcinomatous  hour-glass  contraction,  the  growth  should  be 
resected  if  possible. 

VII.  Tetany  of  Gastric  Origin. — This  is  almost  always  due  to  pyloric 
stenosis,  and  should  be  treated  by  gastrojejunostomy  without  delay. 
The  prognosis  after  operation  is  not  nearly  so  grave  as  used  to  be 
thought.  Moynihan  records  14  cases  without  a  single  death  after 
gastroenterostomy. 

GENERAL      CONSIDERATIONS. 

Before  describing  some  of  the  chief  methods  of  performing  the 
operation  of  gastrojejunostomy,  it  is  important  to  draw  attention  to 
certain  points  which  are  essential  to  all  of  them. 

(1)  The  opening  must  be  a  large  one,  at  least  2\  to  3  inches  long, 
for  otherwise  it  may  contract  or  even  become  closed,  especially  when 
the  pylorus  is  not  completely  or  only  temporarily  obstructed,  as  in 
certain  cases  of  ulceration  in  the  prepyloric  region. 

(2)  The  orifice  must  be  placed  at  the  lowest  part  of  the  stomach 
as  the  patient  stands,  for  most  of  the  food  has  to  pass  through  the 
orifice  during  the  day.  There  is  much  evidence  to  show  that  vomiting 
and  recurrence  of  symptoms  are  largely  due  to  malposition  of  the 
orifice.     (3)   Some  of  the   mucous  membranes  of  the  stomach  and 


GASTROJEJUNOSTOMY. 


501 


Pig.  191. 


jejunum  should  bo  removed  in  order  to  prevent  valve  formation.  An 
elliptical  opening  is  thus  made  instead  of  a  mere  slit,  (Moynihan  and 
Littlewood,  loc.  infra  cit.).  When  the  Murphy  button  is  used,  this  plan 
is  not  necessary,  for  the  button  induces  sufficient  sloughing,  but  the 
si/e  of  the  aperture  made  by  a  button  which  must  be  small  enough  to 
travel  through  the  ileum  is  too  small  for  satisfactory  permanent  drainage 
of  the  stomach.  Moreover,  it  heals  by  granulation,  and  is  therefore 
unusually  liable  to  contract. 

(4)  The  Use  of  Clamp  Forceps. — Long  slightly  curved  (damp  forceps 
are    invaluable  for  this    operation,  for  they 

arrest,  hemorrhage,  prevent  any  leakage,  and 
steady  the  parts  during  the  operation;  they 
also  greatly  facilitate  the  suturing  and  pre- 
vent purse-string  contraction  of  the  orifice. 
Mayo  Robson's  or  Moynihan's  modifications 
of  Doyen's  clamps  are  very  good  ;  and  Car- 
wardine's  gastrojejunostomy  clamps  (Fig. 
191),  although  the  blades  are  straight,  are 
excellent,  for  the  two  clamps  lock  and  thus 
retain  the  parts  in  contact  without  the  aid 
of  an  assistant.  Doyen,  Guinard,  and  other 
Continental  surgeons  were  using  clamps  for 
this  operation  towards  the  end  of  the  last 
century  (Moynihan,  Lancet,  1906,  vol.  i.  p. 
1856).  Littlewood*  and  Moynihanf  were 
amongst  the  first  to  use  and  recommend  them 
in  this  country,  and  Moynihan's  writings 
have  done  much  to  popularise  them  here  and 
in  America.  Now  their  value  is  almost 
universally  recognised. 

(5)  Sutures. — It  is  best  to  use  a 
tinuous  catgut  suture  which  pierces 
all  the  coats,  and  to  reinforce  this  by 
a  continuous  sero-muscular  suture  of 
fine  silk  or  Pagenstecher's  thread.  It 
is  essential  for  the  deep  suture  to 
pierce  all  the  coats,  so  that  it  may  not 
bite  out  before  firm  union  has  occurred, 
and  lead  to  disastrous  leakage.  A 
continuous  suture  is  far  more  quickly 
applied  than  interrupted  sutures,  and 
a  continuous  piercing  suture  controls 
haemorrhage  better  than  any  other 
available  means,  and  for  this  purpose 
the  turns  should  not  be  more  than  one-eighth  of  an  inch  apart.  Hal- 
sted's    suture,  although  it    is  the   most   secure  of  the  sero-muscular 


Carwartline's  clamps  for  gastro- 
jejunostomy. The  blades  are  longer 
than  those  of  the  intestinal  forceps, 
and  they  are  fenestrated  to  prevent 
slipping.  The  handles  lock  together, 
and  thus  automatically  keep  the 
stomach  and  jejunum  in  apposition. 


*  Mr.  H.  Littlewood  on  "  Intestinal  Suture  by  Means  of  Continuous  Catgut  Stitch  and 
Excision  of  the  Mucous  Membrane"  (Lancet,  1901,  vol.  i.,  p.  1817);  a  paper  read 
before  the  Leeds  and  West  Hiding  Medico-Chirurgical  Society  on  Oct.  19,  1900.  The 
paper  is  illustrated,  showing  the  use  of  Doyen's  clamps  for  gastrojejunostomy. 

t  Mr.  Moynihan  [Brit,  Med.  Jitntrn.,  Dec.  9,  1900,  p.  1631). 


502 


OPERATIONS    ON    TIIK    ABDOMEN. 


stitches,  docs  not  control  haemorrhage  well,  and  several  deaths  from 
bleeding  have  followed  its  use.  .Moreover,  it  is  not  so  secure  a>  a 
piercing  suture,  and  as  it  does  not  bring  the  mucous  edges  together 
properly,  it  is  very  apt  to  be  followed  by  the  formation  of  valvular 
folds  of  mucous  membrane,  which  may  obstruct  the  orifice  unless  this 
is  very  large.  The  deep  suture  may  he  either  a  circular  (overstitch) 
or  a  mattress  one;  the  latter  secures  better  inversion  towards  the  end, 
but  is  more  likely  to  cause  puckering  unless  properly  applied.  The 
knots  should  be  upon  the  mucous  surface,  for  leakage  is  less  likely  to 
take  place  than  if  the  knots  are  tied  upon  the  peritonaea!  surface. 

The  continuous  Lembert  or  Gushing  suture  should  be  used  to 
reinforce  the  deep  one,  and  to  secure  wide  serous  apposition  and 
union.     The  suture  should  turn  in  a  little  more  of  the  serous  surface 


Fig.  192. 


Small  omentum 
Stomach 


Gastro  -colic 
omentum 


Stoma,  ch 


Mesocolon 
Mesentery 
Colon 


Mesentery 


Small  intestine 


Colon 


A.  Fig.  B.  Pig.  C. 

1  r astro- jejunostomy  shown  diagrammatically. 
Fig.  A.      The   parts  are  here  shown  in  their  normal  relations  and  attitm 
The    arrow  1   shows  the  anterior  operation  after  the  method  of  Wolfler,  that 
marked  2  the  method  of  Von    Hacker.      Fig.    B,  anterior  gastrojejunostomy. 
Fig.  < '.  posterior  gastrojejunostomy.      It  will  be  noticed  thai  this  provides  the 
most  dependent  opening  both  in  the  upright  and  prune  positions. 

of  the  stomach  than  of  the  jejunum,  so  that   the  lumen  of  the  latter 
may  not  be  unduly  narrowed  or  flattened. 

Different  Methods. — (1)  Posterior  gastrojejunostomy  without  a  loop 
(a)  with  dislocation  and  reversion  of  the  jejunum,  (6)  without  dislocation 
and  without  reversion  of  the  jejunum ;  {2)  anterior  gastrojejunostomy ; 
{£)  posterior  gastrojejunostomy   with  a  hop;    (4)   Roux's   Y  method; 

(5)  anterior    or    "posterior    loop    operations    with    entero-anastomosis  ,• 

(6)  operations  with  the  insertion  of  mechanical  appliances  ;  (7)  Mc  Gram's 
elastic  ligature  method. 

The  Choice  of  Operation. — It  is  not  yet  certain  which  of  the  many 
methods  adopted  at  the  present  time  is  the  best,  and  it  is  possible  that 
better  ways  will  yet  be  invented.  The  chief  operations  will  be  com- 
pared below  as  far  as  possible. 

(1)  Anatomical  and  physiological  considerations. — If  drainage  of  the 
stomach  depends  to  any  great  extent  upon  gravity,  it  is  clearly  better 
to  make  the  opening  low  down  upon  the  posterior  inferior  surface 
than  anywhere  upon  the  antero-superior  surface.     This  is  true  even 


<:.\sTi;<>-.ii:.ir\<>sTn\iY. 


503 


when  the  body  is  upright,  and  the  advantage  is  greatly  increased  when 
the  patient  is  recumbent  (vide  ETig.  192).     But  the  weight  of  the  long 

limbs  of  the  jejunal  loop  used  for  the  anterior  operation  certainly  drags 
the  anterior  opening  downwards  to  some  extent.  It  must  be  remem- 
bered also  that  the  stomach  is  not  a  passive  bag,  and  that  its  drainage 
is  not  entirely  dependent  upon  gravity.  The  larger  the  stoma,  how- 
ever, and  the  more  damaged  the  muscular  power  of  the  stomach,  the 
greater  the  advantage  of  securing  a  dependent  opening.  The  results  of 
tin-  ingenious  experiments  of  Cannon  and  Blake  upon  the  health  v 
stomachs  of  animals  are  not  strictly  applicable  to  the  diseased  con- 
ditions which  call  for  gastrojejunostomy  in  man.  Physiologically  it 
is  an  advantage  to  make  an  opening  high  up  in  the  jejunum,  so  that  as 
little  as  possible  of  the  small  intestine  may  be  lost  for  the  purpose  of 
digestion  and  absorption ;  but  the  researches  of  Paterson  tend  to  show 
that  absorption  is  hardly,  if  at  all,  diminished  by  anterior  gastro- 
jejunostomy, in  which  the  opening  into  the  jejunum  is  lowest.  It  is  of 
more  importance  to  prevent  the  acid  chyme  reaching  the  jejunum  too 
low  down.  Therefore,  upon  anatomical  and  physiological  grounds,  the 
posterior  operation  without  a  loop  is  better  than  any  anterior  operation, 
and  it  is  more  than  probable  that  the  posterior  no-loop  operation, 
without  dislocation  and  reversion  of  the  jejunum,  is  superior  to  all  other 
methods  of  gastrojejunostomy,  because  it  interferes  less  with  the 
normal  anatomical  and  physiological  conditions  and  relations.  If  any- 
one should  still  prefer  to  use  a  Murphy  button  the  posterior  operation 
is  the  best  one  to  choose  for  it,  for  it  falls  into  the  stomach  in  at  least 
a  third  of  the  anterior  operations,  whereas  it  is  retained  in  the  stomach 
after  only  about  one-tenth  of  the  posterior  operations. 

(2)  The  anterior  operation  may  be  a  little  easier,  more  rapid,  and 
may  cause  less  exposure  and  perhaps  less  shock  than  the  posterior  no- 
loop  operation,  especially  if  performed  b}'  surgeons  of  little  experience 
and  skill,  but  the  difference  is  small,  and  the  time  saved  is  trivial,  for 
most  of  the  time  consumed  in  either  operation  is  spent  in  actually 
making  the  anastomosis. 

A  short  or  diseased  mesocolon  may  occasionally  make  a  posterior 
gastrojejunostomy  difficult  or  even  impossible,  and  adhesions  of  the 
posterior  wall  of  the  stomach  may  very  rarely  do  the  same,  but  it  is 
exceptional  for  growth  or  simple  ulceration  to  affect  the  part  of  the 
stomach  which  is  incised  for  posterior  gastrojejunostomy.  When  this 
part  is  affected,  it  is  generally  too  late  for  the  operation  to  be  performed 
at  all.  A  bulky  great  omentum  may  occasionally  prolong  and  increase 
the  difficulties  of  anterior  gastrojejunostomy. 

The  posterior  no-loop  operations  are  a  little  more  difficult  than  either 
the  anterior  or  posterior  loop  operations,  but  the  difference  has  been 
greatly  exaggerated.  Personally  I  have  not  found  the  posterior  no-loop 
operation  without  reversion  of  the  jejunum  to  be  more  difficult  than  the 
loop  operations.  It  has  been  stated  that  the  jejunum  may  unduly  fix 
the  stomach  in  "no-loop"  operations,  but  there  is  no  real  evidence 
of  the  validity  of  this  theoretical  objection.  In  one  case  in  which  the 
jejunum  originated  to  the  right  of  the  spine,  Munford  (Ann.  of  Surg., 
1906,  vol.  xliii.  p.  88)  unfortunately  performed  the  no-loop  operation, 
with  the  result  that  the  excessive  tension  led  to  separation  and  leakage  at 
the  suture  line,  but  this  case  was,  of  course,  unsuitable  for  the  operation. 


504  OPERATIONS   ON    THE    ODOMEN. 

(3)  Severe  Vomiting  (so-called  "vicious  circle"). — The  evidence 
upon  this  point  is  somewhat  conflicting.  Dr.  Ticehurst  collected 
98  Guy's  Hospital  cases  for  his  able  thesis,  which  has  been  of 
great  help  to  me.  His  cases  and  conclusions  are  of  especial  value, 
because  the  operations  were  performed  by  many  different  surgeons 
between  January,  1899,  and  June,  1905,  so  that  the  facta  and  conclusions 
are  not  gathered  from  the  published  accounts  of  a  series  of  operations 
by  any  one  surgeon,  which  are  too  often  misleading.  In  ninety-eight 
consecutive  operations  at  Guy's  Hospital,  the  anterior  method  was 
chosen  twenty-four  times.  Out  often  cases  of  serious  vomiting  seven 
followed  the  anterior  operation,  and  four  of  these  died,  whereas  this 
complication  only  occurred  three  times  after  64  posterior  operations. 

Mayo  (loc.  supra  cit.),  on  the  other  hand,  states  that  "vicious  circle" 
occurred  most  commonly  after  the  posterior  loop  method,  owing  to  the 
liability  of  the  comparatively  short  loop  to  kink.  In  fifty-three  of 
these  operations  there  were  three  deaths,  but  the  primary  result  was 
good  in  the  others.  Seven  of  the  remaining  fifty,  however,  required  a 
secondary  operation  for  gradually  developing  symptoms  of  obstruction, 
with  regurgitation  of  bile,  &c. 

Acute  serious  vomiting  is  more  likely  to  follow  the  anterior  operation, 
and  it  is  probable  that  chronic  or  gradually  developing  vomiting  is  more 
common  after  the  posterior  loop  operation.  So  far  as  the  evidence 
goes,  vomiting  is  rarer  after  the  posterior  no-loop  operation  than  after 
any  other  method  except  that  of  lloux,  which  is  too  severe  and  tedious 
for  general  adoption.  This  and  entero-anastomosis  will  be  discussed 
later.  It  is  probable  that  vomiting  will  be  least  common  after  Mayo's 
operation  without  dislocation  and  reversion  of  the  jejunum,  but  enough 
data  are  not  available  to  prove  this  theory.  Mayo  states  that  no  death 
and  no  trouble  occurred  in  his  63  cases  operated  upon  by  this  method 
since  July,  1905.  If  serious  vomiting  should  occur,  then  it  would  be 
a  disadvantage  of  this  method  that  entero-anastomosis  could  not  be 
easily  performed  for  its  relief. 

(4)  Intestinal  Obstruction. — This  has  been  a  little  more  frequent  after 
the  posterior  operation.  Moynihan  (Lancet,  1906,  vol.i.p.  1345)  mentions 
three  cases  in  which  the  small  intestine  herniated  into  the  lesser  sac 
through  the  rent  in  the  mesocolon.  This  accident  should  not  occur 
again,  for  it  can  be  prevented  by  sewing  the  edges  of  the  rent  to  the 
jejunum  or  stomach.  This  orifice  has  also  contracted  upon  the 
jejunum  or  upon  the  anastomosis,  but  this  rare  event  is  probably  pre- 
ventable by  careful  suturing,  as  above  indicated.  After  the  anterior 
operation  the  jejunal  loop  lias  compressed  the  colon,  or  vice  versd, 
and  in  one  of  the  Guy's  Hospital  series  both  the  jejunum  and  the  colon 
were  obstructed  by  mutual  compression,  although  the  anastomosis  was 
made  twenty-four  inches  below  the  duodenojejunal  flexure.  The 
obstruction  was  so  complete,  that  the  intestine  between  the  jejunal 
loop  and  the  middle  of  the  tranverse  colon  was  collapsed  and  almost 
empty.  In  one  case  quoted  by  Mayo  the  small  intestine  passed  over 
the  afferent  jejunum,  and  became  strangulated.  Intestinal  obstruction 
is  very  unlikely  after  the  "  no-loop"  operations. 

(5)  Mortality. — The  death-rate  has  been  a  little  higher  after  the 
anterior  operation,  but  this  may  be  partly  due  to  the  almost  exclusive 
adoption  of  this  method  in   the   early   days   of  this   operation,  before 


CASTIIO-.lK.ir.XoSToMY. 


505 


Fig. 


i93- 


experience  and  skill  were   acquired,  and  to  its  selection  in  grave  rases 
to  save  time. 

In  19  malignant  cases  recorded  by  Ticehurst  the  anterior  operation 
had  a  mortality  of  53  per  cent.,  whereas  in  thirty-one  posterior  opera- 
tions for  malignant  disease  the  death-rate  was  35  per  cent.  Dr.  Murphy, 
Dr.  Mayo,  and  most  other  authorities  have  found  the  mortality  of  the 
anterior  operation  to  be  a  little  higher. 

(6)  Perforating  Jejunal  Ulcer. — This  has  been  far  more  frequent  after 
the  anterior  operation,  and  after  adding  entero-anastomosis  to  any 
form  of  gastrojejunostomy.  Moynihan  (Lancet,  1906,  vol.  i.  p.  705), 
mentions  33  cases,  in  twenty-nine  of  which  the  nature  of  this  operation 
is  recorded.  This  grave  complication  followed  seventeen  anterior 
operations,  four  anterior  with  entero-anastomosis,  one  anterior  Y  opera- 
tion, and  six  posterior  loop  operations  with  entero-anastomosis.  Its 
occurrence  seems  to  be  chiefly  due 
to  the  action  of  the  over-acid  chyme 
upon  the  jejunum  low  down,  and 
especially  to  its  action  upon  the  part 
of  the  jejunum  which  is  between  the 
stomach  and  the  intestinal  anasto- 
mosis in  the  cases  in  which  this  plan 
is  adopted. 

Paterson  (lac.  supra  cit.)  also 
thinks  that  it  indicates  unsatisfactory 
drainage  of  the  stomach,  for  hyper- 
chlorhydria  ought  not  to  occur  with 
efficient  drainage. 

(7)  Posterior  operations  allow  a 
more  thorough  examination  of  the 
posterior  wall  of  the  stomach. 

Mr.  Basil  Hall  (Lancet,  1902, 
vol.  ii.  p.  657  ;  Brit.  Med.  Journ., 
Oct.  10,  1903)  has  tried  to  avoid  the 
disadvantages  of  both  anterior  and 
posterior  gastrojejunostomy  by  join- 
ing a  loop  of  jejunum  to  the  posterior  surface  of  the  stomach  through 
a  rent  in  the  gastro-colic  ligament  instead  of  through  the  transverse 
mesocolon.  In  nry  opinion  this  operation  has  nearly  all  the  disadvan- 
tages of  the  anterior  operation  as  enumerated  above,  although  it  should 
provide  better  drainage  ;  it  also  has  all  the  objections  of  loop  operations 
(ride  supra).  Mr.  Basil  Hall  records  twelve  successful  operations 
which  were  performed  as  above  indicated. 

It  may  be  concluded  that  the  arailable  evidence  is  considerably  in  favour 
of  posterior  "  no -loop"  operations.  Therefore  these  operations  are 
described  first,  and  the  procedures  least  recommended  are  described  last. 

Posterior  Gastrojejunostomy  (Von  Hacker)  has  been  very  consider- 
ably modified  in  recent  years.  Czerny  performed  the  operation  without 
a  loop  years  ago,  generally  with  the  aid  of  the  button  and  supplementary 
sutures,  with  great  success.  Dr.  Rogers  states  that  this  operation 
has  been  performed  215  times  for  benign  cases  in  Czerny's  clinic, 
with  only  ten  deaths  (Ann.  of  Surg.,  vol.xxxix.  p.  512).  Mikulicz  used 
a  transverse  jejunal  incision  in  performing  the  no-loop  operation.     The 


Von  Hacker's  operation  from  behind. 
After  Petersen  (Mayo  Robson,  and 
Moynihan.) 


506 


OPKIIATIONS    ON    TIIK    AIJDOMKN. 


advantages  of  avoiding  a  loop  have  become  widely  known  from  the 
writings  of  Petersen,  and  the  operation  has  been  greatly  facilitated  by 
the  aid  of  clamp  forceps.  Mikulicz's  method  of  making  a  transverse 
incision  in  the  jejunum  does  not  allow  a  large  opening  to  be  made, for 

it  must  be  smaller  than  half  the  circumference  of  the  bowel,  otherwise 
it  may  lead  to  obstructive  symptoms  from  kinking  and  valve  formation. 
This  happened  in  four  out  of  forty-three  of  these  operations  recorded 
by  Dr.  W.  J.  Mayo,  and  four  secondary  operations  had  to  be  performed. 

Fig.  194. 


Posterior  gastrojejunostomy  without  a  loop.     (Dr.  W.  J.  Mayo,  Ami.  of  Surg.') 
The  posterior  wall  and  greater  curvature  of  the  stomach,  presenting  through 

the  rent  in  the  mesocolon,  are  marked,  showing  the  oblique  line  <>f  incision  of 
Moynihan.  The  jejunum  lias  been  turned  over  to  the  righl  ;  the  site  of  the 
incision  is  marked.  The  clamps  are  applied  parallel  to  and  include  t lie  lines 
on  the  stomach  and  jejunum. 

The  opening  from  the  stomach  into  the  distal  part  of  the  intestine 
was  successfully  enlarged  by  performing  Finney's  operation  (vide 
p.  469)  on  either  side  of  the  opening.  It  was  impossible  to  make  an 
entero-anastomosis  on  account  of  the  shortness  of  the  available  intestine 
above  the  gastrojejunostomy. 

(A)  Posterior  Gastrojejunostomy  withoiit  a  Loop,  with  reversion  of 

the  Jejunum. 
For  the  following  account  1  am  very  largely  indebted  to  Mr.  Moynihan's 
excellent  description  of  the  operation  which  he  has  done  so  much  to 


CASTKO-.IK.H'XOSTOMY. 


507 


improve,  and  he  and  others  have  used  with  Buch  Bignal  success.*  Murh 
<>l'  what  follows  is  also  based  upon  the  brilliant  work  of  the  brothers 
Mayo.i 

A  vertical  incision  four  inches  long  is  made  three-quarters  of  an  inch 
to  the  right  of  the  middle  line,  over  the  upper  part  of  the  rectus 
abdominis,  and  extending  down  to  the  level  of  the  umbilicus.  The 
rectus  sheath  is  opened,  and  the  muscle  is  freed  and  displaced  outwards. 
The  abdomen  is  then  opened  by  incising  the  posterior  layer  of  the 
fibrous  sheath  and  the  peritonaeum  in  a  line  with  the  original  incision, 
so  that  the  deep  part  of  the  wound  lies  behind  the  rectus  muscle  when 
the  latter  is  released.  A  valvular  wound  is  thus  obtained  for  the 
prevention  of  ventral  hernia. 

The  stomach  and  the  first  part  of  the  duodenum  are  thoroughly 
examined   before  deciding  which  operation,  if  any,  to  perform.     The 


Fig.  195. 


Clamps  side  by  side,  the  first  line  of  suture.     (Mayo  Robsort  and  Moynihan.) 

great  omentum  and  the  transverse  colon  are  drawn  well  forwards 
upwards  and  to  the  right,  making  the  mesocolon  taut,  and  bringing  it 
well  into  view.  A  bloodless  part  of  it  is  selected,  picked  up  with 
forceps,  drawn  downwards  and  away  from  the  stomach,  and  snipped 
with  scissors. 

The  opening  thus  made  into  the  lesser  sac  is  carefully  enlarged  until 
it  admits  three  fingers,  and  through  it  the  posterior  surface  of  the 
stomach  is  thoroughly  examined. 

That  part  of  the  greater  curvature  wdiich  lies  lowest  in  the  abdomen 
is  selected  for  the  site  of  the  anastomosis.  Mayo  places  his  incision 
almost  vertically  below  the  cardiac  orifice,  well  to  the  left  of  the  more 
muscular  pyloric  third  of  the  stomach.  When  the  proper  site  has  been 
noted,  the  left  hand  is  used  to  push  the  posterior  wall  of  the  stomach 
through  the  rent  in  the  mesocolon,  care  being  taken  to  expose  the 
actual  lower  border  of  the  stomach,  and  about  a  quarter  of  an  inch  of 

*  Moynihan's  Abdominal  Operations  (1906),  p.  142. 

t   Dr.  W.  J.  Mayo,  Ann.  of  Surg.,  1905,  vol.  xlii.  p.  641  ;  ibid.,  190G,  vol.  xliii.  p.  537. 


5o8 


oi'K RATIONS   ON   THE    ABDOMEN. 


the  anterior  surface  also,  by  carefully  displacing  the  gastrocolic 
omentum  to  the  required  extent.  Long  curved  clamp  forceps  sheathed 
in  rubber  are  then  placed  obliquely  with  their  handles  to  the  left  and 
below,  and  their  tips  pointing  to  the  right  Bhoulder  and  meeting  just 

in  front  of  the  lowest  point  of  the  greater  curvature  (Figs.  190  to  194). 
The  fold  of  stomach  drawn  into  the  (damp  should  be  at  Leasl  three 
and  a  half  inches  Long. 

Fig.  196. 


Posterior  gastrojejunostomy  without  a  loop.     (Dr.  W.  J.  Mayo.  Ann.  of  Surg.) 
The  gauze  packings   under,  between,  and  around   the  exposed  pouches  and 
clamps  are  shown.     The  forceps  have  their  handles  to  the  right.     The  first  knot 
of  the  haemostatic  deep  suture,  which  pierces  all  the  coats,  is  best  placed  upon  the 
mucous  surface. 


By  drawing  the  transverse  colon  forwards  and  to  the  right,  and 
passing  the  finger  backwards  and  to  the  left  along  the  under-surface  of 
the  mesocolon,  the  duodenojejunal  flexure  is  easily  found.  The 
jejunum  near  its  origin  is  turned  towards  the  right,  and  brought  into 
the  wound.  A  fold  of  it  three  and  a  half  inches  long,  including  the  free 
border,  is  clamped,  the  tips  of  the  blades  being  about  five  inches  and  at 
the  bases  about  one  and  a  half  inches  from  the  duodenojejunal  flexure.* 

The    protruding   portions    of   the  omentum,   colon,  and  excess  of 

*  Dr.  W.  J.  Mayo  prefers  to  place  the  forceps  with  their  handles  to  the  right,  because 
it  is  easier  to  apply  tin  m,  but  it  is  an  advantage  for  the  handles  to  be  held  by  an  assistant 

who  faces  the  operator.     (  Vide  Fig.  196.) 


GASTROJEJUNOSTOMY. 


509 


jejunum  arc  now  returned  into  the  abdomen,  to  avoid  any  possible 
contamination  during  the  next  stage. 

With  the  same  object  a  roll  of  gauze,  moistened  with  hot  normal 
saline  solution,  is  now  placed  between  the  two  clamps,  which  are  after- 
wards closely  approximated  and  held  in  apposition  by  an  assistant 
standing  opposite  the  surgeon.  Carwardine's  special  gastroenterostomy 
clamps  can  be  locked,  and  do  not  need  an  assistant  to  hold  them  together 
(Fig.  191). 

A  continuous  sero-muscular  suture  of  thin  Pagenstecker's  thread  or 
silk  is  now  used  to  join  the  adjacent  edges  of  the  two  viscera  for  a 

Fig.  197. 
\ 


The  stomach  and  jejunum  opened,  the  inner  haemostatic  suture. 
(Mayo  Eobson  and  Moynihan.) 


distance  of  at  least  three  inches.  It  is  begun  on  the  left,  where  the 
tail  thread  of  the  knot  is  held  with  forceps.  The  thread  should  be 
always  held  taut,  to  secure  close  approximation  and  to  raise  a  fold  of 
sero-muscular  tissue  after  each  stitch,  which  simplifies  the  introduction 
of  the  next  one  (Fig.  195). 

When  the  first  half  of  this  superficial  suture  has  been  inserted,  the 
serous  and  muscular  coats  of  the  stomach  and  jejunum  are  carefully 
incised,  so  as  to  expose  and  liberate  the  mucous  membranes  which 
pout  into  the  wrounds.  An  elliptical  piece  of  mucosa,  about  two  and  a 
half  inches  long  and  over  half  an  inch  wide,  is  excised  from  the  stomach 
and  jejunum.  The  incision  thus  made  should  be  a  quarter  of  an  inch 
in  front  of  and  parallel  to  the  posterior  sero-muscular  suture  line. 

The  gastric  mucous  membrane  is  prevented  from  retracting  by  means 
of  tissue  forceps,  if  necessary. 

Reliable  catgut  should  be  used  for  the  deep  suture,  which  must 
pierce  all  the  coats.     It  should  be  commenced  at  the  right  extremity 


5io 


OPKKATIOWS    ON    TIIK    ABDOMEN. 


of  the  incision,  so  that  the  superficial  and  deep  sutures  may  not  have 
their  knots  and  terminations  close  together  (Figs.  196  to  198). 

The  knot  is  placed  upon  the  mucous  surface,  and  the  tail  thread  is 
held  with  forceps.     The  suture  is  continued  as  a  circular  or  overstitch 

Fig.  198 


Inner  suture  nearly  complete.     (Mayo  Robson  anil  Movnihan.) 

as  long  as  inversion  of  the  edges  can  be  easily  made.  As  soon  as  am 
difficulty  arises,  the  needle  is  passed  after  the  method  of  Connell  adopted 
by  Mayo  (vide  p.  362,  Fig  112  B).  This  is  an  excellent  and  rapid  way 
of  completing  the  suture.  Both  knots  should  be  placed  upon  the  mucous 
surface  in  the  manner  already  described  (vide  p.  358,  Figs.  105,  106). 


Fig.  199. 


Clamps  removed.     (Mayo  Knbson  and  Movnihan.) 

Care  must  be  taken  to  keep  the  thread  always  taut,  and  the  turns 
should  not  be  more  than  one-eighth  of  an  inch  apart.  These  precau- 
tions secure  accurate  apposition  of  the  mucous  membranes,  and 
especially  prevent  hemorrhage.  The  clamps  are  now  removed, 
and  if  the  deep  suture  has  been  properly  applied,  very  little  bleeding 
occurs.    The  exposed  parts  are  cleansed  with  moist  sterile  swabs.    The 


CASTKO-.IK.l  ITXOSTOMY. 


5" 


sero-muscular  suture  is  now  continued  after  the  method  of  Cushing 
(Fig.  101),  which  loaves  none  of  the  thread  exposed,  and  therefore. 
lessens  the  chance  of  adhesions.  The  final  knot  is  buried  by  reversing 
the  direction  of  the  last  stitch,  which  should  be  placed  beyond  the 
knot  at  the  starting  point;  the  two  ends  are  then  tied  together.  The 
whole  circle  of  union  is  now  examined,  and  if  necessary  a  reinforcing 
suture  may  be  placed  at  any  weak  spot. 

The  gauze  packs  arc  removed  and  the  parts  cleansed.     The  transverse 
colon  is  brought  out  again,  and  drawn  forward  so  as  to  expose  the   rent 

Pig.  200. 


Posterior  gastrojejunostomy  without  a  loop.     (Dr.  W.  J.  Mayo,  Ann.  of  Surg.') 
The  anastomosis  has  been  completed,  and  the  mesocolon  has  been  sewn  to  the 

jejunum. 


in  its  mesentery  to  enable  the  surgeon  to  fix  its  margins  to  the  jejunum 
or  stomach.  Failure  to  do  this  may  lead  to  the  formation  of  an  internal 
hernia.  I  have  operated  upon  one  patient  in  whom  the  anastomosed 
loop  had  been  drawn  into  the  lesser  sac,  and  had  become  constricted  by 
the  contraction  of  meso-colic  incision  and  the  formation  of  adhesions. 

Four  sutures  are  sufficient,  one  in  front,  one  behindhand  two  at  the 
sides.  Ma}'0  uses  mattress  stitches,  which  are  passed  in  such  a  manner 
that  they  turn  the  raw  edges  of  the  rent  upwards  into  the  lesser  sac,  so 
as  to  lessen  the  risk  of  adhesions. 

Moynihan  sews  the  edges  to  the  jejunum,  while  most  surgeons  use 
the  stomach  for  this  purpose.  The  former  plan  is  easier  to  adopt,  and 
tends  to  prevent  kinking  of  the  jejunum  (vide  Fig.  200). 


512 


OPERATIONS  ON  THE  ABDOMEN. 


The  vise*  ra  are  replaced,  and  the  abdominal  incision  is  closed,  the 
anterior  rectus  sheath  being  overlapped,  as  recommended  by  YVinslow 
and  Noble  {vide  Fig.  43,  p.  103). 

Mr.  Moynihan  has  .used  this  "no-loop  "  method  in  a  great  many 
cases  without  any  trouble.  Dr.  W.  J.  Mayo  (Ann.  oj  Sunt.,  1906, 
vol.  xliii.  p.  537)  1ms,  however,  published  two  cases  in  which  chronic 
bile  regurgitation  of  a  serious  character  developed.  In  each  of  these 
"  the  occasional  regurgitation  of  quantities  of  biliary  and  pancreatic 
secretions  was  a  source  of  great  discomfort  and  considerable  disability. 


Fig.  201. 


Posterior  gastrojejunostomy  without  a  loop.    (Dr.  W.  .1.  Mayo,  Ann.  of  9*rg.~) 
The  position  of  the  oblique  posterior  opening  is  shown  diagrammatically,  also 
angulation  of  the  reversed  jejunum. 

Reoperation  in  both  cases  during  the  past  summer  (1905)  showed  that 
the  cause  of  the  trouble  was  an  angulation  of  the  jejunum  at  its  gastric 
attachment."  These  troublesome  symptoms  occurred  after  two  out  of  56 
"no-loop"  operations  performed  between  January  I  and  July  I,  1905, 
with  only  one  death. 

(B)  Posterior  G-astro-jejunostomy  without  a  Loop,    and  without 
reversion    of  the    Jejunum   (Fig.    202). 

These  cases  led  Dr.  Mayo  to  doubt  whether  it  is  really  necessary  to 

reverse  the  direction  of  the  jejunum  so  that  it  runs  in -the  same  direction 
as  the  stomach.  Normally  the  jejunum  ascends  a  little  from  its  origin 
towards  the  left  and  then  falls  downwards,  backwards,  and  to  the  left 
towards  the  left  kidney  pouch. 

When  it  is  fixed  to  the  stomach  in  the  usual  way,  it  is  rotated  and 


GASTROJEJUNOSTOMY. 


51.3 


moved  to  the  right,  so  that  kinking  may  occur  at  the  anastomosis,  and 

the  distal  part  of  the  bowel  rides  forwards  and  to  the  right  over  the 
prominence  of  the  lumbar  spine.  The  shorter  the  loop,  the  more 
likely  the  kinking;  therefore  this  particular  form  of  obstruction  is 
most  lik<ly  to  follow  the  posterior  loop  operations. 

The  brothers  Mayo  were  unable  to  find  any  valid  reason  for  reversing 
the  normal  direction  of  the  jejunum  in  no-loop  operations,  and  they 

Fig.  202. 


Duodenum 


Opening-  in 
stomach  fc  jejunum 


Mayo's  posterior  gastrojejunostomy  without  a  loop  and  without  reversion  or 
dislocation  of  the  jejunum,  x  x  indicate  the  duodeno- jejunal  flexure.  (Mayo, 
Ann.  of  Surg.~) 


have  therefore  discarded  it.  Now  they  perform  the  anastomosis  without 
disturbing  the  natural  relations  of  the  parts,  and  in  the  last  65  cases 
they  have  had  no  death  and  no  trouble  of  any  kind. 

These  results  are  very  good  as  far  as  they  go,  but  sufficient  time  has 
not  yet  elapsed  to  enable  us  to  make  important  deductions  from  them. 
Now  that  we  know  that  "  vicious  circle  "  is  nearly  if  not  always  due  to 
the  unsatisfactory  position  and  size  of  the  stoma,  there  does  not  seem 
to  be  any  reason  for  rotating  and  dislocating  the  jejunum,  which 
probably  drains  the  stomach  better  when  it  is  left  in  its  natural  position. 

s.— vol.  11.  -  33 


514  OPERATIONS  ON  THE  ABDOMEN. 

This  method  certainly  deserves  a  thorough  trial.  I  have  used  it  in  six 
cases  with  the  most  satisfactory  results,  and  I  helieve  it  to  be  the  best 
method  yet  devised. 

The  only  essential  difference  from  the  usual  no-loop  operation  as 
described  above  is  that  the  incision  in  the  posterior  wall  of  the  stomach 
must  run  downwards  and  to  the  left  instead  of  downwards  and  to  the 
right,  so  that  it  may  be  parallel  to  the  longitudinal  incision  made  in 
the  jejunum  {vide  Fig.  202). 

Hence  the  stomach  clamp  must  be  placed  at  right  angles  to  its  usual 
direction,  and  the  direction  of  the  jejunal  clamp  must  be  reversed  if 
their  handles  are  still  turned  to  the  left.  Mayo  prefers  to  have  the 
handles  to  the  right,  but  it  is  more  convenient  that  they  should  be  on 
the  left,  where  the  assistant  can  hold  them.  The  operation  is  not  more 
difficult  than  the  usual  posterior  operation  with  reversion. 

(C)  Anterior  Gastrojejunostomy  (Wolfler). — After  the  stomach  has 
been  thoroughly  examined  the  lowest  part  of  the  greater  curvature  is 
selected  and  exposed  by  detaching  the  gastro-colic  omentum  and  its 
vessels  from  the  stomach  for  about  one  and  a  half  inches  as  recommended 
by  Kocher.  This  procedure  allows  the  stomach  to  be  drained  at  the 
lowest  point  of  the  anterior  surface.     A  few  vessels  may  need  tying. 

Long  curved  clamp-forceps  are  applied  obliquely  with  their  handles 
towards  the  left  shoulder,  and  their  points  below  and  behind  the  greater 
curvature.    The  fold  included  in  the  forceps  should  be  three  inches  long. 

The  duodeno-jejunal  flexure  is  found  in  the  way  already  described 
(p.  508)  ;  and  the  jejunum  is  traced  downwards  for  about  fifteen  inches, 
where  it  is  clamped  and  joined  to  the  stomach.  It  is  important  to 
actually  follow  the  bowel  from  its  origin.  If  the  piece  of  small 
intestine  which  emerges  below  the  colon  be  chosen,  it  may  prove  to  be 
low  down  in  the  ileum.  If  the  wrong  end  of  the  small  intestine  be 
thus  attached  to  the  stomach,  the  food  taken  will  not  be  subjected  to 
the  natural  processes  of  digestion  and  absorption  and  the  prolongation 
of  life  will  be  brief.  The  importance  of  the  above  is  proved  by  the  fact 
that  the  above  accident  has  occurred  to  operators  of  such  experience 
as  Mr.  H.  W.  Page  (Med.-Chir.  Trans.,  vol.  lxxii.  p.  379).  Here  the 
intestine  attached  to  the  stomach  was  the  ileum,  nine  inches  from  its 
lower  end.  This  patient  lived  for  ten  weeks,  and  though  greatly 
relieved  from  vomiting  and  nausea,  began  to  lose  ground  at  the  end 
of  six  weeks.  Mr.  Page  quotes  some  othe  leases,  a  striking  one  being 
that  of  Lauenstein  (Cent.  J.  CJiir.,  1888,  p.  472).  Here  the  intestine 
opened  was  only  fifteen  inches  from  the  ileo-caecal  valve.  The  patient 
began  to  have  diarrhoea  on  the  fourth  day,  passed  unchanged  food  in  her 
stools,  and  died  on  the  eleventh  day. 

The  selected  loop  of  jejunum  should  be  so  arranged  that  its  distal 
part  may  be  nearest  the  pylorus,  and  lowest  upon  the  stomach,  so  that 
drainage  into  the  proper  limb  may  be  facilitated.  The  details  of 
suturing  are  the  same  as  already  described. 

A  few  sutures  may  be  inserted  to  fix  the  proximal  limb  of  the  jejunum 
to  the  stomach  above  and  to  the  left  of  the  anastomosis.  It  is  important 
to  make  the  opening  low  enough  in  the  jejunum  to  allow  easy 
approximation  of  the  parts  without  tension,  and  without  compression 
of  the  colon  ;  but  the  danger  of  intestinal  obstruction  from  this  cause 
has  been  greatly  exaggerated.      On  the  other  hand,  the  chosen  spot 


GASTRO-JEJUNOST*  )M  i 


515 


must  not  be  low  enough  for  the  loop  to  produce  a  potential  hernial 
aperture. 

In  some  stout  patients  with  bulky  great  omenta,  the  latter  may  have 
to  be  slit  vertically  to  allow  the  proper  part  of  the  jejunum  to  be  brought 
to  the  stomach  without  tension  and  without  troublesome  folding  of 
the  great  omentum. 

Kocher  having  noticed  fatal  cases  occurring  after  successful  suturing 
and  without  peritonitis,  a  fact  only  to  be  attributed  to  the  absorption  of 
intestinal  contents  which  have  reached  and  undergone  decomposition  in 
the  stomach,  unites  the  intestine  not  with  the  two  long  axes  correspond- 
ing, but  with  the  intestine  at  right  angles  to  the  length  of  the  stomach 
and  in  such  a  way  that  the  distal  part  of  loop  descends  in  front  of 
the  proximal  limb.     Still  further  to  ensure  that  the  contents  of  the 


Fig.  203. 


Anterior 
surface 


Sero-muscular 
continuous 
stitch 


Perforating 
continuous  suture 


Kochcr's  anteroinferior  gasi  rojejunostomy  with  valve  formation,  to  guard  the  opening 
of  the  proximal  limb  of  the  jejunal  loop.     (Modified  from  Kocher.) 

stomach  and  those  of  the  proximal  part  of  the  intestine  should  pass  out 
into  the  distal  portion  without  any  regurgitation,  Kocher  makes  a  valve* 
(Fig.  203)  by  infolding  the  convex  upper  wall  of  the  loop  of  intestine 
just  behind  the  anastomotic  opening.  This  transverse  fold  is  main- 
tained by  means  of  a  continuous  sero-muscular  suture  ;  it  is  made 
before  the  loop  is  joined  to  the  stomach.  When  the  operation  is 
completed,  the  proximal  limb  does  not  open  into  the  stomach,  but 
fluid  can  pass  along  the  mesenteric  border  into  the  distal  part  of  the 
intestine.  With  the  same  object  Kocher  makes  the  incisions  into  the 
stomach  and  jejunum  crescentic  with  the  convexity  upwards  ;  this  also 
allows  a  larger  opening  to  be  made  into  the  jejunum,  which  is  incised 
transversely  to  its  axis. 

Prof.  Kocher  has  had  splendid  success  with  this  method,  and  out  of 
100  cases  only  three  deaths  occurred,  and  these  "  were  not  referable  to 

*  'Wolfler  made  a  valve  of  the  'stomach  wall  to  cover  the  orifice  of  the  proximal  limb 
of  jejunum,  but  this  was  not  very  efficient. 

33—z 


5i6  OPERATIONS  ON  THE  ABDOMEN. 

the  complications  of  the  operation,  but  to  the  disease  itself,"  and  Dr. 
Kaiser's  careful  examinations  of  Kocher's  cases  proves  that  the  late 
results  are  excellent.  These  results  are  doubtless  due  more  to  the  great 
experience  and  skill  of  Prof.  Kocher  than  the  special  method  employed. 

(D)  Posterior  Gastrojejunostomy  with  a  Loop. — The  only  essential 
difference  between  this  and  the  posterior  "  no-loop"  operation  already 
described  in  detail  is  that  the  part  of  the  reversed  jejunum  to  be  clamped 
and  attached  to  the  stomach  is  about  eight  inches  below  its  origin  at  the 
duodeno-jejunal  flexure. 

This  makes  the  operation  a  little  easier,  for  the  selected  part  of  the 
bowel  can  be  more  readily  brought  out  of  the  wound  and  secured  by  the 
clamps.  On  the  whole  the  results  obtained  with  this  operation,  which 
has  been  extensively  used,  are  fair,  especially  as  regards  the  immediate 

Fig.  204.  Fig.  205. 


Gastrojejunostomy  '-by    another  Posterior  gastrojejunostomy  by 

method  of  WSlfler's.    (Von  Esmarch  Eoux's  Y  method.    (Mayo  Robson 

and  Kowalzig.)  and  Moynihan.)   The  opening  into 

the  stomach  should  be  close  to  the 
greater  curvature. 

results,  but  the  presence  of  the  short  loop  predisposes  to  obstruction 
by  kinking  or  flattening  at  the  gastric  attachment. 

Therefore  secondary  operations  have  been  unusually  frequent  after 
this  method,  even  more  frequent  than  after  the  anterior  operation. 
Mayo  records  53  cases,  with  3  deaths,  and  7  secondary  operations,  for 
bile*  regurgitation  either  in  small  quantities  often  repeated,  or 
occasionally  in  large  amounts.  For  this  reason  many  surgeons  have 
resorted  to  the  no-loop  operation,  while  others  have  performed  entero- 
anastomosis  at  the  same  time  in  their  endeavour  to  avoid  the  vicious  circle. 

(E)  Roux's  Y  Method. — Wolfler  first  suggested  this  operation,  which 
has  been  improved  and  popularised  by  Rous.  The  jejunum  is  cut  across 
and  the  distal  portion  is  joined  to  the  stomach  either  posteriorly  or 
anteriorly.  The  proximal  end  is  implanted  into  the  left  side  of  the 
distal  part.  The  stomach  is  clamped  in  the  usual  way,  and  the 
jejunum  is  divided  between  two  intestinal  clamps,  holding  the  bowel 
and  the  mesentery.  It  is  simpler  to  secure  a  loop  of  bowel  and  its 
mesentery  with  one  long  clamp.  For  the  posterior  operation  the 
division  should  be  about  six  inches  from  the  duodeno-jejunal  flexure. 


GASTROJEJUNOSTOMY. 


517 


For  the  anterior  operation  the  jejunum  ma)'  be  conveniently  divided 
about  twelve  inches  from  its  origin.  The  mesenteric  vessels  are  secured 
by  transfixing  and  ligaturing  the  mesentery  behind  the  clamps.     The 

distal  part  of  the  bowel  is  then  joined  to  the  stomach  by  two  rows  of 
sutures  as  described  at  p.  506,  and  the  proximal  end  to  the  left  side  of 
the  distal  part  at  least  three  inches  below  the  stomach,  otherwise  bile  and 
pancreatic  juice  may  regurgitate  into  the  stomach.  An  elliptical  piece 
of  gastric  mucosa  is  excised  in  order  to  secure  a  patent  fistula. 

The  advantages  of  the  Y  method. — (1)  It  is  the  surest  method  of 
preventing  "  vicious  circle."  It  is  impossible  for  food  to  pass  from  the 
stomach  into  the  proximal  loop,  and  it  is  difficult  for  bile,  pancreatic 
juice  and  intestinal  contents  to  enter  the  stomach  through  the  gastro- 
enterostomy. (2)  It  provides  an  excellent  means  of  emptying  the 
stomach  without  delay,  and  for  this  reason  it  is  recommended  by 
Kocher  for  all  cases  in  which  this  is  essential,  especially  in  malignant 
or  other  cases  with  early  decomposition  of  the  gastric  contents. 

Fig.  206.  Fia.  207. 


Posterior  gastrojejunostomy  with  Doyen's    operation.        (Mayo 

entero-anastomosis  after  Braun  and  Kobson   and    Moynihan.)      Two 

Jaboulay.     (Mayo  Robson  and  Moy-  anastomosis    and    division   with 

nihan.)     Posterior  view.  occlusion  of  the  proximal  limb. 

The  disadvantages  are :  (1)  That  the  two  anastomosis  make  the 
operation  more  complicated  and  prolonged,  so  that  it  is  not  suitable  for 
grave  cases,  and  routine  use.  (2)  Xow  that  "  regurgitant  "  vomiting 
is  known  to  be  preventable  by  simpler  means,  and  effectual  drainage 
can  be  provided  by  making  a  large  opening  suitably  placed,  it  is  no 
longer  necessary  to  use  Roux's  more  tedious  and  serious  method. 
(3)  The  danger  of  peptic  jejunal  ulcer  is  increased  because  a  portion 
of  the  bowel  is  exposed  to  the  action  of  the  gastric  juice,  without  the 
neutralising  effects  of  the  bile  and  pancreatic  juice  (Paterson).  In 
malignant  disease  this  objection  does  not  hold,  for  jejunal  ulcer  has  not 
yet  been  known  to  followr  in  carcinomatous  cases  (Moynihan,  Lancet, 
1906,  vol.  i.  p.  1071). 

(F)  Gastro-enterostomy  with  entero-anastomosis  (Braun,  Jaboulay 
and  Weir). — This,  a  simpler  but  less  effectual  method,  which  has  been 
designed  for  the  same  purpose  and  has  the  same  objections  as  Roux's 
method.  Entero-anastomosis  has  often  been  resorted  to  for  vomiting 
coining  on  either  early  or  late  after  loop  operations,  and  it  has  generally 
but  not  always  proved  successful.  The  anastomosis  is  made  between 
the  limbs  of  the  loop  about  three  inches  below  the  gastric  attachment. 
The  details  of  technique  have  been  already  described  at  p.  404. 


5i8  OPERATIONS   OX    Till!    ABDOMEN. 

Gastrojejunostomy  and  entero-anastomosis  with  occlusion  of  the 
proximal  limb  of  the  loop,  either  with  the  silver  wire  ligature  of 
Fowler  {Ann.  of  Surg. ,  vol.  xxxvi.  p.  695),  or  the  Scott-Mattolli  Buture 
is  not  to  be  recommended,  for  all  these  complicated  and  tedious  pro- 
cedures are  unnecessary  and  they  have  nearly  all  the  objections  of  loop 
operations  with  entero-anastomosis.  Further,  ligation  or  plication  may 
not  be  effectual  in  preventing  the  olivine  from  entering  the  afferent 
limb,  or  may  even  cause  troublesome  adhesions  necessitating  operative 
treatment  as  in  one  of  Mayo's  cases. 

To  attempt  to  partially  occlude  the  proximal  limb  without  effecting 
entero-anastomosis  lower  down  is  simply  to  court  disaster.  If  the 
pylorus  is  patent  enough  to  allow  any  food  to  pass  on  into  the  duodenum, 
the  afferent  limb  then  becomes  greatly  distended  from  true  intestinal 
obstruction,  which  can  only  be  relieved  by  a  secondaiy  entero- 
anastomosis,  which  may  have  to  be  performed  under  unfavourable 
circumstances. 

Doyen's  method  of  division  and  occlusion  of  the  proximal  limb  was 
followed  by  invagination  of  the  occluded  part  through  the  lateral 
anastomosis  in  one  case  recorded  by  Mayo.  It  is  too  complicated  for 
general  use  (Fig.  207). 

(G)  Gastrojejunostomy  by  Murphy's  Button. — This  is  one  of  the 
simplest  of  all  the  methods  of  gastrojejunostomy  ;  it  is  also  the  least 
satisfactory  (ride  p.  501)  at  the  present  day.  As  has  been  the  case  with 
this  most  ingenious  instrument  after  resection  of  the  intestine,  it  has 
scored  many  brilliant  successes,  but  in  both  cases  there  is  reason  to 
believe  that  the  extreme  simplicit}"  of  the  method  has  led  to  its  use  in 
many  cases  which  have  not  been  published  because  unsuccessful.  Dr. 
Murphy  in  1895  (Lancet,  vol.  i.  p.  104)  spoke  of  there  having  been 
twenty-seven  cases  with  nine  deaths.  Published  results  during  recent 
years  have,  however,  been  far  superior  to  this  ;  for  instance,  Czerny 
has  made  use  of  this  method  more  than  a  hundred  times,  without  a 
death  attributable  to  the  button,  vide  also  the  results  given  on  p.  519. 
Out  of  69  consecutive  cases  collected  by  Dr.  Ticehurst  from  the  records 
of  a  large  general  hospital  in  a  poor  district,  23  died,  three  from  leal, 
into  the  peritonaeum  from  want  of  proper  union,  and  in  one  of  tin  se 
a  perforation  had  also  occurred  near  the  button.  In  four  of  the  fatal 
cases  in  Dr.  Murphy's  list,  death  occurred  from  exhaustion  before  the 
fourth  day,  and  it  is  stated  that  in  each  the  approximation  was  perfect. 
This  date  is  too  early  to  speak  with  confidence  of  the  approximation 
brought  about  by  the  button.  After  remaining  perfect  for  a  longer 
time  it  may  suddenly  fail,  as  in  the  following  case  of  my  own  : — 

A  patient  of  Dr.  Pye-Smith's,  at  Guy's  Hospital,  aged  45.  was  transferred  to  my  care 
in   April   1895,  with  carcinoma  of   the  pylorus.     When    the  Btomach   w  I   the 

growth  was  too  extensive  to  admit  of  pylorectomy.  It  extended  f"r  an  inch  and  a 
half  into  the  pyloric  end  of  the  stomach,  and  sent  numerous  vascular  pro -esses  along 
tin-  lymphatics  into  both  omenta.  I  united  a  loop  high  up  in  the  jejunum  to  the 
anterior  wall  of  the  stomach,  a  little  to  the  cardiac  side  of  the  centre  of  the 
anterior  wall  so  as  to  be  free  of  the  growth.  The  only  difficulty  in  the  operation  was 
making  certain  of  the  jejunum.  Every  step  of  the  union  of  the  viscera  was  rendered 
most  easy  by  the  button.  For  seven  days  the  course  was  uneventful  Bave  tor  obstinate, 
fixed,  gnawing  pain  which  I  attributed  to  the  button  having  to  make  its  way  through 
a  thick-walled  viscus  well  supplied  with   nerves.     <  »n   the  seventh  day  the  bowels  acted 


c.\sti;o.ii:.ii  nostomv. 


5i9 


after  an  enema.  On  the  eighth  this  action  wae  repeated,  and  a  small  slough  was  found 
in  the  stun].  Shortly  after,  symptoms  pointing  to  perforation  occurred,  with  rapid 
collapse  and  death.  It  is  greatly  to  be  regretted  that,  a-  the  man  was  one  of  the 
paying  hospital  patients,  no  necropsy  was  made. 

I  have  already  (p.  370)  spoken  fully  of  what  I  consider  to  be  the 
dangers  of  the  Murphy  button.  It  is  fair  to  tbis  method  to  say  that  the 
carcinoma  was  here  extensive,  vascular,  and  growing  rapidly  in  a 
comparatively  young  patient.  It  is  possible,  therefore,  that  in  spite  of 
my  precaution  I  may  have  placed  it  in  tissues  already  affected  by  growth 
and  thus  certain  to  soften  prematurely.  I  did  not  make  use  of  the 
v.  Hacker  position,  as  preferred  by  Dr.  Murphy,  because  the  anterior  or 
Wolfler  method  has  given  very  good  results,  and  because,  owing  to  the 
extension  of  the  growth  into  the  omenta,  I  was  unwilling  to  disturb  the 
parts  more  than  was  absolutely  needful.  The  button  should  be  passed 
by  the  fourteenth  or  twenty-first  day.  M.  Quenu  gives  the  following 
result  of  a  gastroenterostomy  performed  by  means  of  a  button.  A  3rear 
after  the  operation  the  patient  (who  had  greatly  improved)  began  to  fail, 
and  died  sixteen  months  after  the  operation,  jaundiced  and  emaciated, 
but  without  vomiting.  The  button  wras  found  in  the  stomach,  having 
caused  no  symptoms.  The  communication  between  the  viscera  was 
freely  open.  Recurrence  of  the  carcinoma  had  involved  the  pancreatic 
and  bile  ducts. 

The  button  has  the  following  disadvantages :  The  brothers  Mayo 
{Ann.  of  Surg.,  1905,  vol.  xlii.  p.  646)  in  57  cases  had  four  deaths  from 
separation  at  the  line  of  union  between  the  sixth  and  tenth  day.  Since 
then  they  have  reinforced  the  anastomosis  by  mattress  sutures.  This 
leakage  after  some  days  has  been  a  common  experience.  The  opening 
cannot  be  made  large  enough  for  efficient  drainage,  and  the  orifice  has 
been  shown  to  contract  more  frequently  than  after  other  methods. 
Paterson  in  his  lectures  mentions  three  cases  in  which  the  fistula  had 
completely  closed  after  intervals  of  three  and  five  months  respectively, 
and  two  closures  occurred  in  69  Guy's  Hospital  cases.  The  button 
may  act  as  a  foreign  body  either  in  the  stomach  or  in  the  intestine. 
Mayo  mentions  two  cases  in  which  it  had  to  be  removed  from  the 
stomach.  Dr.  Hawkins  and  Mr.  Nitch  (loc.  supra  cit.)  record  another 
case  in  which  the  button  caused  intestinal  obstruction  which  fortunately 
did  not  end  fatally,  the  button  being  successfully  removed  by  operation. 

As  Dr.  Ticehurst  points  out,  the  button  may  pass  the  right  way,  or 
it  may  enter  the  stomach  or  the  proximal  loop,  or  it  ma}r  reach  the 
duodenum.  In  nine  cases  of  his  collection  it  was  known  to  have  been 
retained  in  the  stomach,  and  in  not  one  of  these  did  the  operation  give 
any  permanent  relief. 

Hildebrand  and  Weir  have  modified  the  button  with  the  object  of 
preventing  its  entrance  and  retention  in  the  stomach  as  far  as  possible, 
but  no  modification  will  certainly  prevent  the  button  falling  into  the 
stomach  in  anterior  operations. 

Dr.  Murphy  (loc.  supra  cit.)  gives  the  following  conclusion  :  (1)  That 
gastrojejunostomy  should  never  be  performed  on  an  extremely  cachec- 
tic patient.  (2)  The  von  Hacker  position  (p.  192)  is  preferable,  though 
that  of  Wolfler  may  be  used.  The  former  favours  the  passage  of  the 
button  into  the  intestine.  Out  of  the  cases  in  which  the  approximation 
has  been  made  to  the  anterior  wall  of  the  stomach,  the  button  has 


520  OPERATIONS   ON    THE    ABDOMEN. 

dropped  back  into  this  viscus  in  four;  in  none  of  them  did  it  give  any 
unpleasant  results,  and  Dr.  Murphy  believes  that  it  would  have  passed 
as  soon  as  the  stomach  had  contracted  in  size  and  the  patient  was  up 
and  about.  (3)  Owing  to  the  poor  reparative  power  of  the  tissues  in 
these  patients,  it  is  well  to  scarify  with  a  needle  the  adjacent  peritoneal 
surfaces  of  stomach  and  intestine :  this  hastens  the  formation  of 
adhesions.  (4)  A  few  interrupted  supporting  sutures  between  the 
stomach  and  intestine,  half  an  inch  from  the  button,  may  be  necessary 
where  there  is  any  tension  on  the  parts.  (5)  The  patient  should 
receive  liquid  nourishment  as  soon  as  the  effects  of  the  anaesthetic 
pass  away. 

The  earlier  steps  of  the  operation  are  as  already  described.  In  placing 
the  button  in  the  stomach  and  jejunum  it  is  advisable,  as  recommended 
by  Carle  and  Fontino  (Arch.f.  klin.  Chir.,  Bd.  lvi.  Heft  1),  to  dispense 
with  the  purse-string  suture,  substituting  one  or  two  simple  sutures  at 
each  side  of  the  button  after  the  latter  has  been  forced  into  the  stomach 
or  intestine  through  as  small  an  incision  as  possible.  This  prevents  the 
puckering  produced  by  the  purse-string  suture,  and  ensures  uniform 
contact  between  broad  serous  surfaces.  Kammerer  (Aim.  oj  Surg., 
July  1900,  p.  30)  adopted  this  plan  in  eleven  successful  cases  of 
posterior  gastrojejunostomy,  and  speaks  strongly  in  favour  of  the 
method. 

(H)  Gastrojejunostomy  by  means  of  Decalcified  Bone  Bobbins. — 
This  method  has  been  recommended  by  Mr.  Mayo  Kobson  (Med.-Cliir. 
Trans.,  vol.  lxxv.  p.  419,  and  Brit.  Med.  Journ.,  vol.  i.  1900,  p.  628) 
(vide  pp.  373  to  376).  It  is  claimed  (Diseases  of  the  Stomach,  Kobson 
and  Moynihan,  1904)  that  this  method  prevents  narrowing  of  the  orifice 
by  tight  sutures ;  that  the  bobbin  acts  as  a  splint  to  and  protects  the 
line  of  suture  ;  that  an  immediate  opening  is  ensured  ;  that  the  button 
soon  dissolves,  leaving  no  foreign  body  in  the  intestine ;  and  that  the 
method  is  rapid,  easy,  efficient  and  safe.  These  advantages  are 
obtained  by  using  clamp  forceps,  which  allow  the  opening  to  be  made 
of  any  desirable  size,  independently  of  the  size  of  bobbin  available. 
For  these  reasons,  we  greatly  prefer  to  dispense  with  bone  bobbins, 
and  employ  the  clamps  of  Doyen  or  Car  war  dine.  The  bobbin  has, 
however,  given  very  good  results  in  the  able  hands  of  its  originator, 
who  still  recommends  it  (Med.  Ann.,  1906,  p.  486). 

In  103  cases  of  posterior  gastrojejunostomy  performed  with  the  aid 
of  the  bobbin,  Mr.  Kobson  states  that  there  were  only  four  deaths,  and 
that  the  anastomosis  was  not  at  fault  in  any  of  these  (Med.  Ann.,  1904). 

Operation. — The  chosen  portions  of  the  stomach  and  intestine  are 
drawn  well  up  into  the  wound,  emptied,  and  held  in  position  by  forceps 
which  act  as  guides  to  the  spots  to  be  opened.  The  peritonseal  sac 
having  been  thoroughly  shut  oft'  with  sterile  gauze,  two  continuous 
sutures,  one  sero-serous  and  securing  peritonseal  apposition  for  fully 
one-third  of  an  inch  from  the  opening  all  round  ;  the  other,  marginal 
and  muco-mucous,  when  drawn  tight,  firmly  applies  the  edges  of  the 
openings  in  the  stomach  and  jejunum  to  the  tube,  thus  preventing  any 
extravasation.  The  sero-serous,  on  a  curved  needle,  is  first  inserted, 
half  or  one-third  of  an  inch  from  the  spot  where  the  viscera  are  to  be 
opened,  first  to  jejunum  and  stomach  alternately,  the  suture  taking  up 
peritonaeum  and  outer  muscular  coat  only.     This  suture  is  left  long  at 


GASTROJEJUNOSTOMY. 


52i 


the  end  where  it  begins,  and  when  the  extreme  opposite  end  is  reached 
it  is  not  unthreaded,  in  order  to  complete  the  suturing  after  the  bobbin 
has  been  inserted,  and  the  marginal  or  muco-mucous  suture  completed. 
The  viscera  are  then  opened,  the  openings  being  just  sufficient  to  admit 
the  bobbin,  but  before  its  insertion  the  marginal  suture,  which  should 
be  of  chromicised  gut,  is  applied  from  right  to  left,  uniting  the  posterior 
margins  of  the  two  visceral  openings,  the  suture  including  mucous 
membrane,  and  being  left  long  on  the  right  and  kept  threaded  on  the 
left.  The  bobbin  is  next  inserted,  and  the  marginal  suture  then  pro- 
ceeded with  round  the  front  until  the  tail  of  the  suture  is  reached :  the 


Fig.  208. 


Elastic 
ligature 


Dr.  McGraw's  elastic  ligature  method  of  gastrojejunostomy.  (Modified  from 
Dr.  H.  0.  Walker,  Journ.  Amer.  Hied.  Assoc,  Jan.  17,  1903.)  The  posterior  sero- 
muscular suture  has  been  placed.  The  elastic  ligature  is  rather  too  near  the 
mesentery  of  the  intestine,  and  a  little  too  high  on  the  stomach. 

two  ends  are  then  tightened,  tied  and  cut  short,  thus  uniting  the 
mucous  surfaces  round  the  tube.  The  serous  suture  is  then  proceeded 
with  half  or  a  third  of  an  inch  from  the  marginal  one  until  the  circuit 
is  completed,  when  the  two  ends  are  tightened,  tied  and  cut  short. 
When  the  anastomosis  is  complete,  the  sutures  cannot  be  seen 
(M.  Robson). 

The  Elastic  Ligature  Method  (McGraw). — This  method  has  been 
discussed,  and  the  mode  of  its  application  has  been  already  described 
under  intestinal  anastomosis,  p.  406  (vide  Figs.  208  to  210). 

Its  use  for  gastrojejunostomy  is  very  similar,  and  it  can  be  employed 
for  performing  either  the  anterior,  or  the  posterior  operation  with  or 


522 


OPERATIONS   ON    TIIK    ABDOMEN. 


without  a  loop.  The  opening  should  be  made  large  enough,  at  least 
two  and  a  half  inches  long.  The  accompanying  figures  illustrate  its 
use.  Care  must  be  taken  to  include  all  the  mucous  membrane  of  the 
stomach  and  jejunum  within  the  bite  of  the  ligature,  and  not  to  pierce 
any  of  the  prominent  folds  of  the  mucosa,  which  may  otherwise  remain 
as  bridges  across  the  fistula  (McGraw,  Med.  News.,  Oct.  24,  1903). 

Although  this  method  is  undoubtedly  simple,  easy,  very  rapid,  and 
accompanied  with  less  risk  of  shock  and  sepsis  than  most  other  methods, 
it  has  the  serious  disadvantage  of  not  providing  an  immediate  opening, 
so  that  mouth  feeding  may  have  to   be  delayed  for  about  four  days  in 

Fig,  209. 


Ligature  to  f  be  the 
elastic  ligature 

Dr.  McGraw's  clastic  ligature  method  of  gastrojejunostomy. 
Dr.  "Walker.)     The  tying  of  the  ligature. 


I  Modified  from 


cases  of  pyloric  obstruction,  for  which  it  is  therefore  absolutely  contra- 
indicated.  The  subjects  of  pyloric  obstruction  are  not  in  a  condition 
to  stand  the  starvation,  and  much  of  the  success  of  the  present  day  is 
due  to  early  feeding  in  these  cases.  Rectal  feeding  is  a  very  poor 
substitute,  especially  in  marasmic  patients.  I  prefer  to  make  the 
anastomosis  with  the  aid  of  clamp  forceps  and  continuous  sutures,  for 
the  reasons  already  given. 

Dr.  W.  J.  Mayo  {Ann.  of  Surg.,  1905,  vol.  xlii.,  p.  646)  records  36 
gastrojejunostomies  by  means  of  the  elastic  ligature,  17  for  benign 
disease  with  2  deaths  (7  per  cent.),  19  for  malignant  disease  with 
3  deaths  (15  per  cent.).  Dr.  Mayo  states  that  the  orifice  is  likely  to 
contract  especially  if  the  pylorus  be  patent,  but  recent  experiments  by 


<:.\STi;o.IKJUNOSTOMV. 


523 


Dr.  Dudley  Tail  and  various  Continental  observers  tend  to  show  that 
if  the  ligature  be  properly  applied,  there  is  no  unusual  risk  of  narrow- 
ing «>f  the  stoma.  It  is  of  course  true  that  with  an  open  pylorus  all 
gastrojejunostomy  openings  tend  to  close  in  time  unless  they  are  made 
of  very  large  size. 

After-treatment. — It  is  certain  thai  surgeons  have  been  over-anxious 
with  regard  to  commencing  to  feed  their  patients  after  this  operation. 
After  careful  suturing,  or  indeed  after  any  of  the  methods  of  gastro- 
jejunostomy, feeding  by  the  mouth  should  he  carefully  begun  within  a 
few    hours   of   the   operation.     Such  liquids  as  peptones,   Valentine's 


Fr<;.  210. 


Dr.  McGraw's  elastic  ligature  method  of  gastrojejunostomy.  (Modified  from 
Dr.  Walker.)  The  operation  completed.  The  sero-muscular  suture  shows  too  much. 
A  Cushing's  suture  is  better,  for  it  buries  itself,  and  is  followed  by  few  adhesions. 

meat  juice,  raw  meat  juice,  champagne,  veal  tea,  brandy  and  water, 
may  be  given  in  teaspoonfuls  every  half-hour  at  first  and  soon  increased 
up  to  half-ounces  every  hour.  Iced  whipped  egg  and  iced  milk  may 
be  given  (Lenhartz),  and  this  has  the  advantage  of  providing  proteid  for 
combination  with  free  hydrochloric  acid  and  of  preventing  its  digestive 
action  upon  the  newly  joined  and  inflamed  tissues.  Jelly  may  also  be 
soon  given.  "When  the  operation  has  been  performed  for  haemorrhage 
more  delay  and  caution  are  required. 

Shock  may  be  treated  by  warmth,  and  by  the  subcutaneous  injection 
of  adrenalin  chloride  (20  m.  of  the  td\to  solution  every  hour),  aseptic 
ergot  or  ernutm.  Collapse  may  be  combated  by  warmth,  rectal  saline 
injections,  subcutaneous  saline  infusions,  either  repeated  or  continuous. 


524  OPERATIONS   OX   THE   ABDOMEN. 

In  graver  cases  intravenous  injection  of  6  per  cent,  solution  of  dextrose 
may  be  used  with  advantage  (Beddard). 

As  soon  as  possible  the  patient  should  be  placed  in  the  semi-sitting 
posture,  in  order  to  prevent  pulmonary  complications  as  far  as  possible, 
ami  also  to  lessen  the  risk  of  vomiting.  If  severe  vomiting  occur, 
rectal  feeding  must  be  adopted,  and  continued  if  it  does  not  increase 
the  vomiting,  as  it  may  do  occasionally.  Gastric  lavage  with  a  soft 
tube  may  be  resorted  to  in  grave  cases  during  the  first  or  second  day, 
while  there  is  but  little  risk  of  doing  any  harm  to  the  sutured 
tissues.  If  the  vomiting  persist  entero-anastomosis,  if  practicable, 
ought  to  be  adopted  without  too  much  delay. 

Complications  and  Sequelae  of  Gastrojejunostomy. 

(A)  In  the  cases  which  recover — 

(i.)  In  most  benign  cases  great  relief  is  given  permanently.  Paterson 
estimates  that  go  per  cent,  of  these  patients  remain  cured,  but  I  think 
that  these  figures  are  optimistic. 

(ii.)  In  many  malignant  cases,  great  relief  is  given  for  a  varying 
number  of  months  from  pain,  vomiting,  dj'spepsia,  &c,  while  a  gain  of 
flesh  is  often  made  and  maintained  for  months. 

(iii.)  In  many  others  the  relief  is  much  more  short-lived ;  the 
patient  after  a  short  period  of  relief,  though  the  appetite  is  voracious, 
makes  no  flesh,  and  quickly  goes  down  hill  again. 

(iv.)  In  a  few  cases  both  innocent  and  malignant.  Acute  and  serious 
vomiting  occurs  from  kinking,  spur  formation,  folds  of  mucous  membrane 
obstructing  the  efferent  limb  of  the  jejunal  loop,  or  water-logging  of 
the  obstructed  proximal  limb,  which  then  causes  closure  of  the  efferent 
opening. 

(v.)  In  a  few  cases  chronic  and  annoying  or  even  serious  vomiting 
gradually  develops  from  the  same  causes  or  from  contraction  of  the 
orifice  or  retention  of  a  Murphy  button. 

(vi.)  In  rare  cases  intestinal  obstruction  occurs  from  undue  pressure 
on  the  colon,  jejunum  or  duodenum,  or  from  the  development  of  an 
internal  hernia. 

(vii.)  Occasionally  a  peptic  jejunal  ulcer  may  perforate. 

Most  of  these  sequelae  have  become  much  more  rare  of  late,  and 
they  should  almost  cease  to  occur  with  greater  perfection  of  technique. 

(B)  In  fatal  cases  the  causes  of  death  have  been  sufficiently  indicated 
in  the  preceding  pages,  viz.,  shock,  collapse  from  previous  exhaustion 
and  want  of  fluids  ;  pulmonary  complications,  which  are  especially  apt 
to  follow  all  operations  upon  the  stomach ;  persistent  vomiting ; 
peritonitis,  whether  due  to  sepsis  introduced  at  the  time  of  the  opera- 
tion or  to  leakage  later  on,  brought  about  by  some  fault  in  the  technique 
of  direct  suture,  by  the  use  of  the  button,  or  by  rough  handling  and 
perforation  of  a  gastric  or  duodenal  ulcer  ;  and  recurrent  haemorrhage 
from  some  of  the  vessels  not  being  secured  by  the  sutures  (or  by 
ligature),  or  from  a  disturbed  gastric  or  duodenal  ulcer. 

GASTROPLICATION. 

This  operation,  which  was  first  performed  by  Bircher  in  1891,  has 
for  its  object  the  reduction  of  the  size  of  a  dilated  stomach.  This  is 
accomplished  by  making  one  or  more  longitudinal  folds  or  tucks  in  the 


GASTROPLICATION.  525 

wall  of  tli«'  stomach  by  means  of  sutures.  The  operation  has  been 
performed  a  number  of  times.  Mayo  Robson  (Lancet,  March  24,  igoo, 
p.  831)  gives  a  list  of  28  cases,  with  two  deaths.  In  one  of  the  fatal 
cases,  however,  death  was  due  to  syncope  two  weeks  after  operation, 
so  cannot  be  ascribed  to  the  operation. 

Some  of  these  operations  were  performed  in  cases  in  which  definite 
pyloric  stenosis  was  the  cause  of  the  dilated  stomach.  It  is  clear  that 
such  a  proceeding  cannot  be  of  any  value  unless  the  pyloric  stenosis  is 
relieved  at  the  same  time  by  pyloroplasty  or  gastrojejunostomy,  and 
even  then  the  propriety  of  gastroplication  is  doubtful,  since  there  is  a 
good  deal  of  evidence  to  show  that  a  dilated  stomach  contracts  very 
considerably  after  removal  of  the  cause  of  dilatation. 

The  application  of  gastroplication  therefore  should  be  limited  to  those 
very  rare  cases  of  idiopathic  dilatation  of  the  stomach.  Even  in  these 
cases  the  question  of  gastrojejunostomy  should  be  considered,  for,  as 
Farquhar  Curtis  {Ann.  of  Surg.,  July,  1900,  p.  4q)  says,  "  If  the  surgeon 
should  chance  to  overlook  some  cause  of  pyloric  obstruction  his  patient 
will  be  sure  of  a  cure  if  he  survives  the  operation,  whereas  gastropli- 
cation will  be  useless  if  pyloric  obstruction  exists." 

Some  years  ago  I  remember  seeing  gastroplication  being  performed  upon  a  middle-aged 
man,  who  was  suffering  from  gastric-dilatation,  which  was  probably  due  to  seasickness  and 
excessive  eating.  Considerable  relief  was  given  for  about  six  months.  Later  anterior 
gastrojejunostomy  was  performed,  and  this  again  gave  temporary  relief.  Subsequently 
posterior  gastrojejunostomy  was  resorted  to,  and  made  the  patient  much  more  comfort- 
able, at  least,  for  a  time.  When  I  last  heard  of  him  he  remained  fairly  well.  During 
the  anterior  gastrojejunostomy  it  was  noticed  that  the  stomach  was  as  large  as  ever. 

Operations  for  the  Relief  of  Gastroptosis — Gastropexy. — Gastro- 
ptosis  rarely  occurs  alone,  but  generally  forms  a  part  of  Glenard's 
disease  or  enteroptosis,  in  which  most  of  the  abdominal  viscera  are 
unduly  movable,  and  the  parietes  wasted  and  flabby. 

The  subjects  of  this  disease  are  usually  women  of  a  neurasthenic 
temperament,  and  they  rarely  derive  much  benefit  from  surgical 
interference  of  any  kind.  Suitable  abdominal  belts  are  usually  sufficient, 
but  they  are  not  always  satisfactory. 

A  certain  amount  of  prolapse  of  the  stomach  also  develops  in  cases 
of  severe  dilatation.  The  prolapsed  stomach  may  become  more  or  less 
obstructed  from  kinking  at  the  pylorus  ;  but  dilatation  is  more  often 
atonic  and  due  to  malnutrition. 

Duret  in  1896  (Revue  de  Chir.,  1896,  p.  430)  sutured  the  stomach  to 
the  anterior  abdominal  wall  above  the  umbilicus  ;  the  patient  was 
greatly  relieved  and  gained  flesh.  Rosving  and  Davies  have  used 
analogous  measures. 

The  chief  objection  to  this  procedure  is  that  it  may  fix  the  stomach 
unduly  and  interfere  with  its  proper  peristalsis  in  the  same  way  that 
adhesions  from  other  causes  do ;  but  the  gravity  of  adhesions  has  been 
greatly  exaggerated. 

H.  D.  Beyea  (Pliil.  Med.  Journ.,  1903,  p.  257)  shortens  the  gastro- 
hepatic  and  gastro-phrenic  ligaments  by  plicating  them  to  the  required 
degree  by  means  of  three  rows  of  interrupted  silk  sutures,  each  suture 
when  tied  making  a  transverse  fold. 

Bier  shortens  the  small  omentum  in  the  same  way,  and  he  also  fixes 
the  pylorus  to  the  capsule  of  the  liver.     Beyea  and  Bier  have  operated 


526  OPERATIONS   ON    THE    ABDOMEN 

upon  four  cases  each,  with  relief  of  symptoms  and  improvement  of  the 
general  health. 

Coffey  {Phil.  Med.  Journ.,  Oct.  11,1902)  sutures  the  gastro-colic 
omentum  about  one  inch  below  the  greater  curvature,  the  parietal 
peritonaeum  about  one  inch  above  the  umbilicus  ;  and  in  bad  cases  he 
advises  fixation  of  the  great  omentum  below  the  pendulous  colon  to  the 
parietal  peritonaeum.     He  records  two  cases  with  great  improvement. 

The  advantage  of  the  method  of  Beyea  is  that  the  gastric  peristalsis 
will  not  be  interfered  with,  and  the  same  is  probably  true  of  Coffey's 
operation. 

Until  more  cases  are  recorded  and  followed  up  it  is  impossible  to 
arrive  at  a  de  fin  ate  conclusion  concerning  the  value  or  otherwise  of 
these  procedures. 

DUODENOSTOMY. 

This  and  the  following  operation  have  been  proposed,  in  cases 
unsuited  for  pylorectomy,  as  a  means  of  getting  nourishment  into  the 
alimentary  canal  below  the  disease,  and  thus  giving  rest  to  the  diseased 
parts,  especially  in  those  cases  of  infiltration  of  the  whole  of  the 
stomach,  rendering  gastrojejunostomy  impracticable.  But  little  favour 
has  been  accorded  to  either  of  these  operations,  and  both  are  destined 
to  be  rarely  required.  Duodenostomy  especially  has  the  serious 
objections  that  it  deals  with  a  fixed  portion  of  intestine,  one  difficult  to 
deal  with,  and  one  into  which  important  fluids  are  poured,  which  thus 
may  readily  escape  from  a  fistula  made  here.  After  mobilising  the 
duodenum  after  Kocker's  method,  the  operation  would  be  more  practi 
cable,  but  for  the  cases  in  which  an  opening  is  needed,  the  pylorus  is 
usually  diseased  and  fixed  so  that  a  jejunostomy  is  more  suitable. 
Furthermore,  all  the  cases  have,  I  believe,  been  fatal. 

JEJUNOSTOMY. 

This  operation  has  the  serious  disadvantage  of  being  liable  to  leakage 
at  a  point  high  up  in  the  alimentary  canal,  where  the  fluids  traversing 
the  bowel  are  of  the  greatest  importance  from  a  nutritive  point  of  view. 
Thus  it  has  followed  in  the  majority  of  cases  that  no  great  prolongation 
of  life  has  resulted  from  this  operation.  Dr.  Hahn  (Deut.  M<d.  Woch., 
1894)  gives  a  list  of  five  cases  of  jejunostomy.  One,  a  case  of  gastric 
carcinoma,  died  in  a  fortnight ;  another,  a  case  of  cesophagal  carcinoma, 
died  in  four  days;  the  third,  a  girl  aged  23,  who  five  weeks  before  bad 
drunk  sulphuric  acid,  died  on  the  eighth  day.  Mr.  Jessett  (Dis.  of  the 
Stomach  and  Intestines,  p.  64)  relates  two  cases  operated  on  for 
oesophageal  carcinoma.  One  survived  nine  months,  when  extension  of 
the  disease  proved  fatal.  The  other  only  survived  seven  weeks.  Mr. 
Golding  Bird  brought  a  case  before  the  Clinical  Society  (Trans.,  vol.  xix. 
j).  70)  ;  here  the  operation  was  performed  for  advanced  carcinoma  of 
the  pylorus.  The  patient  was  making  a  good  recovery  up  to  the 
ninth  day,  when  fatal  peritonitis  occurred  owing  to  an  accident  in  the 
feeding.  Recent  improvements  in  the  operation  may  prove  of  value  in 
preventing  leakage  and  diminishing  the  mortality. 

Indications. — (1)  Cases  of  carcinoma  of  the  pylorus  and  stomach 


JEJUNOSTOMY. 


527 


where  other  operations  arc  impossible.  (2)  Cases  of  carcinoma  of  the 
cardiac  end  of  the  stomach  and  oesophagus  when  gastrostomy  is  out  of 

the  question.  (3)  Cases  of  simple  general  cicatricial  contraction  of 
the  stomach,  the  effect  of  caustic  liquids.  It  has  been  suggested  also 
as  a  means  of  treating  gastric  haemorrhage,  but  this  suggestion  is  to  be 
condemned. 

Operations. — Three  methods  will  be  briefly  described  :  (1)  Maydl's 
method  ;  (2)  Moynihan's  adaptation  of  Witzel  method  of  gastrostomy  ; 
(3)   Gibson's  adaptation  of  Kader's  method  of  gastrostomy. 

The  abdomen  is  opened  through  the  upper  part  of  the  left  rectus  and 
the  duodenojejunal  flexure  is  sought,  and  found  in  the  manner  already 
described  (p.  508).  It  is  then  traced  down  for  about  eight  inches,  and 
a  loop  is  brought  out  of  the  abdomen.  So  far  all  the  operations  are 
alike. 

(1)  MaydVs  Method. — The  loop  is  emptied  and  clamped  across  at 
its  base,  the  clamp  securing  both  limbs  of  the  loop  and  the  mesentery. 
The  intestine  is  cut  across  and  the  mesentery  is  tied  and  incised  to  the 
required  degree.  The  proximal  open  end  is  implanted  into  the  side  of 
distal  part  at  least  three  inches  down,  the  remaining  at  end  is  fixed 
in  the  parietal  wound.  The  peristalsis  in  the  part  of  the  bowel  which 
is  joined  to  the  wound  is  away  from  the  fistulous  opening.  This 
operation  resembles  Roux's  method  of  gastrojejunostomy  (p.  516) 
(Brit.  Med.  Journ.,  June,  1902  ;  Abdominal  Operations,  1906,  p.  243). 

(2)  Moynihan's  Adaptation  of  Witzel  Method  of  Gastrostomy.  —  A 
small  opening  is  made  into  the  intestine  near  the  distal  extremit}'  of 
the  exposed  loop,  and  on  the  side  opposite  to  the  mesentery  a  rubber 
tube  about  the  size  of  a  No.  12  catheter  is  inserted  "  and  fixed  by  a 
single  catgut  stitch,  which  includes  the  cut  edge  of  the  bowel  and  the 
side  of  the  tube."  The  tube  is  laid  upon  the  ante-mesenteric  border 
(towards  the  origin  of  the  jejunum),  and  buried  by  means  of  a  continuous 
suture  {vide  Figs.  164,  165).  The  tube  should  be  buried  for  about  two 
inches,  and  the  suture  should  extend  well  below  the  opening  into  the 
intestine.  The  intestine  is  fixed  to  the  parietal  peritomeum,  and  the 
wound  closed  around  the  tube,  which  is  left  long.  A  funnel  may  be 
inserted  in  the  end  of  the  tube  for  feeding  purposes.  At  first  only 
about  six  to  ten  ounces  are  given.  Mr.  Golding-Bird  found  that  a 
meal  of  fifteen  or  twenty  ounces  every  four  hours  caused  symptoms 
of  over-distension.  Moynihan  states  that  "  after  the  first  few  days  up 
to  a  pint  may  be  given  in  the  space  of  ten  minutes." 

(3)  Gibson's  Adaptation  of  Kader's  Method  of  Gastrostomy  (Bost.  Med. 
and  Surg.  Journ.,  Sept,  25,  1902). — This  is  not  nearly  so  suitable  as 
the  method  just  described,  for  the  shape  and  size  of  the  small  intestine 
does  not  favour  the  adoption  of  Kader's  method  with  a  sufficient 
guarantee  against  leakage,  without  also  causing  undue  narrowing  of 
the  intestine  and  interference  with  the  flow  of  fluid  from  the  intestine 
above. 


CHAPTER  VIII. 
EXCISION    OF    THE    SPLEEN:     SPLENOPEXY. 

Indications. — All  of  these  are  rare,  and  many  of  them  are  still 
doubtful. 

i.  Cystic  Spleen. — When  this  is  found  to  be  unsuited  for  incision  and 
drainage.  Mr.  K.  Thornton's  case  of  this  kind  was  the  first  successful 
splenectonvy  in  England.  In  some  cases  extensive  adhesions  make 
splenectomy  impossible. 

2.  Injury. — This  has  been  already  alluded  to  when  gunshot  injuries 
of  the  abdomen  were  considered  (p.  433).  Other  cases  in  which  it  may 
be  called  for  are,  prolapse  of  a  spleen,  injured  or  not,  through  a  wound, 
rupture  of  the  spleen,  and  stabs  of  this  viscus.  Hitherto  surgeons  have 
often  been  deterred  from  attempting  to  remove  a  ruptured  spleen  by 
the  frequency  with  which  this  injury  is  complicated  by  injury  to  other 
abdominal  or  thoracic  organs,  especially  the  liver  itself.  From  the 
shock  of  these  the  patient  never  rallies  sufficiently  to  justify  explora- 
tion. Fresh  interest  will  be  called  to  this  matter  by  three  successful 
cases  of  splenectomy  for  rupture  of  the  spleen  brought  by  Messrs. 
Ballance  and  Pitts  before  the  Clinical  Society  {Lancet,  vol.  i.  1896, 
p.  484). 

In  the  first  case,  under  Mr.  Ballance,  a  boy,  aged  10,  had  been  struck  five  days  before 
his  admission  into  St.  Thomas's  Hospital  by  a  "  full-pitched  ball "  on  the  left  side. 
Severe  pain  followed,  but  passed  off  until  a  few  hours  before  admission.  At  this  time 
severe  shock  was  present  from  which  the  patient  rallied  slightly.  The  spleen  was 
removed  through  a  four-inch  incision  in  the  left  linea  semilunaris.*  It  was  noticed 
that  a  speniculus  was  left  behind.  The  boy  recovered  rapidly,  and  was  in  robust 
health  five  months  later,  but  the  superficial  glands  had  enlarged. 

In  the  second  case,  also  under  Mr.  Ballance,  the  patient,  a  woman,  aged  45,  had  been 
run  over  by  a  hansom  cab.  Shock  was  so  marked  a  feature  that  operation  was  not 
justified  until  the  next  day.  Though  the  patient  left  the  theatre  in  a  desperate 
condition,  in  ten  days  she  was  apparently  convalescent.  Then  she  began  to  go  down- 
hill, and  by  the  eighteenth  day  her  condition  was  again  critical,  with  weakness, 
emaciation,  thirst,  drowsiness,  &c.  The  administration  of  extract  of  sheep's  spleen 
and  raw  bone  marrow  daily  restored  her  gradually  to  convalescence  and  ultimately  to 
complete  recovery.     Some  groups  of  external  lymphatic  glands  could  be  felt  in  this  case. 

In  the  third  case,  under  the  care  of  Mr.  Pitts,  a  man,  aged  36,  had  fallen  on  an  iron 
girder,  striking  his  left  side.  He  complained  of  pain  there,  but  was  otherwise 
apparently  well.  About  four  hours  later  he  became  suddenly  collapsed.  Four  hours 
afterwards  he  had  responded  sufficiently  to  restoratives  to  make  operation  justifiable. 
This   patient,   when  apparently   convalescent,  began   to   lose   ground    in  a  similar  way 

*  In  one  at  least  of  these  three  cases  the  spleen  appears  to  have  been  removed  by  a 
median  incision.  This  would  have  the  advantage  of  allowing  the  operator  to  investigate 
the  state  of  the  liver  and  kidneys. 


EXCISION    OF   THE   SPLEEN.  529 

i"  the  second  patient.    Cod-liver  oil  and  1 1  marrow  were  given,  but   II   was  not  (ill 

arsenic  was  administered  that  any  real  improvement  was  observed.     Ee  ultimately  gained 
robust  health,  bui  all  the  superficial  Lymphatic  glands  could  be  felt  enlarg 

In  each  of  these  cases  the  spleen  was  not  only  ruptured,  in  the  third 
completely  across,  but  the  vessels  in  the  hiluni  were  torn  across  also. 

The  authors  remarked  that  where  this  was  not  present  a  rupture  of 
moderate  severity  might  perhaps  be  treated  by  suture.  As  to  the 
diagnosis  of  ruptured  spleen  these  brilliant' successes  point  to  the  value 
of  the  following:  (a)  The  locality  of  the  injury;  (/>)  the  evidence  of 
internal  haemorrhage  ;  (c)  the  great  increase  of  fixed  splenic  dulness ; 
(<I)  the  evidence  of  an  increasing  collection  of  fluid  in  the  abdomen,  and 
of  the  fact  that  while  the  dulness  in  the  right  flank  can  be  made  to  dis- 
appear by  change  of  position,  that  in  the  left  flank  remains  constant. 
The  operation  should  be  performed  as  soon  as  the  diagnosis  is  made, 
for  to  wait  for  reaction  from  collapse  is  to  wait  for  more  hemorrhage, 
and  to  throw  away  whatever  chance  the  patient  may  have  of  recovery 
from  early  operation.  If  the  operation  be  too  long  delayed  infection  of 
the  clots  will  occur  (Dudgeon).  In  the  case  of  the  spleen  where  an 
escape  of  blood  alone  follows  on  the  rupture,  the  last  mentioned  most 
grave  condition  will  not  follow  so  quickly  as  in  the  case  of  the  kidney. 
The  peritoneal  sac  should  be  cleansed  as  thoroughly  as  possible  from 
all  blood  and  clots.  Every  precaution  for  meeting  shock  should  be 
taken  before  and  after  the  operation.  Care  must  be  taken  not  to 
delay  the  operation  too  long.  In  a  recent  case  at  Guy's  Hospital  one 
of  us  (R.  P.  R.)  operated  too  late  to  save  the  man,  who  was  blanched 
and  collapsed  from  hemorrhage. 

A  packing  case  had  fallen  upon  the  patient's  right  shoulder,  twenty-five  hours 
before  the  operation  ;  pain  in  the  left  side  and  collapse  came  on  rapidly,  but  these  passed 
off  so  that  an  operation  was  not  considered  necessary  at  first.  About  an  hour  before 
the  operation  the  man  became  rapidly  worse,  and  developed  all  the  signs  of  internal 
hemorrhage  and  dulness  in  the  splenic  region.  An  incision  was  made  through  the  left 
rectus  and  the  spleen  was  removed  without  much  difficulty,  the  pedicle  having  been 
secured  as  soon  as  possible  with  intestinal  clamp-forceps.  Continuous  subcutaneous 
i illusion  of  saline  solution  was  adopted  after  the  operation,  but  death  occurred  eighteen 
hours  afterwards. 

3.  In  rare  cases  of  suppuration  involving  the  spleen,  but  incision  and 
drainage  are  more  commonly  called  for,  and  are  less  dangerous. 

4.  Movable  or  Wandering  Spleen. — When  this  condition  causes 
troubles,  analogous  to  those  of  movable  kidney,  not  relieved  hy  a  belt 
or  splenopexy. 

Dr.  McGraw  [Med.  Rec,  vol.  xxxiii.  No.  26)  removed  an  enlarged  and  dislocated 
spleen,  which  formed  a  tumour  in  the  right  iliac  fossa,  and  partially  displaced  the 
uterus  and  bladder.  A  week  later  pain  in  the  left  shoulder  and  left-sided  pleuro- 
pneumonia supervened.  Nine  months  afterwards  the  ligature  was  coughed  up.  Re- 
covery followed. 

The  prolapsed  spleen  is  often  enlarged,  and  its  pedicle  may  get 
twisted.  Twisting  of  the  pedicle  and  dislocation  may  lead  to  symptoms 
of  chronic  or  acute  intestinal  obstruction,  from  interference  with  the 
colon.  I  have  operated  upon  one  case  in  which  a  diagnosis  of  intus- 
susception had  been  made,  the  twisted  and  prolapsed  organ  having  been 
mistaken  for  the  tumour  of  that  disease.     The  spleen  was  untwisted  and 

s. — vol.  11.  34 


530  OPERATIONS  ON  THE  ABDOMEN. 

replaced,  and  the  child  recovered.  No  sutures  were  used  to  fix  the  spleen, 
on  account  of  its  congested  state,  and  the  grave  condition  of  the  infant. 
OperatioD  is  far  more  satisfactory  here  than  in  most  other  morbid 
conditions  of  the  spleen,  as  shown  hy  the  statistics  of  the  last  decade 
which  are  given  by  Collins  Warren  (Ann.  of  Surg.,  1901,  vol.  i.  p.  521). 
During  this  period  43  cases  of  extirpation  of  wandering  spleen 
have  been  recorded  with  only  three  deaths. 

5.  Malignant  Disease. — Primary  sarcomatous  disease  of  the  spleen 
is  extremely  rare.  Up  to  the  year  1890,  five  cases  of  splenectomy  for 
sarcoma  were  reported  by  Hagen,  of  which  three  recovered  and  two 
died.  From  1891 — 1900  Warren  reports  five  further  cases,  including 
one  of  his  own,  of  which  four  recovered  and  one  died.  Jepson  and 
Albert  (Ann.  of  Surg.,  1904,  vol.  xl.  p.  80)  have  collected  32  cases, 
with  11  splenectomies  and  one  enucleation.  Three  of  the  11  patients 
died  from  the  operation,  and  three  of  recurrence.  Two  have  survived 
for  more  than  four  years. 

6.  Splenic  Ancemia. — This  condition  must  be  carefully  distinguished 
from  splenic  leukaemia.  The  latter  is  associated  with  marked  leucocy- 
tosis,  which  is  not  the  case  in  splenic  anaemia.  The  chief  symptoms 
are  splenic  hypertroph}',  gradually  increasing  anaemia,  of  the  secondary 
type  (leucopaenia),  and  a  tendency  to  haemorrhages.  Collins  Warren 
describes  a  case  in  which  the  disease  was  cured  after  removal  of  the 
spleen,  and  also  mentions  seven  cases  reported  by  Sippy,  five  of  which 
recovered  after  splenectomy.  Levison  (Ann.  of  Surg.,  vol.  xxxviii. 
p.  670)  records  a  successful  case,  and  refers  to  another  by  Harris  ; 
also  to  16  recorded  by  Maragliano  and  Terille  with  three  deaths,  two 
from  haemorrhage,  but  the  diagnosis  was  not  certain  in  either  of  these. 
Abortion  followed  the  operation  in  one  case,  and  curetting  proved  fatal. 

7.  Malarial  Spleen. — With  regard  to  the  question  of  operation  for 
this  condition  Collins  Warren  says  :  "  Quite  a  number  of  malarial 
spleens  have  been  removed  in  recent  years,  and  the  mortality  per 
cent,  of  the  operation  is  still  diminishing.  Hagen  has  collected  88 
cases  of  malarial  hypertrophy  of  the  spleen,  exclusive  of  wandering 
spleen.  Of  these  cases,  24  previous  to  the  year  1890  gave  a 
mortalit}7  of  62*5  per  cent.,  while  64  cases  operated  after  the  year 
1890  gave  a  mortality  of  23*4  per  cent.  When  we  consider  the  very 
large  size  that  the  organ  often  attains  in  this  disease,  and  the  unfavour- 
able constitutional  condition  of  the  patient,  such  results,  if  not  all  that 
we  could  hope  for  are  at  least  encouraging." 

8.  Leukamia. — This  operation  has  been  so  invariably  fatal  that  it 
ought  to  be  abandoned.* 

Operation. — The  preliminary  steps  will  be  directed  to  ensure  asepsis 
and  to  diminish  shock.  The  incision  has  usually  been  one  in  the  linea 
alba.  The  advantages  of  this  in  the  case  of  ruptured  spleen  have  been 
given  above.  For  other  cases,  that  near  the  linea  semilunaris,  or  one 
parallel  to  and  about  one  and  a  half  inches  below  the  left  costal  margin 
(vide  Fig.  211)  would  probably  give  better  command  over  the  pedicle. 
In  any   case  the  incision  must  be   made    free    enough    to    give   easy 

*  The  late  Mr.  Greig  Smith  gave  18  cases  ;  Mr.  Thornton,  13  ;  Mr.  Collier,  16 — 
all  fatal.     The  only  case  which  has  recovered — Franzolini's  of  Turin  ( Wien.  Med.  Woeh., 

1883,  No.  20) — is  considered  one  of  hypertrophy  by  Thornton,  Collier,  and  Cr< '■!.■. 


EXCISION    OF    TIIK    SPLEEN. 


53i 


access  to  the  pedicle  without  the  need  of  traction  upon  the  latter. 
Additional  room  may  he  gained  by  division  of  the  left  rectus.  All 
hemorrhage  having  been  stopped,  the  peritomeum  is  opened  freely  and 
the  hand  explores  the  tumour.  If  at  tins  stage  the  surgeon  is  satisfied 
that  tin'  adhesions  between  the  spleen  and  the  diaphragm  are  extensive 
and  intimate  he  will  do  well  to  close  his  wound.  If,  however,  it  is 
decided  to  proceed,  any  adhesions,  as  of  the  overlying  omentum,  are 
separated,  between  ligatures  if  needful.  Where  the  adhesions  are  very 
broad,  interlocking  chain-ligatures  must  be  employed.  In  a  very  few 
cases  the  use  of  the  thermo-cautery  may  be  justified.  Any  adhesions 
with  the  pancreas  are  very  difficult  to  deal  with.  Esmarch  and  Kowalzig 
advise  removal  of  a  portion  of  this  viscus.  The  spleen  is  next  brought 
out  of  the  wound,  the  lower  extremity  first,  and  sterile  gauze  is 
carefully  packed  around  it.     This    extraction  of  the  viscus  must  be 


Fig.  211. 


Pancreas. 


Kocker's. 

Mayo  Kobsorfs 
gall  bladder 
incision. 
Ureter 
In  pelvi9 


-  Spleen . 
Spleen. 

Ileo-siemoid- 

ostomy 

and  excision 

of  rectum. 


Incisions  for  exposing  the  spleen. 
The  incisions  for  various  other  operations  are  shown. 


carried  on  with  the  utmost  caution  and  gentleness,  as  its  friability  may 
easily  lead  to  a  tear  and  most  profuse  oozing,  and  as  dragging  on  the 
pedicle  may  easily  induce  collapse,  and  is  also  likely  to  lead  to  some 
small  vessel  retracting  from  the  ligatures  as  they  are  applied,  and 
causing  fatal  hemorrhage. 

The  spleen  being  wholly  outside  the  body,  the  most  important  part  of 
the  operation,  securing  the  pedicle,  remains.  The  lieno-renal  ligament 
and  the  gastro-splenic  omentum  have  to  be  tied.  Collins  Warren  finds 
that  the  remainder  of  the  operation  is  greatly  facilitated  if  the  spleen 
is  at  this  stage  rotated  forwards  so  that  the  posterior  surface  of  the 
organ  is  in  front.  A  better  view  of  the  pedicle  is  thus  obtained  without 
stretching,  and  the  application  of  ligatures  is  therefore  rendered  easier. 
The  pedicle,  if  present,*   must  now  be   carefully  examined.     If  the 


*  In  case  of  Mr.  L.  Browne's  (Lancet,  vol.  ii.  1877,  p.  310)  there  was  no  pedicle  as  such, 
four  very  large  arteries  being  met  with  and  secured  with  double  ligatures. 

34—2 


532  OPERATIONS   ON    THE   A.BLOMEN. 

patient' b  condition  is  good,  the  safest  plan  will  be  to  secure  the  vessels 
us  far  us  possible  separately,  the  pedicle  being  divided  as  the  late 
Mr.  Greig  Smith  suggested,  piecemeal  between  pressure-forceps;  where 
there  is  not  time  for  this,  it  will  be  wiser  to  secure  the  vessels  in  two 
or  three  portions,  transfixing  in  two  places,  and  interlocking  the 
ligatures  (Thornton),  hone-  damp-forceps  may  be  found  very  useful 
to  secure  and  hold  the  whole  pedicle  as  suggested  by  Mr.  Moynihan. 
I  have  used  intestinal  (lamps  in  one  case  to  arrest  profuse  bleeding  from 
the  severely  lacerated  spleen.  The  wide  pedicle  was  then  transfixed 
and  ligatured  between  the  clamp  and  the  stomach.  Sterilised  silk 
should  be  used,  fairly  stout,  and  not  tied  so  tightly  that  it  will  cut  its 
way  through  too  quickly.  However  the  pedicle  is  treated,  the  following 
precautions  should  be  followed  :  (i)  To  prevent  any  tension  being 
exerted  on  the  pedicle  (vide  supra).  (2)  To  secure  every  vessel. 
(3)  To  divide  these,  in  a  relaxed  condition,  at  a  sufficient  distance  from 
the  ligatures.  (4)  Not  to  include  the  tail  of  the  pancreas.  (5)  After 
all  the  ligatures  have  been  applied,  it  may  be  well  for  sake  of  safety  to 
throw  one  round  the  whole.  (6)  Not  to  twist  the  spleen  round  at  all 
in  dealing  with  the  pedicle.*  When  oozing  from  adhesions  is  very 
likely  to  take  place,  especially  when  a  large  gap  is  left  by  the  removal 
of  a  huge  spleen,  plugging  with  iodoform  gauze  after  the  method  of 
Mikulicz  will  be  advisable  (p.  339). 

The  abdominal  sac  is  next  cleansed  and  the  parietal  wound  completely 
closed  except  in  septic  cases  or  those  requiring  temporary  gauze  packing 
for  troublesome  oozing. 

Causes  of  Death. — By  far  the  most  frequent  is  haemorrhage.  This 
may  be  from  the  omentum  adherent  over  the  spleen,  from  the  large 
vessels  to  this  viscus,  from  some  small  vessel  which  has  retracted,  from 
the  splenic  vein,  or  from  sponge-like  adhesions  (Bryant). 

Mr.  Batch,  of  Bombay  {Lancet,  1889,  vol.  ii.  p.  1053),  met  with  ;i  case  in  which  death 
took  place  a  few  hours  after  the  splenectomy,  owing  to  oozing  from  some  adhesions 
between  the  spleen  and  the  diaphragm,  which  had  required  separation. f  The  pedicle 
was  safely  secured.  In  another  case  (Centr.  f.  Chir.t  July  18,  1885),  death,  twenty-four 
hours  after  the  operation,  was  due  to  bleeding  from  t  he  abdominal  incision,  owing  to  the 
defective  coagulation  of  leuksemic  blood.    The  ligature  on  the  pedicle  was  firm. 

The    after-treatment   of  post-operative    anaemia,    &c,    is   given    at 

P-  527- 

Splenopexy    or    Fixation   of   a   Wandering    Spleen. — This    is    an 

operation  which  is  rarely  required,  for  undue  mobility  of  the  spleen  is 

usually  only  a  part  of  Glenard's  disease,  when  it  can  be  best  treated  by 

means  of  abdominal  supports.     In  other  cases  the  mobility  is  due  to  an 

increase  of  size,  due  to  organic  disease,  which  may  or  may  not  require 

operative  treatment.     In  some  cases,  however,  a  wandering  Bpleen  may 

cause  pain,  sickness,  and  faintness,  and  may  prevent  the  patient  from 

leading  tin  active  life.     When  a  good  belt  has  been  well  tried  and  has 

failed  to  afford  relief,  an  operation  may  be  suggested. 

*  Sir  S.   Wells  (Med.    Time*  and  Gaz.,  Jan.  6,  18GG,  p.  4)  draws  attention  to  this. 
Having  done  so  in  order  to  bring  the  vessels  into  a  cord,  the  Bplenic  eein  was  ruptured. 
j   See  also  G.  A.  Wright's  case  [Med.  CAron.,  Dec.  1888).    Tins  surgeon  suggests  the 

of    a    long,  sharply-curved    tenaculum    for   stopping   bleeding    from  a  deeply-- 
ressel  in  the  bach  of  the  abdomen. 


EXCISION    OF   THE   SPLEEN.  533 

[n  suitable  cases  without  any  disease  of  the  spleen,  bul  only  undue 

mobility,  splenopexy  should  be  preferred  to  Bplenecl y,  and  it  ought 

to   be   more   free   of  immediate   danger  and  of  possible   changes   in 
nutrition  (p.  527)« 

Operation  has  only  been  adopted  in  a  few  cases  so  far,  and  in  th< 
B  different  method  1ms  been  invented  for  almost  every  patient. 

Mr.  J.  Basil  Hall  lias  contributed  an  interesting  article  upon  the 
Bubject  (Ann.  of  Sun/.,  vol.  xxxvii.  p.  481),  and  be  lias  recorded  a  case 
«>t'  bis  own  in  which  he  used  an  ingenious  method.  He  collected 
nine  cases,  including  his  own,  with  no  deaths,  but  since  then  a  few 
more  operations  have  been  performed.  The  following  are  some  of  the 
methods  that  have  been  employed. 

In  1895  Kouwer  (quoted  by  Basil  Hall)  used  a  lumbar  incision  and 
induced  the  formation  of  adhesions  by  means  of  tampons  placed  around 
it.  This  proved  successful  in  one  case,  the  spleen  being  well  fixed 
four  years  later.  The  tampons  had  to  be  removed  from  another  patient, 
because  they  produced  symptoms  of  intestinal  obstruction. 

Bydygier,  in  1895,  made  a  pouch  for  the  spleen,  between  the  parietal 
peritonaeum  and  the  diaphragm  upon  the  lateral  wall  of  the  splenic 
fossa;  this  he  performed  through  a  median  abdominal  incision. 

Tu  flier,  Giordano,  and  Greiffenbagen  have  passed  sutures  through 
the  parenchyma  of  the  spleen  and  the  parietes ;  severe  haemorrhage 
followed  in  Greiffenhagen's  case.  The  spleen  is  so  friable  that  all 
suture  methods  are  to  be  condemned. 

Bardenhauer  made  a  vertical  incision  in  the  left  flank,  and  separated 
the  peritonaeum  from  the  parietes.  He  then  brought  the  spleen  out 
through  a  small  opening  in  the  peritonaeum.  This  opening  was 
narrowed  round  the  pedicle,  so  that  the  spleen  was  retained  in  the 
subperitonaeal  tissues,  and  the  wound  closed  over  it. 

Basil  Hall  fixed  only  the  lower  part  of  the  viscus  in  the  wound  by 
narrowing  the  peritonaeal  incision  and  posterior  rectus  sheath,  so  that 
the  edges  gripped  the  spleen,  at  the  narrow  isthmus  formed  by  a  deep 
notch  upon  the  anterior  border  near  the  lower  pole.  He  also  promoted 
the  formation  of  adhesions  by  rubbing  the  peritonaeum  of  the  splenic 
fossa.  The  rectus  muscle  was  brought  over  the  prolapsed  part,  and 
the  wound  closed.     The  patient  was  completely  relieved. 


CHAPTER  IX. 
OPERATIONS  ON  THE  LIVER  AND  BILIARY  TRACTS. 

OPERATIONS  ON  THE  LIVER. 

HYDATIDS.— HEPATIC  ABSCESS.— REMOVAL  OF  GROWTHS 

OP  THE  LIVER. 

OPERATIONS   FOR  HYDATIDS. 

Incision  and  enucleation  will  be  described  ;  the  milder  measures  of 
puncture  and  electrolysis  proved  successful  in  many  cases,  but  we  do 
not  know  for  certain  how  the  death  of  the  parasite  was  brought  about 
by  them  in  successful  cases.  At  the  present  time  these  uncertain 
methods  have  been  rightly  abandoned,  although  they  were  useful  in 
pre-antiseptic  days,  when  they  were  much  safer  than  the  more  radical 
procedures.  The  surroundings  of  hydatids  of  the  liver  are  of  truly 
vital  importance,  and  sudden  death  has  followed  tapping  more  than 
once.  Thus,  in  Mr.  Bryant's  case  (Clin.  Soc.  Trans.,  vol.  xi.  p.  230), 
while  a  hydatid  cyst  was  being  tapped,  the  portal  vein,  which  had  been 
pushed  upwards  and  forwards  by  the  projection  of  the  cyst  on  the 
under-surface  of  the  liver,  was  transfixed.  Death  followed  in  five 
minutes,  and  was  thought  by  Dr.  Fagge  to  be  due  to  hydatid  fluid 
being  sucked  into  the  vein  as  the  trocar  was  withdrawn. 

In  a  Russian  case  (Lond.  Med.  Record,  1885,  p.  414)  the  pulse 
suddenly  stopped  while  the  cyst,  which  had  been  exposed  by  abdominal 
section,  was  being  stitched  to  the  incision.  At  the  necropsy,  a  crumpled 
echinococcus  had  made  its  way  into  the  right  auricle,  and  a  fragment 
of  one  into  the  right  division  of  the  pulmonary  artery,  by  an  opening 
between  the  thinned  cyst  and  the  inferior  vena  cava.  Mr.  Willett 
(Brit.  Med.  Journ.,  Nov.  13,  1886)  mentioned  a  case  in  which  he  had 
to  aspirate  a  doubtful  swelling  of  the  liver.  He  used  an  ordinary --sized 
needle,  and  within  two  minutes  the  patient  was  dead.  It  tinned  out 
to  be  a  case  of  malignant  disease.  No  large  vein  had  been  pricked, 
and  there  was  no  haemorrhage.  The  sudden,  fatal  syncope  seemed  due 
to  the  impression  made  on  the  nervous  system  through  the  solar 
plexus.  Several  other  deaths  from  syncope  have  been  recorded. 
Peritonitis,  empyema,  or  subdiaphragmatic  abscess  may  arise  from 
leakage  at  the  point  of  puncture  after  the  withdrawal  of  the  needle  or 
trocar.  Hydatid  infection  of  these  regions  may  also  occur  from  the 
same  cause.  Suppuration  in  the  sac  occasionally  took  place  even  after 
taking  all  precautions  against  infection  from  the  instruments  employed. 

(A)  Incision    and  Drainage. — Indications. — This  method   is  to  be 


OPERATIONS    FOR    HYDATIDS. 


535 


preferred  to  enucleation  when  suppuration  lias  occurred  within  or 
aiound  the  sac,  when  the  latter  is  calcareous  and  adherent  to  vital 
structures,  when  severe  haemorrhage  occurs,  when  it  is  important  to 
complete  the  operation  without  delay  on  account  of  pulmonary  com- 
plications, and  when  it  is  impossible  to  completely  remove  the  disease. 
It  may  be  carried  out  in  one  or  two  stages,  but  it  is  better  to  complete 
the  operation  at  one  sitting  if  possible.  The  operation  is  thus  per- 
formed :  The  parts  being  cleansed  and  the  other  preliminary  steps 
taken,  the  surgeon  makes  an  incision  about  four  inches  long  over  the 
most  prominent  part  of  the  swelling  (previously  carefully  percussed) 
down  to  the  peritonaeum.  This  incision  should,  if  possible,  be  made 
in  front.  Sufficient  access  may  be  usually  obtained  through  one  of 
the  incisions  used  for  exploration  of  the  gall  bladder  (vide  Fig.  211, 
p.  531).  Even  if  a  cyst  or  abscess  shows  its  greatest  point  of  pro- 
minence through  the  ribs,  it  should  not  be  opened  here  unless  it  is 
quite  certain  that  the  pleural  space  is  obliterated ;  moreover,  the 
large  drainage-tube  needful  necessitates  resection  of  a  portion  of  a 
rib.  In  rare  cases  the  thoracic  route  is  the  best,  when  the  hydatid  is 
placed  upon  or  near  the  convex  upper  surface  of  the  liver.  In  these  cases 
the  liver  may  be  reached  below  the  reflection  of  the  pleura,  which  may 
be  displaced  upwards  (vide  Fig.  212,  p.  538).  All  haemorrhage  is 
next  arrested,  and  the  peritonaeum  is  divided  and  secured  with  tissue 
forceps.  The  liver  is  now  recognised,  and  sterile  gauze  tampons  are 
carefully  packed  in  on  either  side  so  as  to  prevent  any  escape  of  fluid 
into  the  peritonaeal  sac  or  over  the  parietal  wound. 

The  needle  of  an  aspirator  or  a  fine  trocar  is  then  thrust  in,  and  the 
existence  of  fluid  beneath  thus  verified,  and  the  fluid  evacuated  as  far 
as  possible.  As  the  needle  is  withdrawn  the  liver  is  incised,  and  a 
finger  quickly  plugs,  and  then  enlarges  to  an  inch  and  a  half,  the 
opening  made  by  the  knife.  Haemorrhage,  if  free,  is  easily  arrested 
thus,  or  by  sponge-pressure.  Escape  of  fluids  into  the  peritonaeal  sac 
is  prevented  by  the  use  of  the  tampons  already  mentioned,  by  an 
assistant  keeping  the  edges  of  the  wound  carefully  adjusted  to  the  liver, 
and,  lastly,  by  the  next  step,  which  consists  in  hooking  up  the  opening 
in  the  liver  with  the  finger,  and  in  stitching  the  edges  of  the  wound  in 
the  liver  to  that  in  the  abdomen  with  a  continuous  suture  of  chromic 
gut.  While  inserting  this,  care  must  be  taken  to  unite  peritonaeum  to 
peritonaeum,  and  to  take  up  a  sufficiency  of  liver-tissue  by  inserting 
the  needle  well  away  from  the  edges  of  the  wound.  As  the  sutures  are 
inserted  the  tampons,  &c,  must  be  gradually  withdrawn,  and,  if  the 
fluid  escapes  very  freely,  it  may  be  well  to  turn  the  patient  over  on 
one  side.  Any  scolices  which  are  within  reach  are  next  removed,  and, 
if  the  cyst  is  firmly  stitched  and  the  patient's  condition  good,  the  con- 
tents and  wall  of  the  hydatid  ma}r  be  cleared  out  with  sponges  on 
holders,  aided  by  scoops.  All  handling  must  be  of  the  gentlest.  A  large 
drainage-tube  is  then  inserted,  and  the  usual  gauze  dressings  applied. 

Operation  by  Two  Stages. — An  incision,  four  inches  long,  is  made 
through  the  abdominal  wall  over  the  most  prominent  part  of  the  swell- 
ing. All  bleeding  having  been  carefully  stopped,  the  peritonaeum  is 
picked  up  and  slit  open.  The  liver,  recognisable  by  its  characteristic 
colour,  is  at  once  seen  moving  with  respiration.  To  make  certain  of 
the  position  of  the  fluid,  a  fine  trocar  may  be  now  thrust  in.     If  the 


OPERATIONS   ON    THE    ABDOMEN. 

cyst  be  crammed  with  acolices,  very  little  llui<l  escapes;  it  it  be  an 
acephalocyst,  the  fluid  may  s]>irt  out  under  the  high  pressure  nol 
infrequently  met  with.  After  a  few  ounces  have  been  withdrawn,  any 
Leaking  is  Btopped  by  sponge  pressure  or  Buture,  the  parietal  peritonaeum 
is  Btitched  to  the  edges  of  the  wound  by  a  few  points  of  catgut  suture, 
the  wound  plugged  with  strips  of  iodoform  gauze  wrung  out  of  carbolic 
acid  (i  in  20),  and  the  dressings  firmly  bandaged  on  with  a  good  deal 
of  pressure  so  as  to  keep  the  abdominal  wall  as  far  as  possible  in 
contact  with  the  liver.*  On  the  third  day  the  operation  is  completed 
by  incising  the  liver,  now  well  adherent, and  inserting  a  large  draining- 
tube.  I  have  operated  by  both  methods  on  patients  of  my  colleagues 
I>r.  Pye- Smith,  Dr.  ]•'.  Taylor,  and  Dr.  Newton  Pitt.  All  the  ca 
did  well,  though  in  two  the  complete  filling  up  of  the  cavity  w;is  very 
tedious.  One,  a  woman,  three  months  pregnant  at  the  time  of  the 
operation,  went  her  full  time  subsequently. 

(11)  Enucleation. — A  number  of  cases  in  which  the  cyst  has  been 
enucleated  from  the  liver  have  now  been  reported,  and  the  Buccess  met 
with  has  been  considerable.  Thus  Posadas  (Revue  de  <  'hirurgie,  March, 
1899,  p.  374)  reports  23  cases,  of  which  19  recovered,  and  four  died. 

This  method,  which  was  first  introduced  by  Mr.  Knowsley  Thornton 
(loc.  infra  <it.),  is  only  suitable  for  some  cases. 

The  tumour  is  exposed  by  a  free  incision,  and  isolated  from  the  rest 
of  the  peritoneal  cavity  by  means  of  tampons  of  iodoform  gauze.  After 
being  emptied  the  whole  endocyst  is  enucleated  from  the  ectocyst  and 
the  liver ;  the  cavity  in  the  latter  is  then  obliterated  as  far  as  possible 
by  means  of  catgut  sutures,  and  the  abdominal  incision  sutured  without 
drainage. 

This  operation  is  clearly  much  more  severe  than  incision  and 
drainage,  and  moreover  the  mortality  (over  17  per  cent.)  is  xt'iy  much 
too  high.  It  should,  therefore,  not  be  performed  except  under  special 
circumstances,  e.g.}  when  the  cyst  is  single,  small,  near  the  surface, 
and  not  suppurating  or  calcified. 

Pulmonary  complications  contra-indicate  this  operation,  and  s< 
haemorrhage  may  prevent  its  satisfactory  completion.  Reaccumulation 
of  fluid  within  the  cavity  has  occurred  in  a  number  of  cases,  and 
suppuration  in  a  few.  Secondary  drainage  may  have  to  be  resorted  to 
on  these  accounts.  Therefore,  it  is  wise  to  suture  the  liver  around 
the  incision  to  the  parietal  peritonaeum  before  closing  the  wound. 
This  also  protects  the  peritonaeum  from  risk  of  leakage  and  infection. 
Pedunculated  hydatid  cysts  originating  in  the  liver  have  been 
completely  excised. 

HEPATIC    ABSCESS.— HEPATOTOMY.f 

Tapping  by  a  trocar,  and  draining  the  abscess  by  the  cannula  left  in, 
or  a  drainage-tube  passed  through  the  cannula,  the  hitter  being  then 

*  One  case  bulged  out  the  right  lower  ribs  most   markedly.    For  reasons  al 
given,  1  preferred  to  attack  it  in  the  front  of  the  right  bypochondrinm.     On  exposing 
the  liver,  a  hydrocele  trocar  passed  through  an  incli  ami  an  half  of  hepatic  tissue  before 
fluid  was  reached.    Very  little  haanorrhage  followed  the  completion  of  the  second  stage  of 
the  operation. 

t  This  term  is  also  applicable  to  incision  of  the  liver  for  hydat 


HEPATIC    ABSCESS.— HEPATOTOMY. 


537 


withdrawn,   is  unsatisfactory,  for    the   following  : — (i)    The 

cannula    and  tube   may   slip   out.      (2)  The   drainage   is   inefficient. 

(3)  If  the   pus   leaks  into   the   periton&Bal    sac,   it   does   so   unseen. 

(4)  The  trocar  may  puncture  important  parts.  Thus,  in  one  case  of 
Mr.  K.  Thornton's  {Med.  Times  and  Oaz.,  1883,  vol.  i.  p.  89),  the 
omentum,  containing  large  veins,  lay  over  the  liver.  (5)  Puncture 
and  drainage  would  he  quite  insufficient  in  eases  where  more  than  one 
abscess  existed.  When  the  circumstances  are  not  favourable  for  a 
major  operation  and  skilled  assistance  is  not  available,  this  met  hod 
may  still  he  found  useful  for  deep  abscesses.  It  is  to  a  free  incision, 
however,  that  we  must  look  for  a  permanent  cure.  This  may  be 
employed  in  three  ways  : 

1.  Direct  incision  and  drainage,  when  tenderness,  cedema,  and 
redness  make  it  prohable  that  adhesions  exist.  This  needs  no  further 
comment.  2.  Incision  and  drainage  by  abdominal  section  in  two 
stages.  3.  Incision  and  drainage  by  abdominal  section  at  one  sitting. 
When  the  patient  is  anaesthetised  immediately  before  the  operation,  in 
doubtful  cases,  the  liver  should  be  explored  with  an  aspirating  needle 
of  medium*  size  over  any  suspected  area  or  through  the  eighth 
intercostal  space  in  the  axillary  line.  If  pus  be  found  the  operation 
should  he  at  once  proceeded  with. 

The  methods  of  treating  an  hepatic  abscess  by  abdominal  section, 
whether  in  one  or  two  stages,  have  already  been  spoken  of  at  p.  535, 
under  the  heading  of  Hydatids.  They  have  the  following  advantages 
over  other  modes  of  treatment: — {<()  The  benefit  of  a  free  incision  and 
thorough  drainage ;  (b)  the  surgeon  can  see  what  structures  he  is 
dealing  with  ;  (c)  bleeding  from  the  liver  can  be  seen  and  arrested ; 
(iJ)  pus  can  be  prevented  from  escaping  into  the  peritonaeal  sac  by 
packing,  &c. 

Very  little  need  be  said  here  of  the  treatment  by  abdominal  section 
in  addition  to  that  already  written  at  p.  535.  In  the  two-stage  method 
the  surgeon  will  open  the  peritoneal  sac,  suture  the  parietal  peritonaeum 
to  the  edges  of  the  wound,  insert  some  gauze,  and  endeavour,  by  well- 
adjusted  bandaging,  to  keep  the  abdominal  parietes  in  contact  with  the 
liver,  opening  the  abscess  on  or  after  the  third  da}'. 

In  the  method  by  direct  incision,  a  free  incision  of  four  or  five  inches 
is  made  and  the  parietal  peritonaeum  united  to  the  subcutaneous  tissues 
of  the  wound.  The  position  of  the  pus  having  been  verified  by  a  fine 
trocar  or  aspirator  needle,  tampons  of  iodoform  gauze  are  carefully 
packed  around.  The  abscess  is  then  incised,  and  the  opening  at  once 
plugged,  and  freely  dilated  with  the  finger.  Any  escape  of  pus  into 
the  peritonseal  sac  is  prevented  (1)  by  the  careful  packing  ;  (2)  by  the 
finger  hooking  up  the  liver  against  the  wound ;  (3)  by  an  assistant 
keeping  the  parietes  steadily  against  the  liver.  Haemorrhage  is  con- 
trolled by  forceps  or  sponge-pressure.     When  the  abscess  is  empty!  its 


*  It  is  essential  for  the  needle  to  be  of  good  size  to  allow  the  rather  thick  pus  to  flow. 
Sir  Patrick  Manson  advices  that,  ••  at  least,  six  punctures  be  made  before  the  attempt 
to  find  it  is  abandoned"  (Tropical  Diseases,  p.  369). 

t  The  late  Mr.  Grreig  Smith  (Abdorn.  Surg.,  p.  527)  advised  that,  if  the  abscess  does  not 
empty  itself  readily,  a  large  tube  lying  in  carbolic  lotion  may  be  pinched  at  the  end,  and 
when  placed  at  the  bottom  of  the  abscess  will  act  as  a  syphon.     He  also  draws  attention 


53« 


MPKIIATIOXS    ON    TIIK    AI'.DnMKX. 


opening  is  plugged  with  a  sponge,  and  the  liver  and  the  parietes  being 
still  kept  accurately  together,  the  tampons  first  inserted  are  removed, 
and  the  edges  of  the  liver  wound  stitched,  with  carbolised  Bilk  passed 
with  curved  needles  mm  holder,  to  the  edges  of  the  abdominal  incision, 
care  being  taken  to  keep  peritona?al  surfaces  well  in  contact.  A  large 
rubber  tube  is  passed  into  the  abscess  cavity  and  fixed  to  the  edges 
of  the  parietal  wound  by  means  of  a  salmon-gut  suture.  Care  must 
be  taken  not  to  pass  the  tube  too  far  in,  lest  it  cause  sloughing  from 
pressure  upon  the  wall  of  the  abscess,  which  may  be  thinly  separated 


Retracted 

muscles 


Diaphragm 


,#m 
»    - 


Exposure  of  the  diaphrngm  and  liver  through  the  thoracic  wall  below  the 
pleural  reflection  for  hepatic  and  subdiaphragmatic  abscess.  The  patient  lies 
on  his  diseased  side  in  the  semi-prone  position  to  avoid  interference  with  the 
action  of  the  healthy  lung,  and  to  prevent  any  chance  of  its  bronchi  becoming 
filled  with  pus  or  other  fluid,  which  may  escape  during  the  administration  of  the 
anaesthetic. 

from  the  peritonaeum  in  places.  A  considerable  thickness  of  dry  gauze 
dressings  will  be  needed  at  first,  and  will  require  frequent  renewal. 
This  will  be  facilitated  by  the  use  of  a  many-tailed  bandage. 

Treatment  of  Cases  of  Hydatid  or  Abscess  of  the  Liver  which 
have  opened,  or  which  threaten  to  open,  into  the  Chest. — I  refer 
here  to  those  grave  and  difficult  cases  where  a  hydatid  cyst  or  hepatic 
abscess,  instead  of  making  its  way  towards  the  abdominal  wall,  works 
upwards,   thrusting  up   the  base  of  the  lung.     Perhaps  the  first  few 

to  the  need  of  exploring  the  abscess  cavity  for  signs  of  a  second  abscess,  and,  if  this  be 
found,  opening  it  with  the  finger  or  dressing-forceps.  All  manipulations  now  must  be  of 
the  gentlest  for  fear  of  haemorrhage. 


HEPATIC    ABSCESS.— HEPATOTOMY.  539 

tappings  have  drawn  off  Quid  from  the  front,  but  after  this  the  cyst 
recedes  from  the  epigastric  region  as  in  Mr.  I  (wen's  case  (loc.  infra  cit.). 
In  other  and  rare  cases  the  cyst  or  abscess  has  been  opened  from  the 
front  or  the  side  through  the  abdomen, but  insufficient  drainage  is  ilms 
given.  In  such  cases  the  advice  given  on  p.  535  must  be  set  aside,  and 
the  fluid  must  be  drained  through  chest,  and  below  the  pleura  if 
possible,  in  order  to  avoid  the  development  of  pneumothorax,  and 
lessen  the  risk  of  infection  of  the  pleural  cavity  (Fig.  212). 

The  pleura  may  be  already  adherent  in  suppurative  cases.  It  may 
be  remembered  thai  the  lower  reflection  of  the  pleura  forms  an  oblique 
line  running  a  little  below  the  sixth  rib  in  the  nipple  line,  the  eighth 
rib  in  the  axillary,  the  tenth  in  the  parascapular,  and  the  eleventh  at 
the  spine.  An  incision  may  be  so  arranged  that  a  portion  of  one  or 
more  ribs  or  cartilages  may  be  removed  and  the  liver  exposed  through 
the  diaphragm  below  the  pleural  reflection,  which  may  be  displaced 
upwards  if  necessary.  The  same  plan  may  be  adopted  also  in  the 
treatment  of  subdiaphragmatic  abscess  as  recommended  by  Elsberg 
(Ann.  of  Surg.,  vol.  xxxiv.  p.  729). 

Mr.  Godlee  sutured  the  diaphragmatic  and  costal  layers  of  pleura* 
round  the  edge  of  an  aperture,  made  by  removing  a  portion  of  rib,  and 
then  opened  an  hepatic  abscess.  Mr.  Thornton,  treating  a  similar 
affection  with  a  view  of  obtaining  a  funnel  through  the  pleura,  along 
which  the  pus  could  escape  safely,  first  raised  the  parietal  pleura  all 
round,  so  as  to  get  a  little  free  edge,  then  made  a  very  careful  longi- 
tudinal incision  through  the  visceral  pleura,  raised  it  all  round,  and  then 
with  a  tine  curved  needle  united  the  two  layers  with  a  continuous  fine 
silk  suture.  A  channel  being  thus  made,  the  liver-abscess  was  opened 
b}r  a  curved  trocar,  the  puncture  converted  into  an  incision,  and  a  large 
drainage-tube  inserted.  Mr.  Owen,  in  the  case  of  a  hydatid  cyst  which 
encroached  upon  the  thorax,  incised  the  eighth  intercostal  space,  first 
behind  the  anterior  axillary  line.  As  soon  as  the  costal  pleura  was 
divided,  air  rushed  freely  in  with  a  very  audible  sound,  and,  the  finger 
being  introduced,  the  diaphragm  was  at  once  felt  bulging  up  along  the 
inner  surface  of  the  ribs,  while  the  lung  had  retired  beyond  reach. 
The  intercostal  space,  which  was  fairly  roomy,  was  forcibly  widened, 
but  it  was  not  thought  necessary  to  excise  a  piece  of  rib.  The 
phrenic  pleura  and  the  diaphragm  were  then  carefully  incised,  and  the 
abdominal  cyst  was  discovered.  A  certain  amount  of  its  contents  were 
withdrawn  by  aspiration,  so  as  to  relieve  its  tension,  and  to  permit 
of  some  of  the  face  of  the  sac  being  drawn  through  the  diaphragm,  and 
across  the  shallow  pleural  cavity  to  the  skin  wound,  to  which  it  was 
secured  by  four  harelip  pins.  The  serous  surfaces  thus  placed  in 
contact  were  found  firmly  adherent  on  the  fourth  day.  An  incision 
was  then  made  into  the  cyst,  and  a  drainage-tube  inserted.  All  three 
patients  recovered. 


*  Mr.  Godlee  (Brit.  Med.  Journ.,  1887,  vol.  ii.  p.  872),  Mr.  K.  Thornton  (ibid.  1886, 
vol.  ii.),  Mr.  Owen  (67m.  Soc.  Trans.,  vol.  xxi.  p.  78),  and  others  have  successfully  adopted 
this  course. 


54° 


OPERATIONS    ON    THE    ABDOMEN. 


REMOVAL    OF    PORTIONS    OF    THE    LIVER    FOR     NEW 

GROWTHS. 

This  operation  will  always  remain  a  rare  one  from  the  in  frequency 
of  growths  which  admit  of  removal.  Keen  (Ann.  of  Surg.,  Sept.  1899, 
p.  267)  has,  however,  collected  no  less  than  74  eases,  in  an 
important  paper  from  which  most  of  what  follows  has  been  gathered. 
The  mortality  has  so  far  been  only  14*9  percent.,  so  that  the  risk  of  the 
operation  is  certainly  not  a  very  serious  one.  Some  idea  of  the  variety 
of  tumours  that  have  been  removed  from  the  liver  may  be  obtained  from 
the  following  list  which  Keen  gives : — Constricted,  accessory,  or  her- 
niated left  lobe,  five  cases;  syphiloma,  12  cases;  carcinoma,  17 
cases:  adenoma,  seven  cases;  sarcoma,  five  cases;  angioma,  four 
cases  ;  cavernoma,  one  case ;  cystoma,  one  case ;  angio-fibroma,  one 
case;  small  calculi,  one  case;  endothelioma,  one  case;  hydatid  cysts, 
20  cases. 

Anschultz  (quoted  by  Haubold,  Ann.  of  Surf/.,  1904,  vol.  xxixx.  p.  243) 
in  1903  analysed  the  records  of  96  resections  of  new  growths  of 
the  liver.  Seventeen  died  from  the  operation ;  10  were  treated  by 
excision,  tamponade  and  pressure  with  one  death:  for  seven  the  thermo- 
cautery was  used,  and  all  recovered.  Of  25  in  which  deep  ligation  and 
excision  were  adopted,  two  died.  And  out  of  six  in  which  preliminary 
clamping  was  used,  two  died.  Of  21  done  by  intrahepatic  ligature 
and  excision,  six  died ;  and  of  24  in  which  the  elastic  ligature  was 
used,  six  died.  In  12^  per  cent,  of  the  cases  the  resected  mass  was 
gummatous  ;  two  of  these  patients  died.  The  ultimate  results  of  resec- 
tions for  malignant  growth  have  been  very  poor,  only  temporary  relief 
having  been  afforded,  and  some  delay  of  death  in  those  who  have 
survived  the  operation.  To  excise  a  gumma  of  the  liver  is  both 
unnecessaiy  and  unjustifiable,  except  perhaps  in  some  cases,  where 
preliminary  treatment  with  iodides  and  exploratory  operation  have 
failed  to  indicate  the  true  nature  of  the  tumour.  Lockwood  has 
successfully  removed  a  Iliedel's  lobe  for  the  relief  of  pain  (Lancet, 
July,  25,  1903). 

Ransohoff  {Med.  News,  April  16,  1904)  excised  a  mass  from  the  liver, 
which  upon  microscopical  examination  proved  to  be  tuberculous.  The 
elastic  ligature  was  used  but  this  cut  into  the  liver  and  caused  profuse 
haemorrhage  next  day.  The  growth  was  then  removed  with  the  cautery. 
The  patient  died  a  few  days  later  of  haematemesis  of  uncertain  cause. 

The  chief  difficulty  met  with  is  haemorrhage  ;  this  has,  however,  been 
satisfactorily  controlled,  either  by  isolating  the  tumour  by  means  of  an 
elastic  ligature  before  removal,  or  by  dividing  the  liver-substance  with 
the  cautery,  and  ligating  any  large  vessels  mei  with  while  this  is  being 
done.  Keen  removed  a  carcinomatous  left  lobe  weighing  one  pound 
and  five  ounces  from  a  man  aged  50,  by  the  latter  method,  which  he 
describes  as  follows  : — 

"  The  operation  was  done  entirely  with  the  Paquelin  cautery.  It 
took  from  twenty  to  thirty  minutes  to  sever  the  left  lobe  from  the 
remainder  of  the  liver.  The  haemorrhage  was  not  very  severe,  except- 
ing when  I  burned  into  some  of  the  larger  veins.  Each  of  these,  when 
opened,  I  was  able  instantly  to  close  by  my  left  forefinger.     Then, 


SURGICAL   TREATMENT   OF   CIRRHOSIS    OF   THE   LIVER.     5.41 

temporarily  laying  aside  the  cautery,  I  passed  a  catgut  ligature  under  each 
by  means  of  a  Hagedorn  needle,  and  one  of  my  assistants  tied  it  slowly 
but  firmly.  Five  ligatures  were  thus  applied.  Three  of  the  veins 
required  ligatures  of  both  of  the  divided  ends.  The  haemorrhage,  except 
from  these  large  veins,  was  arrested  by  the  Paquelin  cautery,  except 
that  occasionally,  when  I  laid  aside  the  cautery  to  apply  a  ligature, 
temporary  packing  with  iodoform  gauze  was  of  great  service  in  arrest- 
ing the  parenchymatous  haemorrhage."  The  cavity  left  was  partially 
occluded  by  means  of  sutures,  the  remainder  being  loosely  packed  with 
gauze.     Complete  recovery  took  place. 

In  other  cases  the  charred  surfaces  after  suturing  have  been  treated 
without  drainage  without  any  untoward  result. 

When  the  elastic  ligature  is  employed,  long  steel  pins  are  so  placed 
as  to  prevent  the  ligature  from  slipping,  and  the  tumour  then  removed 
half  an  inch  beyond  the  ligature.  The  wound  is  then  closed  round  the 
stump,  which  must  be  carefully  kept  aseptic.  In  a  case  treated  success- 
fully in  this  way  by  Mayo  Robson,  the  pedicle  left  was  as  thick  as  the 
wrist,  and  after  the  separation  of  the  slough  a  granulating  surface  was 
left.  This  gradually  contracted,  and  the  patient  made  a  good  recovery. 
One  of  the  best  ways  of  preventing  haemorrhage  is  to  isolate  the  growth 
by  means  of  stout  catgut  ligatures  passed  through  and  through  the 
liver  around  the  growth  before  the  latter  is  excised  (Anschultz). 


THE    SURGICAL    TREATMENT    OP    CIRRHOSIS    OF    THE 
LIVER    WITH    ASCITES. — EPIPLOPEXY. 

Professor  Talma  was  the  first  to  suggest  this  operation  in  1889,  "but 
to  Mr.  Rutherford  Morison  belongs  the  credit  of  having  brought  the 
first  case  to  a  successful  issue"  (Frasier,  Amer.  Joum.  Med.  Sci., 
December,  1900). 

Mr.  Morison  was  quite  unaware  that  anyone  had  previously  suggested 
and  already  performed  the  operation  when  he  first  tried  it,  and  published 
his  paper  in  the  Lancet  of  May  27,  1899. 

In  a  later  contribution  (Ann.  of  Surg.,  vol.  xxxviii.  p.  360)  Mr.  Ruther- 
ford Morison  gives  the  following  account  of  the  way  in  which  he  was 
led  to  operate. 

"  I  can  now  only  claim,  for  Dr.  Drummond  and  myself,  that  our 
views  and  treatment  were  entirely  independent  and  original.  His 
belief  was  that  in  certain  cases  of  cirrhosis  of  the  liver,  ascites  might 
be  prevented  by  an  increased  circulation  through  the  enlargement  of 
normal  channels  between  the  portal  and  systemic  veins.  Mine,  that 
if  his  explanation  was  correct,  it  might  be  possible  to  cure  ascites  by 
the  formation  of  a  new  and  accessory  circulation,  for  which  purpose  I 
devised  the  operation  described." 

The  normal  communications  between  the  portal  and  systemic  veins 
are  not  at  all  free,  and  are  practically  limited  to  two  situations  as 
between  the  gastric  and  oesophageal  veins  at  the  cardiac  end  of  the 
stomach,  whereby  blood  may  flow  from  the  portal  system  into  the 
azygos  veins  and  superior  vena  cava.  Sometimes  these  veins  may 
greatly  enlarge  in  alcoholic  cirrhosis,  and  may  rupture  into  the 
oesophagus  and  lead  to  fatal  haemorrhage. 


542  OPERATIONS   ON    THE   ABDOMKX. 

(b)  Between  the  superior  hemorrhoidal  tributaries  and  those  of  the 
middle  and  inferior  hemorrhoidal,  whereby  portal  blood  may  reach 

the  iliac  and  even  the  axillary  and  subclavian  veins  through  the 
superficial  and  deep  epigastric  veins. 

So  far  there  is  very  little  evidence  that  any  considerable  venous 
anastomosis  takes  place  through  the  adhesions  formed  between  the 
omentum,  liver,  or  spleen  and  the  parietes,  although  it  is  stated  that 
"  in  the  case  operated  upon  by  Lens  venous  channels  were  easily  found 
in  the  new  adhesions  which  had  formed  between  the  omentum  and  the 
parietal  peritonaeum  (Moynihan,  Abdominal  Operations). 

It  is  more  than  probable  that  any  good  which  may  follow  the 
operations  which  have  been  designed  for  establishing  vascular  anasto- 
mosis is  really  due  more  to  the  drainage  carried  out  at  the  same  time, 
and  to  the  interference  with  the  secreting  function  of  the  hepatic  and 
splenic  peritonaeum. 

Indications. — In  view  of  some  undoubted  recoveries  which  have 
followed  it,  the  operation  of  epiplopexy  is  certainly  worthy  of  con- 
sideration, especially  when  the  grave  prognosis  of  alcoholic  cirrhosis 
under  medical  treatment  is  remembered.  It  is  a  mistake  to  think, 
however,  that  the  disease  is  always  fatal  even  after  ascites  has  developed, 
and  recovery  ma}'  follow  paracentesis  in  a  few  cases. 

Epiplopexy  should  certainly  be  reserved  to  early  cases  either  before 
or  soon  after  the  onset  of  ascites ;  and  in  the  absence  of  general 
debility,  cardiac  or  renal  disease  and  jaundice.  Immediate  cholaemia 
and  early  death  followed  the  operation  in  an  early  case  under  the  care 
of  Dr.  Fawcett,  at  Guy's  Hospital.  The  patient  seemed  to  be  a  favour- 
able one  for  the  operation,  which  was  performed  soon  after  the  develop- 
ment of  ascites.  And  in  many  other  cases  the  results  have  been  the 
same.     Death  may  occur  from  shock,  cholaemia,  infection,  or  exhaustion. 

If  the  operation  is  advised  at  all,  the  immediate  dangers  and  the 
poor  prospect  of  permanent  relief  should  be  honestly  explained  to 
those  who  have  the  ultimate  responsibility  of  deciding  for  or  against  it. 

Operation. — The  abdomen  is  opened  under  general  or  local 
anaesthesia ;  the  former  is  not  sufficient  in  some  cases,  but  the  latter 
is  especially  dangerous  in  these  cachectic  patients.  The  incision  is 
made  above  the  umbilicus  and  near  the  middle  line,  a  valvular 
wound  being  adopted.  The  fluid  is  drained  and  mopped  away  until 
the  peritonaeum  is  rpuite  dry.  As  far  as  possible  the  peritonaea!  surfaces 
of  the  liver,  spleen,  and  parietes  are  roughened  by  gauze  friction,  and 
the  great  omentum  is  extensively  sutured  to  parietal  peritonaeum  which 
has  been  rawed  by  friction.  Catgut  is  the  safest  suture  material  to 
use.  Drainage  may  be  established  through  a  stab- wound  carefully 
made  above  the  bladder  and  pubis,  but  unless  great  care  be  taken 
this  may  lead  to  septic  infection  sooner  or  later,  and  for  this  reason 
some  surgeons  jn'efer  to  dispense  with  it.  The  upper  wound  is  carefully 
sutured  in  overlapping  layers  in  order  to  avoid  ventral  hernia. 

The  omentum  has  been  fixed  in  the  parietal  wound  in  some  cases, 
but  this  is  not  to  be  recommended  on  account  of  the  danger  of  hernia. 
Schiassi  makes  a  vertical  incision  a  little  below  the  left  costal  margin 
opposite  the  middle  of  the  clavicle,  and  another  one  running  outwards 
from  the  upper  end  of  the  first  incision.  A  triangular  flap  consisting 
of  all  the  tissues  down  to  the  peritonaeum  is  then  raised,  and  a  vertical 


SURGICAL   TREATMENT   OF   CIRRHOSIS  OF   THE    LIVER. 


543 


incision  made  in  the  peritonaeum.  The  spleen  and  great  omentum  are 
withdrawn  sufficiently  to  allow  the  surgeon  to  fix  them  in  the  wound, 
which   is  then  sutured. 

Results. — Mr.  Morison's  first  case,  like  others  before  it,  was 
unsuccessful,  but  the  next,  a  woman,  was  relieved  of  her  ascites  and 
survived  for  two  years,  when  she  died  from  an  operation  undertaken 
for  ventral  hernia,  the  result  of  the  former  operation.  Another 
successful  case  recorded  by  the  same  surgeon  is  quoted  in  detail  below. 
Sinclair  White  also  records  two  successful  operations,  the  patients 
being  both  well  a  year  after  the  operation  (Brit.  Med.  Journ.,  Oct.  10, 
1903).  On  the  whole,  however,  the  operation  cannot  be  said  to  have 
been  a  success.  Out  of  105  cases  collected  by  Greenough,  the 
mortality  was  29*5,  and  only  nine  showed  improvement  after  two 
years. 

.Out  of  six  cases  recorded  by  Harris  five  died  within  a  month  of  the 
operation,  and  the  other  one,  probably  a  syphilitic  case,  was  alive  but 
unrelieved  after  five  months.  It  is  fair  to  state  that  all  these  patients 
were  in  advanced  stages  of  their  disease  at  the  time  of  the  operation. 

Koslowski  found  that  46  per  cent,  of  168  cases  were  either  improved 
or  cured  after  the  operation. 

Monprofit  (quoted  by  Moynihan)  collected  224  cases,  in  213  of 
which  the  results  were  known.  About  20  per  cent,  died  from  the 
operation,  and  about  20  per  cent,  died  subsequently  from  cachexia  or 
concomitant  disease.  Recurrence  of  the  effusion  took  place  in  about 
12  per  cent.  Improvement  occurred  in  a  little  over  12  per  cent.,  and 
recovery  in  about  33  per  cent. 

It  may  be  safely  concluded  that  these  results,  which  refer  to  pub- 
lished cases,  are  far  better  than  the  real  results  of  the  operation,  many 
failures  being,  as  usual,  buried  in  oblivion. 

There  is  not  enough  evidence  available  at  present  to  enable  us  to 
arrive  at  any  accurate1  conclusion  concerning  the  place  and  value  of  this 
operation,  which  is  still  decidedly  upon  its  trial. 

The  following  is  a  case  of  undoubted  cirrhosis  of  the  liver,  in 
which  a  brilliant  recovery  followed  an  operation  by  Mr.  Rutherford 
Morison  : — 

The  patient  was  an  alcoholic  man,  aet.  52,'who  had  been  tapped  14  times,  18  gallons 
and  i\  pints  of  fluid  having  been  withdrawn  in  all,  but  without  any  permanent  relief. 
Medical  treatment  and  paracentesis  having  failed,  the  patient  was  admitted  into  the 
surgical  wards  of  the  Koyal  Infirmary,  Newcastle-upon-Tyne.  The  following  account  is 
taken  from  the  Ann.  of  Surg.,  vol.  xxxviii.  p.  360  :  "  On  admission  to  the  surgical  ward 
his  condition  was  described  as  follows  :  He  was  a  thin  man  with  sallow  complexion, 
sunken  cheeks,  and  yellow-tinted  conjunctiva,  his  tongue  was  clean  and  moist,  appetite 
fairly  good,  arteries  slightly  atheromatous,  pulse  ninety-two,  and  temperature  normal.  No 
jaundice  or  other  disease  discovered  beyond  what  follows.  His  abdomen  was  much 
distended,  and  the  physical  signs  were  those  of  a  large  collection  of  free  fluid  ;  the  left 
side  of  the  scrotum  was  swollen  from  fluid  distending  a  hernial  sac.  Dilated  subcutaneous 
veins  were  visible,  starting  from  the  neighbourhood  of  the  umbilicus,  and  terminating  in 
one  large  trunk  on  either  side,  which  ran  up  over  the  chest  into  the  axilla.  The  direction 
of  the  blood  current  was  ascertained  to  be  from  below  upward.  Percussion  showed  an 
increased  splenic  and  diminished  liver  dulness.  There  was  some  oedema  of  the  feet  and 
legs  extending  as  far  as  the  middle  of  the  calf.  On  Aug.  29, 1899,  the  patient  was  operated 
upon,  under  chloroform.  An  incision  about  four  inches  long  opened  the  abdomen  between 
the  ensiform  cartilage  and  the  umbilicus.     The  subperitoneal  fat  was  vascular,  and  bled 


544  OPERATIONS   ON   THE   ABDOMEN. 

freely.  A  large  amount  of  clear  straw-coloured  fluid  escaped  as  soon  as  the  peritonaeum 
was  divided.  A  second  opening  was  next  made  between  the  umbilicus  and  tlic  pubis 
large  enough  to  admit  a  half-inch  diameter  glass  drainage  tube,  which  passed  through 
and  into  the  pelvis.  Some  adhesion  was  present  between  the  liver  and  the  omentum, 
and  between  the  omentum  and  the  abdominal  wall.  The  liver  was  firm,  finely 
granular  on  the  surface,  and  of  about  normal  size.  The  spleen  was  hard  and  enlarged 
to  at  least  double  its  normal  size.  The  abdominal  cavity  was  dried  with  sponges,  special 
care  being  taken  to  rub  the  surface  of  the  visceral  peritonaeum  opposed  to  them.  The 
omentum  was  fixed  across  the  anterior  abdominal  wall  by  catgut  sutures.  The  upper 
incision  was  entirely  closed  by  catgut  sutures.  The  lower  was  kept  open  for  a  drainage 
tube,  through  which  the  fluid  was  pumped  out  of  the  pelvis.  Over  the  dressings,  broad 
long  strips  of  adhesive  plaster  were  applied  transversely  from  the  chest  above  to  the 
drainage-tube  opening  below.  This  was  for  the  purpose  of  keeping  the  upper  part  of  the 
abdominal  cavity  empty  of  fluid  and  the  parietal  closely  applied  to  the  visceral  peritonaeum. 

"Two  nurses,  with  a  reliable  knowledge  of  antiseptic  wound  treatment,  were  told  off 
to  look  after  the  tube,  and  keep  any  fluid  from  collecting  in  the  pelvis  or  from  escaping 
on  to  the  dressings.  The  operation  was  well  borne,  and  his  recovery  straightforward." 
From  ten  to  twenty  ounces  of  fluid  were  removed  daily  for  the  next  fortnight  or  more, 
but  on  October  10  the  tube  was  left  out,  for  there  was  no  fluid  coming  through  it. 
Three  weeks  later  he  was  readmitted  and  230  ounces  of  liquid  were  removed. 

"  January  3,  1900  :  Better  ;  signs  of  very  little  fluid  in  belly.  From  this  date  there  was 
no  further  accumulation  of  fluid,  and  at  the  present  time  (February,  1903)  he  is  very  well, 
never  looked  better,  is  fat  and  strong,  and  has  a  good  appetite.  There  are  no  signs  of 
fluid  in  the  abdomen.  The  veins  in  the  abdominal  wall  are  very  large  ;  lie  complains  of 
some  dragging  pain  in  the  abdomen  ;  the  liver  can  be  felt  adherent  to  the  abdominal 
wall "  (note  by  Mr.  G.  Grey  Turner,  Surgical  Registrar). 


OPERATIONS  ON  THE  BILIARY  TRACTS:  CHOLECYSTOS- 
TOMY  —  CHOIiECYSTOTOMY  —  CHOLEDOCHOTOMY  — 
CHOLECYSTENTEROSTOMY  —  CHOLECYSTECTOMY  — 
TREATMENT   OF  BILIARY  FISTULA. 

As  the  indications  for  these  operations  are  nearly  always  gall-stones 
or  their  complications,  it  will  he  well  first  to  briefly  consider  the 
different  sites  in  which  biliary  calculi  are  met  with  and  the  chief 
evidence  hy  which  they  may  be  differentiated,  it  being  always  under- 
stood that,  as  several  of  the  following  conditions  may  coexist,  the 
symptoms  to  which  a  group  of  gall-stones  in  one  position  gives  rise 
often  runs  into  those  of  another,  (i)  The  calculus  or  calculi  arc  in  the 
gall-bladder.  The  symptoms  here  will  be  chiefly  recurrent  attacks  of 
colic,  or  a  dull  aching  pain  associated  with  local  tenderness  and  often 
with  pyrexia.  No  swelling  may  be  present  unless  a  calculus  exists 
lower  down,  and  for  the  same  reasons  there  will  be  no  jaundice. 
(ii)  The  stone  or  stones  are  in  the  cystic  duct.  Here  there  will  be  colic, 
and  presence  of  a  swelling  having  the  characters  of  a  distended  gall- 
bladder. Jaundice  is  as  a  rule  absent,  but  if  a  calculus  in  the  cystic 
duct  makes  pressure  on  the  common  hepatic  duct  this  point  of  guidance 
will  be  lost,  (iii)  The  calculus,  one  or  more,  occupies  the  common  duct. 
This,  according  to  the  duration  of  the  mischief,  will  be  more  or  less 
dilated,  and  the  same  applies  to  the  tracts  behind,  unless  other  calculi 
are  present  here.  In  addition  to  colic,  jaundice  will  be  present,  and  if 
adhesions  are  forming,  if  any  ulceration  or  septic  process  is  going  on, 
pyrexia  may  be  present  also.  The  gall-bladder,  as  pointed  out  by 
Mr.   Terrier,   Mr.   Mayo  Robson,  and  others,   is  usually  contracted, 


CHOLECYSTOSTOMY. 


545 


shrunken,  and  matted  down  by  adhesions  in  these  cases,  so  that  no 
tumour  will  be  present.  Should  distension  of  the  gall-bladder  be  present 
in  association  with  the  symptoms  mentioned  above,  it  is  to  be  looked 
upon  as  pointing  rather  to  malignant  disease  than  to  the  presence  of 
gall-stones.  Other  points  which  may  help  in  deciding  between  these 
two  conditions  are  the  time  the  trouble  has  lasted,  the  persistency  of 
jaundice,  and  the  age  and  general  condition  of  the  patient. 

Mr.  Mayo  Robson  (Diseases  of  the  Gall-bladder  and  Bile-ducts) 
points  out  that  calculi  are  more  often  situated  in  the  common  bile- 
duet  than  has  been  hitherto  supposed,  having  found  this  condition  in 
39*4  per  cent,  of  his  operations  performed  for  gall-stones.  The 
same  author  also  draws  attention  to  the  very  important  fact  that 
multiple  calculi  in  the  common  duct  are  more  frequent  than  solitary 
ones,  (iv)  Very  rarely  stones  may  form  in  the  hepatic  ducts,  but  this 
is  nearly  always  secondary  to  obstruction  of  the  common  bile-ducts. 

In  addition  to  the  above  it  must  be  remembered  that  gall-stones  are 
generally  associated  with  inflammatory  complications,  which  vary 
greatly,  both  as  regards  the  parts  involved  and  the  intensity  of  the 
process.  Even  in  the  most  simple  cases  some  degree  of  adhesion  from 
local  peritonitis  will  be  present,  and  in  the  more  complicated  cases  the 
difficulties  that  the  operator  may  have  to  face  may  be  extreme.  Some 
of  these  will  be  referred  to  later  in  the  accounts  of  the  various  opera- 
tions. The  following  may  be  mentioned  as  some  of  the  special  compli- 
cations of  gall-stones  that  may  call  for  surgical  intervention: — Empyema 
of  the  gall-bladder,  abscess  around  the  gall-bladder  or  bile-ducts,  sup- 
purative cholangitis,  chronic  catarrhal  inflammation  of  the  gall-bladder 
and  bile-ducts,  and  phlegmonous  cholecystitis. 

An  operation  for  gall-stones  is  usually,  in  the  first  instance,  under- 
taken for  exploratory  purposes,  the  special  operation  which  is  called  for 
being  then  undertaken,  according  to  the  conditions  found  to  be  present. 
The  steps  of  the  exploration  will  therefore  be  first  described,  and  the 
details  of  the  separate  operations  given  subsequently. 

As  a  prophylactic  against  the  troublesome  hasmorrhage  which  is 
liable  to  attend  operations  upon  patients  suffering  from  jaundice,  Mayo 
Robson  {Diseases  of  the  Gall-bladder  and  Bile-ducts)  recommends  the 
administration  of  chloride  of  calcium.  He  prescribes  thirty-grain 
doses  every  four  hours  for  a  few  days  before  operation,  and  continues 
the  administration  for  some  time  after  the  operation,  giving  it  either  by 
the  mouth  or  per  rectum.  Neither  this  nor  gelatin  have  been  found 
to  have  any  certain  effect  in  lessening  the  bleeding,  and  the  only  reliable 
method  of  avoiding  it  is  by  prompt  ligation  of  all  bleeding  vessels 
during  the  operation. 

Operation. — The  patient  is  prepared  in  the  usual  way,  and  the  skin 
is  thoroughly  cleansed  and  compressed  on  the  preceding  day.  Every 
precaution  is  taken  against  shock.  In  order  to  render  the  parts  more 
accessible,  Mayo  Robson  (loc.  supra  cit.)  places  a  firm,  narrow  sand-bag 
under  the  patient's  back  at  the  level  of  the  liver.  This  brings  the 
common  duct  two  to  three  inches  nearer  to  the  surface,  and  also  tends 
to  open  out  the  costal  angle,  and  displace  the  intestines  downwards 
away  from  the  liver. 

Moynihan  (Abdominal  Operations,  p.  516)  also  advises  tilting  of  the 
table  so  that  the  patient's  head  is  several  inches  higher  than  his  feet. 

s.— vol.  11.  35 


54r> 


•  ■IT.KATIONS    ON    Till!    Al!l»«  »M  K.V 


The  anaesthetic  will  usually  be  the  A.C.E.  mixture  or  chloroform, 
ether  being  un  suited  to  many  of  these  patients,  often  middle-aged  and 
stoul  and  flabby,  and  the  subjects  ofchronic  bronchitis.  The  abdomen 
having  been  cleansed  again,  one  of  the  following  incisions  is  made  use 

of: — (i)  A  vertical  one,  over  the  prominence  of  any  swelling  present, 
or  straight  down  from  the  tip  of  the  cartilage  of  the  ninth  rib  through 
the  outer  part  of  the  sheath  and  fibres  of  the  rectus  muscle.  It  should 
be  four  inches  long  to  begin  with,  and  should  he  prolonged  down  to  the 
level  of  the  umbilicus  if  more  room  is  wanted  for  the  exploration  of  the 
common  duct.  This  incision,  if  the  wound  be  widely  retracted,  will 
answer  in  nearly  all  cases.  Where  the  adhesions  are  very  difficult  to 
deal  with,  more  room  may  be  got  by  adding  to  an  oblique  incision 


Fig.  213. 


Pancreas. 


Kocker'a. 

Mayo  Robsorfs 
gall  bladder 
incision. 
Ureter 
in  pelvis. 


Ileo-sigmoid.- 

ostomy 

and  excision 

of  rectum. 


Incision  for  exposing  the  gall-bladder  and  bile-ducts.     Various  other  incisions 

are  shown. 


carried  inwards  along  the  margin  of  the  ribs  at  its  upper  extremity 
(vide  Fig.  213). 

Dr.  Bevan  (Ann.  of  Surg.,  vol.  xxx.  p.  17)  prolongs  the  incision, 
horizontally  outwards  at  its  lower  end,  but  this  step  is  rarely  necessary. 

In  stout  patients  it  is  an  advantage  to  make  the  wound  in  the  skin 
and  subcutaneous  fat  more  extensive  than  the  deep  part  through  the 
muscle  as  recommended  by  Movnihan.  The  flabby  superficial  layers 
then  fall  away  and  diminish  the  depth  of  the  wound. 

Professor  Kocher  uses  an  oblique  incision  about  four  inches  long, 
running  one-and-a-half  inches  below  and  parallel  to  the  costal  margin, 
and  with  its  centre  a  little  external  to  the  outer  border  of  the  rectus. 
This  gives  a  very  good  view  and,  from  its  high  position,  it  is  not  likely 
to  be  followed  by  ventral  hernia,  if  care  be  taken  in  suturing,  although 
muscle  fibres  and  nerves  are  cut  across  (Fig.  213). 

Mayo  Robson's  incision  is  preferable  and  gives  sufficient  room  in 
nearly  all  cases.*     Any  vessels  which  need  it  are  secured  with  chromic 

*  Another  useful  incision  which  is  always  employed  by  some  operators,  and  which  is 
excelleutly  suited  for  those  cases  where   much  difficulty  is  expected,  is  a  transverse  or 


CFloLKfYSTOSTOMY. 


547 


gut.  The  posterior  layer  of  the  rectus  Bheath  and  the  peritonsBum  are 
incised  together  without  any  attempl  to  separate  them  from  one  another. 
A  gnu/..'  pack  is  placed  in  the  righl  kidney  pouch  to  catch  any  fluid  thai 


Fio.  214. 


LAver 


Common  Me  duct 
with  stone  in  it 


Duodenum. 


Hepatic  duct 


Biliary  papilla 


Exploration  of  the  gall-bladder  and  bile-ducts.     Choledochotomy  and 
duodeno-choledochotomy. 

may  be  set  free  ;  and  an  aseptic  pad  is  inserted  at  the  lower  and  inner 
part  of  the  wound  to  protect  the  stomach  and  intestines  {vide  Fig.  214). 

curvilinear  one,  starting  a  little  below  the  tip  of  the  ninth  rib,  at  the  outer  edge  of  the 
rectus,  and  passing  in  a  transverse  or  curvilinear  direction  into  the  loin;  if  extra  room  is 
needed  it  may  be  carried  as  far  as  the  outer  edge  of  the  quadratus  lumborum.  This  gives 
the  best  access  of  all,  but  we  must  wait  for  the  results  of  cases  which  have  been 
adequately  watched  before  we  can  accept  as  certain  the  statement  that  the  transverse 
incision  is  no  more  likely  to  be  followed  by  a  ventral  hernia  than  is  the  vertical  one,  because 
it  is  in  the  upper  and  firmer  part  of  the  abdominal  wall.  This  incision  is  recommended  by 
Mr.  R.  Morton,  of  Newcastle-on-Tyne  (Ann.  of  Surg.,  August,  1895.  p.  181).  He  gives 
the  credit  of  it  to  Dr.  John  Duncan,  of  Edinburgh.  Besides  the  excellent  access  which 
the  incision  gives,  there  is  another  advantage  which  will  be  given  when  the  subject  of 
drainage  is  considered.  This  incision  is  practically  the  same  as  Courvoisier's,  much  used 
on  the  Continent  and  in  America — viz.,  an  incision  about  ten  inches  long,  running  obliquely 
parallel  to  the  lower  border  of  the  right  ribs,  and  about  half  an  inch  below  them,  with  its 
centre  lying  over  an\r  swelling  that  is  present. 

35—2 


548  OPERATIONS   ON    THE   iLBDOMEN. 

The  gall-bladder  and  bile-ducts  are  then  carefully  explored,  with  a 
view  of  deciding  us  to  the  further  measures  ilutt  may  be  necessary. 

Omental  and  other  adhesions  generally  require  separating,  and  in 
doing  this  greal  care  must  be  taken  to  arrest  all  haemorrhage  and  to 

avoid  lacerating  any  of  the  adherent  viscera. 

[f  possible,  the  liver  should  he  pulled  downwards  and  forwards  into 
the  wound,  and  then  tilted  so  that  its  lower  surface  is  displayed,  as 
recommended  by  Mr.  Mayo  Robson  (/<»•.  supra  cit.).  The  assistant 
should  hold  the  tilted  anterior  border  of  the  liver  and  the  gall  bladder, 
while  the  surgeon  examines  the  bile  ducts  which  are  thus  brought  well 
for wa ids  into  view  (vide  Fig.  214). 


CHOLECYSTOSTOMY. 

If  the  gall-bladder  is  distended  and  free  from  adhesions,  it  is  isolated 
by  means  of  sterile  gauze,  then  aspirated  and  opened. 

If,  on  the  other  hand,  the  gall-bladder  is  small  and  shrunken  and 
imbedded  in  adhesions,  these  must  now  he  dealt  with.  The  difficulties 
met  with  here  may  be  due  merely  to  omentum  or  distended  intestines 
concealing  the  gall-bladder,  or  adhesions  may  have  taken  place  about 
this  structure  to  a  varying  degree.  The  following  case  of  Mr.  Robson 's 
is  a  good  instance  of  the  difficulties  which  may  be  met  with  : 

The  tumour  on  being  exposed  "  seemed  to  be  composed  of  liver,  gall-bladder,  stomach, 
and  omentum  matted  together.  No  fluctuation  could  be  made  out,  and  the  tumour 
seemed  so  firm,  hard,  and  nodulated  as  to  give  the  impression  of  being  malignant.  An 
exploring  syringe  pushed  deeply  into  the  swelling  simply  withdrew  a  little  blood  I  but  on 
pushing  the  needle  through  the  overlapping  edge  of  the  liver,  in  the  direction  of  the 
cystic  duct,  pus  was  withdrawn.  On  attempting  to  separate  the  liver  from  what  was 
supposed  to  be  the  gall-bladder,  pus  began  to  well  up,  but  fortunately  none  of  it  escaped 
into  the  peritonaeal  cavity,  as  sponges  had  been  packed  round  the  opening.  On  dilating 
the  opening  sufficiently  to  admit  the  finger,  gall-stones  were  at  once  felt,  one  of  which, 
about  the  size  of  a  small  walnut,  was  easily  removed  ;  the  second,  impacted  in  the  cystic 
duct,  broke  in  removal,  leaving  the  distal  portion  still  within  the  duel  :  this  was  removed 
with  considerable  difficulty,  as,  on  account  of  the  matting  of  the  parts,  the  linger  could 
not  be  passed  beyond  the  cystic  duct  to  aid  in  its  expulsion  ;  after  its  removal  the  index 
finger,  on  being  pushed  into  the  duct  as  far  as  possible,  discovered  another  impacted  stone, 
which  it  was  found  impossible  to  remove.  As  the  sequel  showed,  this  was  perhaps  rather 
a  happy  circumstance,  for,  on  account  of  the  depth,  the  friability,  and  the  adhesions  of  the 
gall-bladder,  it  was  found  impossible  to  suture  it  to  the  surface,  as  the  Btitchee  would 
not  hold  ;  hence,  after  the  suppurating  cavity  had  been  washed  out  with  a  solution  of 
fiuosilicate  of  soda  (gr.  x.  —  Oj)  and  a  drainage-tube  inserted,  the  upper  and  lower 
ends  of  the  incision  were  drawn  together  by  silk  sutures  so  as  to  somewhat  limit  the 
opening.  The  peritonaeal  cavity  was  left  freely  open,  two  Bponges  being  placed  on 
each  side  the  opening  into  the  gall-bladdei  so  as  to  absorb  any  discharge  (lowing  out  of  it. 
They  were  at  first  changed  every  two  hours,  antiseptic  precautions  being  adopted. 
At  the  end  of  two  days  they  were  removed,  one  being  simply  applied  directly  over 
the  drainage-tube,  so  as  to  press  the  parietal  peritonaeum  into  contact  with  the 
visceral." 

The  patient  made  a  complete  recovery. 

In  some  cases  the  gall-bladder  may  be  actually  buried  in  adhesions, 
involving  such  structures  as  the  abdominal  wall,  omentum,  duodenum, 
and  pylorus.  The  liver  must  be  tilted  and  the  intestines  held  aside 
with  gauze  tampons,  so  arranged  as  to  shut  off  the  general  peritonaeal 


CIIOLI'X'YSTOSTOMY. 


549 


sac.  A  gauze  pack  must  always  be  placed  in  the  right  kidney  pouch, 
where  any  escaping  Liquid  and  blood  will  gravitate  (vide  Fig.  214).  The 
adhesions  arc  then  most  carefully  separated  with  a  fine  blunt  dissector 
(Fig.  136),  a  steel  director,  or  curved  scissors,  bleeding,  chiefly  trouble- 
some oozing  from  adhesions,  being  checked  by  Ligature  or  by  firm 
pressure  with  gauze.  While  this  is  being  effected  the  operator  must 
lie  prepared  in  some  cases  for  an  escape  of  pus,  which  has  been  shut 
in  by  these  adhesions,  outside  the  gall-bladder  or  the  ducts  lower  down. 
In  one  case  of  Mr.  Thornton's  (Brit.  Med.  Journ.,  1886,  vol.  ii.p.  902), 


Fig.  215. 


Mayo  Eobson's  scoops 
for  gall-stones. 


the  majority  of  the  stones — 412  were  removed — la}r  in  a  cavity  in  the 
liver  substance.  Through  the  liver-tissue  which  presented  in  the 
incision  stones  could  be  felt  moving  on  each  other :  the  gall-bladder 
was  small  and  atrophied  ;  a  large  stone  occupied  the  common  duct. 
Here  the  large  stone  originally  in  the  gall-bladder  had  become 
impacted  in  the  common  duct,  the  other  stones  being  formed  in  the 
hepatic  duct  and  above  it  in  the  liver,  where  they  gradually  hollowed 
out  a  cavity. 

The  gall-bladder  having  been   found  and  freed  from  adhesions,  is 


Fig.  216. 


Anderson's  forceps  for  the  extraction  of  gall-stones.  As  the  blades  unlock, 
either  can  be  introduced  separately,  and  then  used  as  a  probe  or  scoop.  In  a 
difficult  case  these  forceps  are  very  helpful.     (Down's  Catalogue.) 

brought  into  the  wound  if  possible,  and  having  been  isolated  by  means 
of  gauze  tampons,  it  is  first  emptied  by  aspiration.  The  puncture  is 
then  enlarged  and  the  gall-bladder  held  and  steadied  with  forceps, 
while  a  forefinger  is  inserted  to  feel  for  calculi. 

The  gall-bladder  having  been  steadied  with  forceps  prior  to  any 
manipulations  which  may  be  needful — and  the  extraction  of  a  stone 
fixed  low  down  in  the  cystic  duct  is  often  a  prolonged  affair — any 
calculi  which  lie  near  the  surface  are  removed  with  scoops  (Fig.  215), 
dressing-forceps,  or  the  forceps  shown  in  Figs.  216  and  218.  Of  these 
I  have  found  the  one  to  the  left  of  Fig.  218,  though  its  blades  appear 


55o 


OPERATIONS  ON  THE  ABDOMEN. 


somewhat  clumsy,  very  efficient  in  extracting  stones  when  the  ducts 
are  dilated.  Where  a  stone  impacted  low  down  in  the  cystic  duct 
resists  nil  efforts  at  extraction  from  the  gall-bladder  by  scoops  or 
forceps,  attempts  must  be  made  to  push  it  up  into  the  gall-bladder  by 
a  finger  introduced  into  the  abdomen  through  the  lower  part  of  the 
wound.  This,  after  the  gall-bladder  has  been  secured  by  sutures,  is 
left  open — kept  plugged  with  iodoform  gauze  or  a  sterilised  pad — 
so  that  a  finger  can  be  introduced  from  time  to  time  to  assist  any 
instrument  working  from  the  gall-bladder,  or  to  dislodge  any  calculus 
out  of  the  cystic  duct.  If  all  attempts  at  removal  or  dislodgment  fail, 
the  calculus  must  be  treated  by  choledochotomy  or  cholecystectomy. 

In  grave  cases,  especially  with  suppuration,  the  surgeon  will  have  to 
be    content    with    drainage   of  the    gall-bladder.       The   calculus  may 

Fig.  217. 

Retaining 
suture 


--Skin 
zzjl     Rectus 


""TV^abdomini  s 

i^^Deep  layer  of 
*<?   rectus  sheath. 
Peritoneum 


1  Purse-string-  suture 
going  through  all  the  coats 

Drainage  of  the  gall-bladder  and  fixation  of  it  to  the  parietal  peritonaeum  and 
deep  layer  of  the  rectus  sheath.     (After  Summers.) 


become  dislodged  spontaneously  and  be  discharged  externally.  Injec- 
tions have  occasionally  been  successful  in  removing  the  stone.  If  the 
mucous  fistula  persist  and  cause  serious  inconvenience,  a  secondary 
operation  may  have  to  be  undertaken  for  its  treatment,  under  more 
favourable  circumstances. 

To  drain  the  gall-bladder  a  rubber  tube  should  be  passed  into  it  for 
about  two  inches  and  fixed  in  position  by  means  of  a  purse-string  suture 
piercing  the  sero-muscular  coats  of  the  gall-bladder,  and  the  side  of 
the  tube.  This  procures  inversion  of  the  edges  of  the  incision,  and 
the  serous  surfaces  become  approximated  on  removing  the  tube,  and 
the  fistula  closes  rapidly.  The  peritonajal  coat  of  the  gall-bladder  is 
then  secured  to  the  parietal  peritonaeum  at  several  points,  and  the 
rubber  tube  is  fixed  to  the  cutaneous  edge  of  the  wound,  in  order  to 
prevent  its  premature  removal  by  any  accidental  traction  upon  it.  The 
tube  loosens  and  comes  away  alter  about  a  week,  and  the  fistula  rapidly 
closes  if  there  is  no  obstruction  in  the  biliary  passages  (vide  Fig.  217). 

In  some  instances  it  will  not  be  possible  to  bring  the  gall-bladder 


CHOLECYSTOSTOMY. 


551 


up  to  the  abdominal  incision  and  suture  it  there.  Mayo  Robson  meets 
tins  difficulty  as  follows.  He  says,  "it  has  at  times  been  possible  to 
tuck  down  the  parietal  peritoneum  to  the  edges  of  the  gall-bladder 
opening,  and  so  to  effect  suture  of  the  contiguous  margins  ;  but  in 
several  cases  where  this  could  not  be  done  the  right  border  of  the  omen- 
tum has  been  sutured  to  the  margin  of  the  gall-bladder  opening  and  to 
the  parietal  peritonaeum,  thus  forming  a  tube  of  peritonaeum  around  the 
dramage-tube,   and   shutting  out  the  general  peritoneal  cavity."     If 

Fig.  218. 


Tait's  cholelithotomy  forceps.     (Greig  Smith.) 

neither  of  these  plans  is  available,  a  tube  should  be  fixed  in  the  gall- 
bladder by  a  purse-string  suture,  and  surrounded  with  gauze  packing. 
This  will  be  found  quite  efficient  in  preventing  leakage  into  the 
peritoneal  cavity.  In  many  cases  it  is  best  to  excise  the  useless  and 
contracted  gall-bladder,  and  this  is  all  the  more  justifiable  because 
the  thickened  wall  may  be  already  in  an  early  stage  of  carcinomatous 
disease.  Several  cases  have  been  recorded  in  which  the  gall  bladder  has 
been  discovered  after  its  removal  to  be  affected  with  malignant  disease, 
although  this  was  not  even  suspected  at  the  operation.  In  rare  cases 
dense  adhesions  may  prevent  the  removal  of  the  whole  gall-bladder,  and 
then  the  mucosa  may  be  carefully  dissected  away  from  its  surroundings. 


552  OPERATIONS    ON    THE   ABDOMKN. 


CHOLECYSTOTOMY. 

Here  the  gall-bladder  is  sutured  at  once  after  the  extraction  of  the 
stones,  e.g.,  with  a  continuous  suture  of  the  mucous  membrane,  and 
then  a  row  of  Lembert's  sutures,  and  returned  into  the  peritonaea!  sac. 
This  step  has  two  grave  objections,  (i)  It  is  not  so  safe  as  cholecystos- 
tomy,  owing  to  the  risk  of  leakage  if  the  walls  of  the  gall-bladder  are 
at  all  inflamed  and  softened.  This  is  just  an  instance  of  an  operation 
where  we  hear  of  the  successful,  but  never  of  the  unsuccessful  cases. 
(2)  It  is  very  difficult  to  be  certain  that  all  the  ducts  are  patent.  If  a 
stone  be  left  behind,  suturing  and  returning  the  gall-bladder  will  give 
rise,  in  the  immediate  future,  to  dangerous  tension  on  the  sutures  by 
the  back-flow  of  the  bile,  while  it  prevents,  later  on,  any  attempts  being 
renewed  through  the  open  gall-bladder.  (3)  "When  the  gall-bladder 
is  left  after  the  removal  of  gall-stones,  drainage  is  essential  for  the 
successful  treatment  of  the  chronic  or  acute  inflammatory  conditions, 
which  partly  cause  and  partly  result  from  the  lithiasis.  For  these 
reasons  this  operation  has  been  deservedly  abandoned,  and  it  is  only 
mentioned  here  to  warn  the  too  ambitious  and  unwary. 

CHOLELITHOTRITY. 

The  term  has  been  applied  to  crushing  a  gall-stone  inside  one  of  the 
ducts.  The  method  was  first  adopted  by  Lawson  Tait,  who  made  use 
of  forceps  in  order  to  crush  the  stone.  Mayo  Bobson  used  to  crush 
the  stone  by  pressure  between  the  thumb  and  finger ;  the  fragments 
were  then  pressed  on  into  the  duodenum  or  washed  through. 

Cholelithotrity  has  been  rightly  abandoned,  for  it  is  uncertain,  and 
may  be  incomplete.  The  bile-ducts  may  also  be  injured  without  the 
knowledge  of  the  surgeon. 

CHOLEDOCHOTOMY. 

This  term  has  been  given  to  the  operation  of  removing  stones  from 
the  biliary  ducts  by  direct  incision.  This  method  has  gained  ground 
very  much  of  late  years.  Its  safety  in  careful  and  competent  hands 
has  been  established,  and  it  has  been  proved  that  stones  impacted  deep 
in  the  cystic  or  in  the  common  duct,  which  otherwise  must  have  been 
left  behind  as  persistent  sources  of  misery  or  as  causes  of  an  open 
biliary  fistula,  extraction  by  opening  the  gall-bladder  or  cholelithotrity 
having  proved  impossible,  can  now  be  safely  removed.  The  common 
bile-duct  becomes  smaller  towards  its  termination,  its  diameter  being 
about  8  mm.  in  the  first  part,  5  mm.  in  the  second  part,  and  3^  mm. 
in  the  intra-mural  or  third  part,  where  it  may  be  narrower  than  the 

-tic  duct  (Padula,  Ann.  <l  Med.  Navale,  November,  1903). 

In  its  first  part  the  duct  is  fortunately  near  the  free  i'(]-se  of  the 
lesser  omentum  in  front  of  the  portal  vein  and  to  right  of  the  hepatic 
artery. 

"While  the  important  relations  of  these  ducts — especially  the  common 
— must  always  be  remembered,  the  presence  of  the  stone  itself  forms 
a  reliable  guide,  as  long  as  the  incision  is  made  directly  over  it.  An 
inflamed  lymphatic  gland  maybe  mistaken  for  a  Btone. 


CHOLEDOCHOTOMY. 


553 


We  will  take  the  operation  for  removal  of  a  calculus  from  the 
common  duel.     The  preliminary  exploration  is  described  al  p.  545. 

(1)  Stone  impacted  in  the  First  Part  of  the  Common  Bile  Duct, 
above  the  duodenum.  The  incision  in  the  abdominal  wall  being 
lengthened  if  necessary  so  as  to  give  satisfactory  exposure  of  the 
parts  concerned,  the  liver  is  held  up,  the  edges  of  the  wound  are 
held  widely  open,  and  the  position  of  the  stone  accurately  defined. 
Large   retractors    (Fig.    219)    may  here    be    found    useful  in  keeping 

Fig.  219. 


Thomas's  Hospital  intestine  retractor. 


back  the  intestines.  The  area  of  operation  is  then  carefully  shut 
off  by  sterile  gauze  packing  (vide  p.  547),  and  any  adhesions  over  the 
stone  are  very  carefully  separated*  while  the  duodenum  is  drawn 
down  or  turned  aside.  The  stone,  firmly  held,  is  raised  as  high  as 
possible.  The  incision  is  not  to  be  made  until  the  surgeon  feels 
certain  that  he  is  directly  over  the  stone.  Two  mattress  sutures  may 
be  introduced  into  the  wall  of  the  duct  before  incising  it.       These 


Fig.  220. 


rSc 


niri     nma  — bgnyga^ 


Moynihan's  scoop  and  grooved  probe. 

serve  to  close  the  incision  afterwards,  and  also  act  as  guides  (Mayo). 
The  escape  of  bile,  which  is  very  profuse,  and   usually  infective,  if  it 

*  The  importance  of  patience  and  care  in  separating  adhesions  is  shown  by  the  fact 
that  even  in  Mr.  Mayo  Robson's  experienced  hands  fsecal  extravasation  took  place  from 
a  small  perforation  in  the  colon,  caused  by  the  separating  adhesions  during  the  removal 
of  a  stone  from  the  common  duct,  the  injury  being  unrecognised  at  the  time.  Another 
instructive  case  is  that  of  Ross  (Canadian  Practitioner,  April,  1894).  Here  several  stones 
weie  lodged  in  the  common  duct,  the  duodenum  was  accidentally  torn,  and  this  opening 
was  enlarged  in  the  hope  of  reaching  the  stones  through  the  opening  in  the  duct,  but  this 
point  could  not  be  found.  The  common  duct  was  accordingly  opened  and  the  stones 
removed.  The  duct  was  sutured,  but  owing  to  the  friability  of  the  tissues  at  the  site  of 
the  roughened  stone,  it  was  impossible  to  prevent  the  leakage  of  bile.  Drainage  was 
employed  with  iodoform  gauze.  The  bile  continued  to  flow,  but  increased  suddenly  after 
vomiting,  and  the  case  ended  fatally  fifty-six  hours  after  the  operation. 


554  OPERATIONS   ON    THE    ABDOMEN. 

has  been  long  pent  up  or  if  the  blocked  duct  is  diluted,  must  be  met  by 
assiduous  sponging  and  careful  packing  of  the  kidney  pouch  of 
peritonseum. 

After  removal  of  the  main  stone  the  ducts  must  be  thoroughly  and 
systematically  explored,  for,  as  has  already  been  pointed  out,  there  are 
usually  several  stones  present,  and  the  failure  to  remove  them  all  will 
render  the  operation  useless  in  late  cases  of  obstruction  of  the  common 
duct.  Stones  may  have  formed  in  the  hepatic  ducts,  and  may  be  over- 
looked, and  give  rise  to  recurrence  of  symptoms.  This  exploration 
should  be  carried  out  with  the  finger  if  the  ducts  are  sufficiently  dilated, 
or  failing  this,  by  a  bent  probe  or  small  scoop  (vide  Fig.  220).  The 
finger,  however,  should  be  emplo}red  wherever  possible,  because  it  is 
the  only  really  certain  method.  Mayo  Robson  strongly  emphasises 
this  point,  and  mentions  a  case  in  which  a  probe  and  scoop  failed  to 
discover  a  stone  which  was  found  afterwards  on  digital  examination. 
The  probe  should  be  passed  into  the  duodenum  to  make  certain  that 
the  ampulla  is  patent. 

The  ducts  having  been  cleared,  it  remains  to  consider  the  different 
means  of  treating  the  opening  in  the  duct.  If  the  passages  above  and 
below  are  patent,  if  the  opening  is  accessible,  and  if  the  patient's 
condition  admits  of  further  prolonging  of  the  operation,  sutures  should 
certainly  be  employed  for  the  additional  security  which  they  give.* 
The  escape  of  bile  being  prevented  by  the  pressure  of  the  fingers  above 
the  opening,  the  incision  by  which  the  stone  has  been  extracted  is 
closed  by  a  continuous  suture  of  catgut  for  the  duct  itself,  while  a 
second  set  of  sutures  of  silk  are  used  to  draw  together  the  cut  edges 
of  the  overlying  peritonseum.  The  sutures  are  best  inserted  b}r  a  small 
curved  needle  held  in  pressure-forceps,  by  Mr.  W.  A.  Lane's  cleft 
palate  needles  held  in  his  special  needle-holder  (vide  Fig.  221,  Vol.  I.), 
or,  as  recommended  by  Mr.  M.  Robson,  by  a  rectangular  cleft-palate 
needle.  The  value  of  a  free  incision,  opening  up  the  wound  in  every 
direction,  tilting  the  liver,  drawing  down  the  duodenum  and  colon, 
and,  perhaps,  the  use  of  an  electric  lamp,  will  be  very  apparent  now. 
The  assistants  must  be  assiduous  with  well-applied  sponge-pressure. 
In  the  words  of  Dr.  Binnie,  of  Kansas  City  (Ann.  of  Surg.,  November, 
1894,  p.  563),  "  a  difficulty  which  occasionally  confronts  the  surgeon  is  to 
distinguish  at  the  bottom  of  a  deep  and  narrow  pit  the  wounded  duct 
from  oozing  adhesions  recently  divided." 

Dr.  Halsted  (John  Hopkins  Hosp.Bidl.,  April,  1898)  recommends  the 
use  of  a  small  metal  hammer  in  order  to  facilitate  the  introduction  of 
sutures.  The  head  of  the  hammer  is  made  in  a  variety  of  sizes,  and  is 
fitted  with  a  long  slender  handle  (Fig.  221).  The  hammer  chosen 
should  be  large  enough  to  fully  distend  the  duct.  The  head  of  the 
hammer  is  passed  through  the  incisionin  the  duct,  and  serves  to  steady 
the  latter  and  also  to  lift  it  up  towards  the  surface  while  the  sutures 
are  passed.     The  hammer  is  then  removed  and  the  sutures  tied. 

With  advantages  of  a  free  incision,  arching  of  the  back,  tilting  of  the 
liver,  and  good  assistance,  the  suturing  is  not  so  very  difficult,  and  but 
few,  if  any,  surgeons  now  use  the  hammer. 

*  Even  if  the  sutures  do  not  hold,  they  do  good  by  preventing  or  lessening  the  escape 
of  bile  while  adhesions  arc  forming  to  shut  <>fT  the  peritonaea!  sac 


CHOLEDOCHOTOMY.  555 

In  many  cases,  it  is  not  advisable  to  close  the  incision  in  the  common 
bile-duct,  especially  if  there!  is  septic  cholangitis,  and  if  the  gall-bladder 
is  not  available  for  drainage.  A  tube  may  be  tied  in  the  rootofthe  cystic 
duct  when  the  gall-bladder  has  been  removed.  Many  surgeons  preferto 
dispense  with  sutures,  asarule,  because  of  the  safety  and  the  beneficial 
effects  of  drainage,  and  the  risk  of  narrowing  of  the  passage  by  suturing. 

Drainage. — It  will  be  safer  always  to  use  this  in  some  form  or  other' 
whenever  the  ducts  have  been  incised,  but  with  more  elaborate  pre- 
cautions, of  course,  when  no  sutures  have  been  inserted.  To  take  the 
latter  case  first. 

A  rubber  tube  is  passed  upwards  towards  the  hepatic  duct,  and 
secured  in  position  by  means  of  a  catgut  suture,  which  pierces  the  side 
of  the  tube  and  the  edges  of  the  wound  in  the  duct.  To  prevent 
contamination  of  the  peritonaeum,  a  rubber  tube  surrounded  with  a  layer 
of  gauze,  and  containing  a  gauze  wick  which  projects  at  both  ends,  is 
passed  into  the  kidney  pouch  below  and  outside  the  wound  in  the 
common  bile-duct.  In  some  cases  drainage  may  be  established  through 
a  stab  wound  into  the  loin.     Mr.  Rutherford  Morison,  of  Newcastle,  has 


Fig.  221. 

■iSc 


I 


Halsted's  hammer. 


drawn  attention  to  the  importance  of  draining  the  kidney  pouch  (Brit. 
Med,  Journ.,  vol.  ii.  1894,  p.  968).  He  there,  shows  that  in  the  right 
hypochondrium,  between  the  liver  and  the  colon,  is  a  natural  space 
with  barriers  which  separate  it,  more  or  less  completely,  from  the 
general  sac.  Bile  may  be  allowed  to  escape  into  this  space  as  long  as 
it  is  efficiently  drained  by  an  incision  made  through  the  posterior 
parietes  immediately  below  the  lower  end  of  the  right  kidney.  If  the 
curved  incision  which  Mr.  Morison  and  others  recommend  be  made 
use  of,  the  drainage-tube  will  be  in  the  lower  and   outer  angle  of  the 

wound.  .,. 

If  the  method  which  has  been  described  above  be  followed  it  will 
be  rarely  necessary  to  drain  directly  through  the  loin,  and  this  additional 
wound  can  be  safely  dispensed  with  except  when  suppuration  exists. 

Dr.  E.  Abbe,  of  New  York,  recommends  the  method  of  drainage 
shown  in  Fig.  222,  which  he  has  used  successfully  (loc.  supra  cit.).     A 


*  It  has  been  stated  that  drainage  is  not  needed,  as  pure  bile  does  not  excite  peritonitis. 
I  am  of  opinion  that  the  surgeon  can  rarely  tell  for  certain  whether  the  bile  is  pure  or 
not  Certainly  in  cases  where  there  have  been  repeated  attacks  of  cholelithiasis  with 
pyrexia  it  is  extremely  probable  that  the  bile  is  infected  from  the  intestines-*^.,  with  the 
bacillus  coli  communis.  And  this  is  the  more  likely  when  any  part  of  the  ducts  has  been 
long  dilated  into  a  large  sac. 


556 


OI'KUATIONS    <)\    TIM-:    AIJDOMKX. 


Fig.  222. 


stone  having  been  removed  from  the  common  duct,  a  Large  drainage- 
tube  was  passed  into  the  hepatic  duct  through  the  opening  in  the 
common  duct,  this  opening  being  then  sewn  up  with  fine  silk.  Around 
the  tube  which  emptied  the  hepatic  duct  m  Larger  one  was  placed, 
reaching  to  the  common  junction,  and  a  Light  iodoform  tampon  was 
linally  pushed  in.  All  the  bile  came  through  the  tube  for  five  days; 
the  inner  one  was  removed  <m  the  second  day,  and  the  sinus  closed  in 
three  weeks,  the  patient  making  an  excellent  recovery. 

If  the  flow  of  bile  is  profuse,  Byphonage  may  be  adopted,  the  fluid 
being  conducted  into  a  basin  at  the  side  of  the  bed.  In  that  case  it 
is  wise  to  fix  the  tube  to  the  skin,  so  that  it  may  not  be  accidentally 
dragged  and  displaced. 

The  tube  will  become  detacdied  in  about  a  week,  and  may  be  removed. 

The  larger  tube  draining  the 
kidney  pouch  may  lie  gradu- 
ally withdrawn  from  the  fourth 
to  the  eighth  day. 

Where  the  opening  has 
been  closed  with  sutures  it 
will  still  be  wise  to  use  a 
wicked  drainage-tube  for  a 
day  or  two,  the  indication 
for  this  being  clearer  in  cases 
where  the  suturing  has  1"  ,  q 
attended  with  difficulty,  where 
the  edges  of  the  duct  are 
much  bruised,  and  where  any 
contraction  may  exist  in  the 
biliary  passage  below. 

The  surgeon  may  also 
make  use  of  some  of  the 
adjacent  soft  parts  to  act  as 
a  dam  between  the  duct  and  surface,  and  so  prevent  the  bile  from 
entering  the  peritonseal  sac,  or  he  will  employ  drainage  and  iodoform 
gauze.  Amongst  the  soft  parts  that  are  handy,  the  omentum  at  once 
presents  itself  as  the  most  available.  Air.  Mitchell  Banks  {Liver- 
pool Med.-Chir.  Journ.^  1897,,  p.  307)  in  a  case  of  cholecystostomy, 
in  which  the  incision  in  the  gall-bladder  could  not  be  united  to  that  in  the 
abdominal  wall,  made  use  of  "the  round  ligament  of  the  liver  and  some 
neighbouring  omentum,  which  be  fastened  to  the  gall-bladder,  and 
succeeded  in  so  banking  it  up  as  to  prevent  the  bile  from  (lowing 
into  the  peritonaea!  cavity.'"  Binnie,  of  Kansas  City  (Inc.  supra  cit.), 
made  use  of  separated  adhesions  after  extracting  a  calculus  through 
the  opened  cystic  duct. 

"  Suture  of  the  wounds  in  the  bladder  and  the  duct  might  have  been  possible,  but 
as  it  would  certainly  have  taken  much  time,  I  decided  in  drain,  bul  at  the  same  <  i iu< ■ 
to  build  up  of  omentum,  mesentery,  .-mil  existing  adhesions,  a  diaphragm  between  the 
track  of  the  drain  and  the  general  peritonaea!  cavity.  Thus  the  wounded  biliary  passages 
were  left  open.  A  few  stitches  of  catgut,  judiciously  placed,  bound  together  the  various 
structures  above  mentioned  in  such  a  way  that  in  a  few  hem-  they  became  an  impervious 
rampart  of  adhesions.  .  .  .  A  rubber  drain  was  also  passed  t"  the  bottom  of  the  wound, 
and  surrounded  throughout  its  whole  length  with  a  liberal  Bupply  of  iodoform  gauze." 


Abbe's  method  of  suture  and 
drainage.  A  drainage-tube  has 
been  placed  in  the  hepatic  duct ; 
an  opening  in  the  common  duct 
is  sutured.  The  gall-bladder  has 
been  removed.  This  fact  is  not 
shown. 


/ 


CHOLEDOCHOTOMY.  557 

(2)  Stones  impacted  in  tho  Second  Part  of  the  Common  Bile-duct 
behind  the  duodenum  and  the  bead  of   the  pancreas4  or  within  the 

hitter. 

[f  possible  the  stone  should  be  pushed  upwards  into  the  firsl  pari  of 
the  duct,  whence  it  can  be  more  safely  and  more  1  asily  removed. 
Failing  this,  the  duodenum  may  be  mobilised  by  incising  the  parietal 
peritonaeum  about  an  inch  to  the  right  of  the  descending   part  and 

turning  the  hitter  forwards  and  inwards  (p.   474). 

The  calculus  is  sought,  and  if  found  it  serves  as  the  hest  guide  to  the 
duet,  which  may  be  embedded  in  the  head  of  the  pancreas,  which  may 
have  to  be  incised.  When  the  stone  has  been  found  it  may  be 
possible  to  push  it  back  into  and  remove  it  from  the  supra-duodenal 
part  of  the  duct  as  adopted  by  Lane  {Clin.  Soc.  Trans.,  1894,  p.  149). 
If  this  is  not  possible  the  duct  must  be  incised,  and  calculus  removed, 
and  drainage  always  established.  Berg  (Zeut.  f.  Chir.,  1903,  No.  27) 
recommends  this  method  in  preference  to  duodeno-choledochotomy. 

The  objections  to  this  route  are  that  it  is  difficult  and  may  be 
accompanied  by  severe  haemorrhage  from  the  pancreas.  Moreover, 
the  duodenum  or  even  the  vena  cava,  which  lies  behind  the  duct, 
may  be  lacerated  if  there  is  much  matting  from  chronic  inflammatory 
changes. 

In  such  cases  it  is  easier  and  safer  to  adopt  the  trans-duodenal  route, 
as  Kocher  did  in  one  case,  on  account  of  severe  haemorrhage  from  the 
pancreas,  which  made  him  give  up  the  retro-duodenal  route.  Wounds 
of  the  pancreas  are  always  to  be  avoided  if  possible  (vide  p.  570)- 

(3)  Stones  impacted  in  the  Ampulla  of  Vater  —  Duodeno- 
choledochotomy  (vide  Figs.  214,  223). — Dr.  McBurney  was  the  first  to 
perform  this  operation  in  1891.  He  lays  stress  upon  the  following 
procedure : — 

"In  all  cases  which  are  not  complicated  by  very  deep  adhesions, 
involving  the  common  duct  and  descending  portion  of  the  duodenum, 
it  is  easy  and  very  desirable  after  determining  the  presence  of  a 
calculus  in  the  lower  part  of  the  duct  to  pass  the  left  forefinger  through 
the  foramen  of  Winslow  to  a  point  behind  the  calculus.  With  the 
finger,  the  lower  end  of  the  common  duct,  the  calculus,  and  the 
descending  portion  of  the  duodenum,  can  be  lifted  forward  so  as  to 
bring  these  parts  nearly  or  quite  to  the  level  of  the  abdominal  incision,  t 
The  duodenum  is  then  incised  in  its  anterior  wall  for  from  one  to  one 
inch  and  a  half,  the  orifice  of  the  duct  (which  is  usually  markedly 
altered  as  to  the  colour,  &c.)  is  easily  found  and  enlarged  with  knife 
or  scissors  or  forceps,  and  the  stone  removed.  All  of  this,  and  even 
suture  of  the  intestinal  wound,  should  be  completed  without  removing 
for  a  moment  the  left  forefinger  from  its  supporting  position"  (Dr. 
Hancock,  Ann.  of  Surg.,  vol.  xliii.  p.  72)  (vide  Fig.  223). 

When  an  incision  is  made  through  the  posterior  wall  of  the  duodenum 
into    the    common   bile-duct   before    it    becomes    intra-mural,    as   in 


*  A  stone  impacted  in  the  duct,  low  down,  may  give  a  hard  or  nodular  feel  which 
may  suggest  malignant  disease  of  the  head  of  the  pancreas  ;  an  exploring  needle  will  clear 
up  the  case. 

t  If  the  duodenum  is  not  mobile  enough,  the  peritonajum  to  the  right  of  it  may  be 
incised  to  the  required  degree  (p.  474). 


558 


nl'Ki: ATIONS    ON    TIM'.    AI'.DOMEN. 


Kocher's  case,  extravasation  of  bile  may  occur  info  i  he  retro-peritonaea] 
tissues,  unless  the  incision  in  the  duel  is  accurately  sewn,  us  advised 
by    Kocher,  when  the  papilla  is  patent;  if  any  obstruction  exists  at 

the  orifice,  the  edge  of  the  incision  into  the  bile-duct  should  he 
sutured  to  those  of  the  wound  in  the  posterior  wall  of  the  duo- 
denum, thus  establishing  a  fistula  between  the  gall-duct  and  the 
duodenum. 

If  an  incision  has  been  already  made  into  the  common  bile-duct  in 
its  first  part,  a  piece  of  gauze  may  be  drawn  downwards  from  it  to  the 

Fig.  223. 


Duodeno-cholcdochotomy ;  stone  in  the  common  duel  Low  down.  The  duodenum 
has  been  freed  and  brought  to  the  surface  preparatory  to  being  opened.  (Moynihan, 
Abdominal  Operations.} 

duodenum,  thus  removing  any  debris  (Mayo  and  Kehr)  ;  hut  if  free 
drainage  is  established  into  the  duodenum,  it  is  not  necessary  to  make 
a  separate  incision  for  drainage  of  the  common  bile-duct.  A  scoop 
must  be  passed  upwards  along  the  bile-duct  to  prove  the  absence  of 
stones  higher  up  before  the  duodenal  incision  is  closed  in  the  usual 
way  with  two  continuous  sutures. 

The  disadvantages  of  the  operation  are — 

(1)  It  is  difficult;  but  when  a  stone  is  impacted  near  it,  the  biliary 
papilla  is  easy  to  find. 

(2)  In  two  of  the  62  cases  collected  by  Hancock,  a  duodenal  fistula 
formed,  and  in  one  of  these  it  led  to  the   death  of  the  patient  from 


CHOLEDOCHOTOMT.  559 

exhaustion;  in  the  other  the  Leakage  spontaneously  ceased.  With 
careful  Buturing  a  duodenal  fistula  should  be  avoidable. 

(3)  It,  has  a  higher  mortality  than  choledochotomy.  [nfection  of  the 
peritonaBum  from  the  duodenal  opening  should  be  avoidable  by  careful 
preparation  of  the  patient  and  skilful  operating. 

The  advantages  which  have  been  claimed  are  that — 

(1)  Drainage  through  the  cutaneous  wound  is  unnecessary. 

(2)  It  is  easier  to  sew  up  an  intestinal  wound  than  one  in  the  bile- 
duct. 

(3)  The  intestinal  wound  heals  more  quickly  and  satisfactorily. 

(4)  The  trans-duodenal  route  gives  an  easy  and  natural  access  to  the 
common  bile-duct  in  its  lower  part. 

(5)  The  biliary  papilla  may  be  enlarged  if  stenosed. 

(6)  A  new  growth  or  pancreatic  stone  in  the  ampulla  may  be 
discovered  to  be  the  cause  of  symptoms,  and  may  be  removed. 

This  method  being  more  severe  and  dangerous  than  opening  the 
bile-duct  above  the  duodenum,  is,  of  course,  only  suitable  for  cases  in 
which  it  is  found  to  be  impossible  to  remove  the  obstruction  in  the 
usual  way. 

Dr.  Hancock  (loc.  supra  cit.)  has  collected  the  records  of  62  trans- 
duodenal operations ;  57  of  these  were  for  the  removal  of  gall-stones, 
three  for  pancreatic  calculi,  and  in  two  new  growths  of  the  papilla  were 
found.  The  mortality  of  the  62  operations  was  12*6  per  cent.,  and 
that  of  the  57  undertaken  for  gall-stones  was  877  per  cent.  The 
death-rate  from  this  operation  will  probably  be  always  higher  than  that 
of  choledochotomy,  because  the  cases  demanding  it  are  often  later,  and 
the  operation  in  itself  is  more  severe. 

CHOLECYSTENTEROSTOMY. 

In  this  operation  a  communication  is  made  between  the  gall-bladder 
and  the  small  or  large  intestine.  Whenever  feasible  the  duodenum  or 
upper  jejunum  should  be  preferred.  "When  the  small  intestine  is  too 
matted  by  adhesions  to  come  up  sufficiently,  the  hepatic  flexure  of  the 
colon  should  be  chosen.  Mayo  joined  the  gall-bladder  to  the  transverse 
colon  in  five  cases  in  which  he  was  unable  to  use  the  duodenum,  and 
the  results  were  excellent.  Cholecystenterostomy  received  great 
impetus  owing  to  the  recommendations  which  it  received  from  Dr. 
Murphy,  of  Chicago,  the  facility  with  which  it  can  be  performed  with 
his  most  ingenious  and  expeditious  button,  and  the  good  results  which 
the  published  cases  show.     The  chief  indications  for  the  operation  are — 

(1)  Irremediable  obstruction  of  the  common  duct,  due  to  calculus  or 
cicatricial  contraction.  The  operation  should  be  rarely  required  for 
calculous  obstruction,  for  it  is  much  better  to  remove  the  obstruction 
if  possible.  In  some  cases  this  may  not  be  practicable,  or  the 
condition  of  the  patient  may  make  the  attempt  inadvisable.  Leaving 
the  stones  may  lead  to  suppurative  cholangitis  or  to  the  development 
of  malignant  disease.  The  second  cause  is  very  rare,  and  it  is 
probable  that  as  time  goes  on,  and  surgery  proves  what  can  be  done 
for  calculi  impacted  here,  this  indication  will  very  rarely  arise. 

(2)  In  irremovable  obstruction  of  the  cystic  duct,  where  cholecystec- 
tomy is  impracticable. 


56o  OPERATIONS   ON    THE    ABDOMEN. 

(3)  A  persistent  fistulous  opening  after  operations  <>n  the  gall-bladder, 
or  due  to  stricture,  or  occlusion  of  the  common  duct,  giving  rise  to  :i 
constant,  escape  of  bile,  causing  persistent  excoriation  and  annoyance, 
owing  to  the  eczematous  rawness.  In  such  cases  the  operation  of 
cholecystenterostomy  was  recommended  twenty  years  ago  in  this 
country  by  Mr.  Willett  (Brit.  Med.  Jovrn.,  vol.  ii.  1886,  p.  903). 

(4)  Mayo  Robson  also  gives  chronic  pancreatitis. 

(5)  Another  indication  which  has  been  sometimes  given  is  malignant 
disease  about  the  head  of  the  pancreas,  occluding  the  common  duct  and 
giving  rise  to  jaundice,  itching,  &c.  In  such  cases  cholecystenterostomy 
must  involve  greatly  increased  risk.  Haemorrhage  and  imperfect  repair 
are  the  chief  dangers,  the  first  especially  so,  as  will  he  seen  from  t In- 
case given  below  of  Dr.  F.  J.  Shepherd,  of  Montreal  (p.  562).  Dr. 
Murphy  himself  (Clticago  Clin. Rev.,  February,  1895)  considers  the  opera- 
tion here  very  unsatisfactory,  there  having  been  seven  deaths  out  of 
eight  cases.  Two  died  from  shock,  one  from  a  twisting  of  the  small 
intestine,  before  the  approximation  was  made,  a  volvulus  being  thus 
produced.  In  another  case  the  gall-bladder  was  so  friable  that  it  tore 
like  wet  paper  when  the  sutures  were  inserted,  and  after  the  bottom  was 
in  position  and  the  abdomen  closed,  the  friable  wall  gave  way,  and 
peritonitis  followed.  Dr.  Murphy  accordingly  advised  that  if  the 
operation  be  made  use  of  in  case  of  obstruction  due  to  malignant 
disease,  it  should  only  be  in  the  early  stage. 

Cholecystenterostomy  may  not  be  practicable  with  a  contracted 
gall-bladder,  and  it  may  be  very  difficult  or  impossible  to  bring  any 
part  of  the  intestine  up  without  kinking  when  adhesions  are  dense 
and  diffuse.  In  such  cases  the  gall-bladder  may  be  joined  to  the 
anterior  surface  of  the  stomach  without  any  ill  effect  from  the  dis- 
charge of  bile  into  the  stomach.  Perrier  (quoted  by  Moynihan)  collected 
seven  recorded  cases  of  cholecystgastrostomy,  with  six  recoveries. 

The  indications  for  cholecystenterostomy  having  been  given,  the 
means  of  performing  the  operation  will  next  be  considered.  These  are — 

(1)  Suture  alone.  The  gall-bladder  is  first  emptied  by  aspiration  and 
then  joined  to  the  intestine  with  the  aid  of  clamp  forceps  and  two 
continuous  sutures,  as  in  the  operation  of  gastrojejunostomy  (p.  506). 
The  aperture  should  be  made  at  least  an  inch  long,  and  catgut  should 
be  used  for  the  deep  suture. 

(2)  Mayo  Eobson's  bobbin.  This  is  inserted  in  the  manner  already 
described  under  "  Entero-anastomosis  "  (p.  373). 

(3)  Murphy's  button.  Cholecystenterostomy  by  this  method  requires 
careful  attention.  The  attractiveness  which  the  simplicity  of  this 
most  ingenious  device  must  always  carry  with  it,  the  success  *  which  it 
has  met  with  in  skilful  hands,  make  it  very  probable  that,  in  the  zeal 
of  securing  an  immediate  success,  this  operation  may  he  performed,  if  it 
has  not  already  been  so,  much  too  often.  Thus,  to  take  both  sides  of 
the  question,  on  the  one  hand  we  have  these  advantages :  tin  two  viscera 
which  are  to  be  united  are  often  readily  reached  by  a  comparatively 
small  Incision.     The  button  is   very  quickly   adjusted,   the   bile   soon 

*  Dr.  Murphy,  in  a  report  up  to  1897,  gives  67  cases  of  cholecystenterostomy  for 
non-malignant  obstructive  jaundice,  with  only  three  deaths,  but  ten  out  of  twelve 
malignant  cases  died  from  the  operation. 


( 'H  O  LKC  VST  KNTK I  {OSTOMY. 


56l 


pusses  by  the  new  channel,  the  jaundice  and  itching  are  lost  and  the 
faeces  again  become  natural.  On  the  other  hand  the  following 
objections  present  themselves  to  every  candid  and  well-informed  thinker. 
(1)  It  is  clear  from  the  account  of  several  of  the  cases  that  the  cause  of 
all  the  trouble  might  have  been  removed,  and  not  only  relieved.  Tims, 
in  several,  stones  were  not  removed  from  the  gall-bladder,  and  the  ducts 
were  not  even  examined.*  Yet  these  cases  are  published  as  successes. 
As  this  operation,  rendered  so  simple  by  Murphy's  button,  is  Likely  to 
be  resorted  to  in  cases  of  stone  impacted  in  the  three  bile-ducts,  it  is 
right  to  point  out  that  modern  methods  and  recent  experience  have 
rendered  removal  of  stones  by  incision  so  safe  in  skilled  hands  that 
this  step,  choledochotomy,  is  always  to  be  preferred,  when  possible,  to 

Fig.  224. 


Cholecystenterostomy  with  Murphy's  button.     (Down's  Pamphlet.) 

cholecystenterostomy.  In  other  words,  those  of  Dr.  McGraw  (Ann.  of 
Surg.,  Aug.  1895,  p.  169),  "we  should  try  not  only  to  relieve,  but  also 
to  cure."  (2)  Another  objection,  though,  I  believe,  only  proved  by  a 
few  cases  as  yet,  is  that  of  septic  infection  of  the  ducts  and  liver  from 
the  intestine.  We  must  remember  how  very  different  are  the  conditions 
after  cholecystenterostomy,  to  those  in  health,  as  regards  a  communica- 
tion between  the  intestine  and  the  biliary  passages.  That  a  patient 
after  this  operation,  as  long  as  the  opening  remains  free,  must  be 
menaced  with   the   danger    of    septic  infection  is  proved   by    a    case 


*  Dr.  McGraw,  of  Detroit,  and  Dr.  Elliot,  of  Boston,  both  bring  a  further  objection 
against  the  button  consequent  on  this,  that  it  often  leaves  behind  it  in  the  form  of  a  stone 
or  stones,  sources  of  irritation,  which  may  develop  later  into  conditions  of  danger.  Time 
must  show,  with  careful  watching  and  accurate  reporting  of  cases,  how  far  this  criticism 
is  justified. 

S. VOL.  II.  36 


562  OPERATIONS  ON   THE   ABDOMEN. 

reported  by  Rickard  (Hull.  Soc.  Chvr.,  t.  xx.  1894^.572).  Here  death 
occurred  fifty-three  days  niter  cholecystenterostomy,  although  the 
patienl  did  well  al  first.  The  necropsy  showed  that  death  was  due 
to  infection  of  the  biliary  passages  from  the  intestine,  numerous 
abscesses  due  to  ascending  infection  being  present.  (3)  There  is  the 
risk  of  contraction.  Unless  the  opening  is  made  very  free,  this  may  set 
in  after  any  method.  (4)  Haemorrhage.  This  risk  must  he  present, 
however  cholecystenterostomy  is  performed,  in  eases  of  obstruction 
from  malignant  disease,  owing  to  the  tendency  to  haemorrhage  in  these 
cases ;  it  is  especially  likely  to  follow  the  use  of  Murphy's  button, 
whenever  a  thickened  condition  or  friability  of  the  tissues  prevents  the 
button  taking  that  grip  which  is  so  essential  for  success.  All  surgeons 
owe  much  to  Dr.  F.  C.  Shepherd,  of  Montreal,  for  the  candid  wax- 
in  which  he  has  drawn  their  attention  to  this  fact  {Ann.  of  Sv/rg.,  May, 
1893,  p.  581)  : 

His  patient,  aged  36,  had  a  biliary  fistula  resulting  from  a  previous  cholecystostomy 
for  jaundice,  pain,  &c,  performed  four  months  previously,  when  no  Btone  was  found. 
Owing  to  the  annoyance  of  the  continual  discharge  of  bile,  the  abdomen  was  opened  again 

by  an  incision  internal  to  the  old  fistula,  and  a  mass  of  malignant  disease  was  now  found 
involving  the  pancreas  and  duodenum.  It  was  decided  to  unite  the  gall-bladder  with  the 
colon  instead  of  the  duodenum,  "as  being  easier  and  more  rapid,  and  quite  as  beneficial." 
The  button  was  introduced  without  very  much  difficulty,  the  purse-string  suture  being 
first  inserted.  Owing  to  the  thickness*  of  the  gall-bladder  there  was  some  puckering, 
and  the  parts  did  not  come  together  without  considerable  pressure  on  the  button.  On 
dropping  back  the  bowel  and  gall-bladder  with  the  button  there  was  no  tension,  and  the 
parts  seemed  to  be  in  accurate  apposition,  and  to  lie  comfortably.  It  was  decided  not  to 
close  the  fistulous  opening,  as  it  was  felt  that  this  would  (dose  of  itself.  On  the  morning 
of  the  fourth  day  (the  patient  having  gone  on  well  in  the  interval)  blood  was  found  to  be 
oozing  from  the  gall-bladder  and  the  abdominal  wound.  In  spite  of  gauze-packing  this 
continued,  and  the  patient  passed  into  a  state  of  collapse.  On  opening  the  abdominal 
wound  it  was  Been  thai  the  haemorrhage  came  entirely  from  the  gall-bladder.  The  button 
had  cut  through  the  thick  and  friable  walls,  and  could  be  easily  seen.  To  remove  the 
button  il  was  necessary  to  incise  both  gall-bladder  and  bowel  and  unscrew  the  button. 
It  being  useless  to  reinsert  the  button,  it  was  decided  to  sew  up  the  openings  in  the  gall- 
bladder and  colon.  A  fresh  oozing  took  place  about  twenty-four  hours  later,  and  the 
patient  sank.  A  partial  necropsy  showed  that  the  obstruction  of  the  common  duct  was 
due  to  malignant  disease  of  the  head  of  the  pancreas. 

(5)  The  button  may  not  be  passed.  This  happened  in  a  case  of  Dr. 
Briddon's  {New  York  Surg.  Soc,  1896).  Here  the  bladder  was  dilated 
with  non-contractile  walls.  The  button  probably  fell  into  this  viscus  as 
the  larger  chamber,  and  there  remained,  two  "months  later,  without 
causing  inconvenience.  Two  other  objections  are  brought  against 
cholecystenterostomy  by  Dr.  McGraw.  (6)  It  produces  adhesions 
between  previously  detached  organs,  adhesions  which  may  interfere 
with  their  movements  and  with  their  actions.  (7)  After  this  operation 
the  bile  is  diverted  through  the  cystic  duct  and  gall-bladder  into  the 
bowel.  The  gall-bladder  takes  on  itself  the  function  of  the  common 
duct,  and  the  common  duct,  remaining  patulous  at  its  upper  end, 
receives  a  certain    amount  of  bile   which   stagnates   under   conditions 


*  It  will  be  noticed  that  no  mention  is  made  of  the  gall-bladder  being  friable,  the 
condition  which  was  found,  a  little  later.  In  have  contributed  so  largely  to  the  fatal  result. 


OHOLECYSTKCTOMY.  563 

which  favour  its  crystallisation,  especially  if,  as  is  often  the  case,  the 
common  duct  already  contains  stones.* 

Of  the  three  methods  above  mentioned,  however,  that  by  means  of 
Murphy's  button,  in  spite  of  the  ahove  objections,  is  probably  the   1> 
to   adopt    on    account  of  its   rapidity  and   efficiency  as   shown    by    the 
results  given  above.     The  operation  itself  is  similar  to  others  in  which 
|he  button  is  employed,  and  does  not  require  any  special   description. 

Owing  to  the  small  size  of  button  used,  there  is  little  or  no  danger  of 
intestinal  obstruction  supervening. 

It  seems  to  me  to  be  quite  unnecessary  to  exclude  the  part  of  the 
intestine  which  is  joined  to  the  gall-bladder,  with  the  object  of  prevent- 
ing the  intestinal  contents  from  reaching  the  gall-bladder.  Moynihan 
in  one  case  adopted  this  plan,  using  what  is  practically  an  adaptation 
of  Roux's  method  of  gastrojejunostomy.  Mikulicz  suggested  the 
anastomosing  the  limbs  of  the  loop  of  intestine  which  is  joined  to  the 
gall-bladder.  Not  only  are  these  complications  superfluous,  but  they 
are  both  impracticable  except  when  the  jejunum  is  used,  which  is 
certainly  not  the  best  part  to  choose  for  several  obvious  reasons. 

Choledoch- enterostomy. — This  operation  may  be  performed  in  much 
the  same  way  as  cholecystenterostomy,  a  fistula  being  established 
between  the  contiguous  parts  of  the  dilated  duct  and  the  duodenum  or 
other  available  part  of  the  intestine.  The  gall-bladder  may  be  so  small 
and  embedded  in  adhesions  from  long  standing  disease,  that  it  may  be 
either  entirely  overlooked  or  may  be  of  no  use  for  short-circuiting.  In 
a  recent  case  one  of  us  (R.  P.  R.)  joined  an  enormously  dilated  common 
bile-duct  to  the  anterior  surface  of  the  first  part  of  the  duodenum  by 
direct  suture  with  the  aid  of  clamp-forceps  used  as  in  gastrojejunostomy. 
The  obstruction  was  due  to  a  calcined  pancreatic  cyst  which  had 
completely  obstructed  the  lower  part  of  the  duct. 

CHOLECYSTECTOMY. 

The  indications  for  this  operation  as  given  by  Mayo  Robson  (loc. 
supra  rit.)  are  as  follows  :  "  (1)  In  bullet  wound  or  other  wound  of  the 
gall-bladder  where  suture  is  impracticable.  (2)  In  phlegmonous 
cholecystitis.  (3)  In  gangrene  of  the  gall-bladder.  (4)  In  multiple,  or 
in  perforating  ulcers.  (5)  In  chronic  cholecystitis  from  gall-stones, 
where  the  gall-bladder  is  shrunken  and  too  small  to  safely  drain,  and 
where  the  common  duct  is  free  from  obstruction.  (6)  In  mucous 
fistula  due  to  stricture  of  the  cystic  duct.  (7)  In  hydrops  of  the 
gall-bladder  due  to  stricture  of  the  cystic  duct ;  as  also  in  certain  cases 
where  the  gall-bladder  is  very  much  dilated.  (8)  In  certain  cases 
of  empyema,  where  the  walls  of  the  gall-bladder  are  very  seriously 
damaged.  (9)  In  cancer  of  the  gall-bladder."  To  avoid  this,  gall- 
stones should  be  treated  with  less  delay,  for  their  long-continued 
irritation  very  frequently  leads  to  the  development  of  carcinoma. 

*  "  Here  then  we  have  the  beginning  of  a  morbid  condition  of  which  no  man  can 
foresee  the  end.  There  is  no  reason  why.  in  the  course  of  time,  the  obstructed  duct  may 
not  become  full  to  overflow  with  numberless  gall-stone-  which  could  not  fail  in  this 
receptacle  to  cause  fully  as  much  disturbance  as  in  the  gall-bladder  itself."  Only  careful 
watching  of  cases  can  prove  whether  the  above  criticisms  are  true.  Those  surgeons  who 
are  familiar  with  Dr.  Med  raw's  work  will  feel  with  me  that  they  cannot  be  lightly  passed 
over. 

36—2 


564         OPERATIONS  ON  THE  ABDOMEN. 

It  has  also  been  suggested  by  Moynihan  and  others  that  the  gall- 
bladder should  be  removed  in  most  cases  of  gall-stones,  when  it  is 
certain  that  there  is  no  obstruction  of  the  common  bile-duet. 

Nearly  all  gall-stones  are  formed  within  the  gall-bladder,  and  are 
secondary  to  pathological  conditions  chiefly  affecting  it.  It  seems  to 
be  reasonable  to  remove  the  source  of  the  trouble  with  the  object  of 
preventing  its  recurrence,  but  true  recurrence  of  gall-stones  is  an 
extraordinarily  rare  event.  Drs.  Mayo  (Ann.  of  Sun/.,  vol.  xliv.  p.  210) 
in  a  review  of  1500  operations  upon  the  gall-bladder  and  bile  passages 
found  but  one  case  of  their  own  in  which  gall-stones  re-formed  in  the 
gall-bladder.  Stones  which  have  been  overlooked  may  be  mistaken 
for  recurrences.  Schott  (Beit.  Z.  Klin.  Chir.,  1903,  xxxix.  S.  427) 
states  that  in  only  5  per  cent,  of  180  cases  from  Czerny's  clinic  were  there 
any  biliary  symptoms,  and  that  in  no  case  was  a  stone  known  to  have 
formed,  although  the  eases  had  been  followed  for  about  six  years  after 
the  operation. 

In  many  cases  it  is  easier  to  remove  the  entire  gall-bladder  and  the 
greater  part  of  the  cystic  duct,  than  it  is  to  extract  the  stones,  which 
may  be  very  numerous,  and  some  of  which  may  be  overlooked  in  the 
cystic  duct  or  elsewhere.  In  such  cases  the  risk  of  infection  is 
diminished,  and  the  chance  of  recurrence  is  entirely  abolished  when 
the  disease  is  limited  to  the  gall-bladder. 

The  mortality  of  cholecystectomy  is  greater  than  that  of  cholecyst- 
ostomy,  even  in  skilled  hands.  Dr.  Mayo  writes  :  "  Cholecystectomy 
has  an  increasing  field  of  usefulness,  but  its  increase  of  mortality, 
which,  although  slight,  is  for  one  reason  or  another  fairly  certain,  prevents 
it  from  replacing  cholecystostomy.  At  the  same  time,  where  the  circum- 
stances permit  of  eas}r  removal  of  the  gall-bladder  and  the  disease  is 
confined  entirely  to  this  organ,  it  is  the  operation  we  most  commonly 
perform  even  in  cases  in  which  cholecystostomy  would  answer  the 
purpose.  But  if  the  patient  is  very  obese,  and  the  gall-bladder  has  a 
broad  attachment  to  the  liver  necessitating  prolongation  of  the  incision 
or  increased  manipulation,  cholecystectomy  is  the  more  difficult  and 
dangerous  operation."  For  the  great  majority  of  operators  chole- 
cystectomy would  be  very  much  more  difficult  and  dangerous  than 
cholecystostomy. 

When  the  gall-bladder  is  removed,  the  need  for  drainage  of  the 
biliary  passages  is  generally  abolished,  and  the  recovery  of  the  patient 
is  thus  accelerated.  Should  drainage  be  called  for,  it  can  be -established 
by  tying  in  a  rubber  tube  passed  into  the  remains  of  the  cystic  duct,  but 
this  is  neither  so  easy  nor  so  safe  as  draining  the  gall-bladder.  It  is 
rarely  wise  to  excise  the  gall-bladder  after  the  removal  of  stones  from 
the  common  bile-duct,  especially  if  cholangitis  exists,  for  secondary 
operations  are  more  often  needed  for  common  duct  cases  than  any 
others.  Moreover  the  gall-bladder  may  be  useful  later  for  drainage  or 
cholecystenterostomy  should  there  be  future  contraction  and  obstruction 
of  the  common  bile-duct,  and  "it  is  also  a  safe  guide  to  the  deep 
ducts  if  future  trouble  should   arise  "  (Mayo,  loc.  dt.). 

Another  reason  for  removing  the  gall-bladder  is  thai  a  thick-walled 
and  contracted  gall-bladder  may  be  the  seat  of  malignant  disease 
which  may  only  be  discovered  by  microscopical  examination  after  it 
has  been  removed.       Dr.  Sherrill  (Ann.  of Sun/.,  vol.  xliv.  p.  866)  draws 


f'HoLKCYSTKCTOMY. 


565 


attention  to  the  frequency  of  this  complication  in  late  cases,  and 
advocates  earlier  operation  in  order  to  avoid  it. 

There  is  little  or  no  real  evidence  thai  carcinoma  may  form  after  the 
removal  of  the  stones,  hut  only  that  the  disease  may  be  overlooked 
in  an  early  stage,  while  it  is  yet  removable  with  hope  of  permanent 
immunity  from  recurrence.  Mayo  mentions  one  patient  who  has  survived 
lor  over  three  years  after  an  early  cholecystectomy  for  this  condition. 

Operation. — The  exploratory  part  of  the  operation  has  been  already 
deserihed  at  p.  545.     When  the  gall-bladder  has  been  carefully  freed 

Fig.  225. 


Cholecystectomy.  The  cystic  duct  and  artery  are  tied,  the  former  as  close  as 
possible  to  its  termination.  The  gall-bladder  is  being  stripped  up  from  the  liver. 
The  cut  end  of  the  cystic  duct  is  closed  by  forceps.  (Moynihan,  Abdominal 
Operations.) 

from  adhesions  (p.  548),  and  the  surgeon  has  decided  to  excise  it  after 
due  consideration,  the  cystic  duct  is  exposed  by  incising  the  peritonaeum 
over  it. 

To  avoid  any  possibility  of  a  mistake,  the  point  of  meeting  of  the 
cystic  with  the  hepatic  and  common  bile -ducts  must  be  seen  (vide  Fig.  214, 

P-  547)- 

The  cystic  duct  is  tied  with  catgut,  and  divided  about  a  quarter  of  an 
inch  from  its  termination  between  the  ligature  and  pressure-forceps, 
which  prevent  leakage  from  the  gall-bladder  and  are  useful  for  gentle 
retraction.  The  stump  is  cleansed  and  any  mucous  membrane  pro- 
truding beyond  the  ligature  is  removed  with  sharp  pointed  scissors, 
and  the  stump  is  buried  by  sewing  the  peritonaeum  over  it. 


566 


OPERATIONS  ON  THE  ABDOMEN. 


The  cystic  vessels  are  sought,  and  will  be  found  usually  :i  little 
above  and  to  the  left  of  the  cystic  duct,  where  they  are  ligatured  and 

divided. 

It  is  of  considerable  advantage  to  secure  the  pedicle  before  attempting 
to  separate  the  viscus  from  the  liver,  so  that  blood  oozing  from  the 
liver  may  not  trickle  back  and  obstruct  the  view;  the  bleeding  is  also 
Lessened  during  the  next  steps. 

The  gall-bladder  is  now  separated  from  the  liver  by  blunt,  dissection 
from  below  upwards  and  forwards.  For  this  purpose  the  index  finger 
may  be  passed  between  the  gall-bladder  and  the  liver  as  recommended 
by  .Mr.  Moynihan  (vide  Fig.  225). 


Fig.  226. 


Cholecystectomy.     The  peritonaeum  is  being  divided  between  the  gall-bladder, 
which  is  partly  stripped,  and  the  liver.     (Moynihan,  Abdominal  Operations.') 

The  peritoneal  covering  is  saved  as  far  as  possible  until  the  separa- 
tion is  completed,  and  then  it  is  so  divided  with  scissors  that  the  edges 
can  be  sewn  together  to  cover  the  raw  surface  of  the  liver.  This 
prevents  adhesions  and  arrests  hemorrhage  from  the  liver  (vide 
Figs.  226,  227). 

Occasionally  when  there  are  dense  adhesions  it  may  be  easier  to 
separate  the  gall-bladder  from  before  backwards.  In  a  normal  case 
this  will  be  simple,  and  all  that  is  needful  is  to  divide  the  reflection 
of  peritonaeum  which  passes  from  the  liver  over  the  gall-bladder,  and 
then  to  shell  out  the  latter  from  its  fossa  by  gently  tearing  through  the 
connective  tissue  and  vessels  which  hold  it  in  place,  with  the  linger  or 
a  pair  of  curved  scissors,  these  being  used  as  a  blunt  dissector  as  well 


CHOLECYSTECTOMY. 


5&7 


as  to  cut  with.  In  cases,  on  the  other  hand,  where  there  is  much 
matting  of  the  parts,  the  omentum,  duodenum,  colon,  pylorus  may  all 
require  most  careful  detachment,  bit  by  bit,  before  the  gall-bladder  is 
reached,  lying  far  from  the  surface,  puckered  and  shrunken.  And 
when  this  is  effected,  repeated  attacks  of  inflammation  may  have  con- 
verted its  immediate  surroundings  into  a  compartment  of  sclerosed 
fibro-fatty  tissue  out  of  which  it  has  to  be  shelled  like  a  kidney,  the 
sih'  of  long-standing  calculous  pyelitis,  from  out  of  its  thickened,  matted 
1  upside.  Friability  of  the  walls  of  the  gall-bladder,  these  tearing  away 
on  the  slightest  traction,  is  another  difficulty  which  may  be  very  present 
with  a  deep-lying  viscus.     The  gall-bladder  having  been  separated  as 

Fig.  227. 


Cholecystectomy.    The   operation  completed  by  suture  of  the  peritonaeum 
over  the  bared  surface  of  the  liver.     (Moynihan,  Abdominal  Operations.) 

far  back  as  the  cystic  duct,  the  first  part  of  this  is  isolated,  and  its 
distal  extremity  tied  with  catgut. 

Care  must  be  taken  not  to  include  the  hepatic,  and  still  more  the 
common  duct,  in  cases  where  the  depth  of  the  wound  and  adhesions 
may  make  the  relations  of  parts  uncertain.  Before  severing  the  duct 
it  will  be  well,  if  two  ligatures  have  not  been  passed,  to  close  its 
proximal  end  with  clamp-forceps  so  that  no  bile  escapes  when  it  is 
divided. 

If  it  is  not  possible  to  bury  the  stump  it  may  be  treated  with  a 
little  pure  carbolic  acid.  When  it  is  not  possible  to  cover  the  raw 
surface  of  the  liver  with  peritonaeum,  the  bleeding,  chiefly  of  the 
nature  of  oozing,  usually  yields  to  well  applied  pressure,  and  the 
abdominal  wound  can  be  safely  closed  without  drainage.     The  anterior 


568 


OPERATIONS  ON  THE  ABDOMEN. 


Fig.  228. 


wall  of  the  rectus  -luatli  should  be  sutuivd  in  an  overlapping  manner 
to  minimise  the  risk  of  ventral  hernia  (vide  Fig.  228). 

Treatment  of  Biliary  Fistula. — This   most    troublesome   affection, 

winch  is  getting  much  less  common,  usually  follows  on  cholecystos- 
tomies.  It  has  already  been  alluded  to,  but  owing  to  its  importance 
and  the  difficulties  which  surround  it,  a  few  more  words  are  required. 
If  of  any  duration  it  depends,  usually,  upon  one  or  two  causes — a  stone 
impacted  in  the  common  duct,  or  malignant  disease  of  the  head  of  the 
pancreas.  The  annoyance  from  the  constant  discharge,  the  difficulty 
of  collecting  this,  the  frequent  change  of  dressings  necessitated  when 
the  patient  is  about,  the  eczema  and  rawness 
around  the  wound,  are  very  great.  In  the  case 
of  an  impacted  stone,  if  it  cannot  be  felt  and 
removed  or  dislodged  by  injections  or  by 
manipulations  from  the  adherent  gall-bladder, 
the  abdomen  should  be  freely  opened  by  an 
incision  to  the  inner  side  of  the  fistula,  expos- 
ing the  gall-bladder  adherent  to  the  parietes ; 
the  ducts  are  then  examined  and  the  stone 
localised  in  the  common  duct,  and  removed 
by  incision.  If  the  above  course  is  really 
impracticable,  cholecystenterostomy  must  be 
performed.  In  some  cases  choledoch-enteros- 
tomy  has  to  be  adopted  (p.  563).  When  the 
only  obstruction  is  in  the  cystic  duct  it  is  best 
to  perform  cholecystectomy  if  the  patient  wishes 
to4  get  rid  of  the  mucous  fistula.  "Where  it  is 
found  that  malignant  disease  is  the  cause  of 
the  obstruction,  if  this  be  in  an  early  stage 
(p.  559),  the  patient's  power  of  repair  good, 
and  the  blood  not  yet  seriously  altered,  chole- 
cystenterostomy should  be  considered. 

The  Mortality  of  operations  upon  the  Gall- 
bladder and  Bile-ducts.  —  This  has  been 
greatly  diminished  during  recent  years,  especi- 
ally in  the  hands  of  surgeons  with  a  large 
experience  of  these  operations.  It  must  not 
be  forgotten,  however,  that  the  average  operator 
does  not  get  nearly  such  good  results  as  those 
mentioned  below.  Dr.  Mayo  (loc.  supm  cit.)  and  his  brother  had  66 
deaths  in  1500  operations  upon  these  organs.  In  the  last  500  cases 
the  death  rate  was  only  3*2  per  cent.  These  statistics  include  all 
operations  for  acute  perforations,  with  septic  peritonitis  and  malignant 
disease  ;  and  also  all  deaths  occurring  in  the  hospital  without  regard 
to  the  length  of  time  after  the  operation.  "There  were  845  chole- 
cystostomies  with  a  mortality  of  2*13  per  cent."  In  the  last  272,  the 
death-rate  was  only  i'47-  There  were  319  cholecystectomies,  with  a 
death  rate  of  3*13  per  cent.,  which  was  reduced  to  1*62  per  cent,  in  the 
cases  included  in  the  last  series  of  500  operations  referred  to  above. 

There  were  207   operations    upon    the    common    duct.     Dr.    Mayo 
divides  them  into  four  groups  : — 

Group  1.     In  one  hundred  and  five,  gall-stones  were  present  in  the 


Dr.  Noble's  method  of 
overlapping  the  aponeurosis 
to  secure  wide  and  firm 
union.     (Ann.  of  Surg.) 


<  I IOLECYSTECTOMY.  569 

common  duct,  but  without,  any  Berious  symptoms  of  Lnfectioii  or 
complete  obstruction.     The  mortality  was  2*g  per  cent. 

Group  j.  There  were  ()i  cases,  in  which  infection  of  the  common 
and  hepatic  ducts  had  occurred,  with  "remittent  fever  "  and  deep 
jaundice  (infective  cholangitis).  Ten  deaths  occurred  giving  a  mortality 
of  16  per  cent.,  and  in  seven  cases  hepatic  duct  stones  had  formed 
and  gave  rise  to  later  troubles. 

The  recurrence  of  stones  also  occurred  in  at  least  three  cases  in 
which  there  was  enlargement  of  the  head  of  the  pancreas. 

Group  3.  There  were  29  cases  with  complete  obstruction  of  the 
common  bile  duct,  with  10  deaths  (34  per  cent.).  The  general  con- 
dition of  these  patients  was  very  bad,  and  some  of  them  had  cedeina 
of  the  feet,  with  bile  stained  fluid  in  the  peritoneal  cavity,  nephritis 
and  more  or  less  cholasmia.  Dr.  Mayo  believes  that  "  it  is  often 
wise  to  wait  for  a  period  of  remission  before  operation  "  in  cases  of 
acute  complete  obstruction. 

Group  4.  There  were  12  operations  for  malignant  disease  with 
four  deaths,  33  j  per  cent. 


CHAPTER   X. 
OPERATIONS   ON  THE  PANCREAS. 

The  Treatment  of  Injuries,  Pancreatitis,  Pancreatic  Calculi, 
Pancreatic  Cysts,  and  New  Growths. 

For  a  knowledge  of  these  diseases  we  are  largely  indebted  to  Senn, 
Fitz,  Opie,  Mikulicz,*  and  Mayo  Ilobson.t  The  last  two  especially 
have  done  brilliant  work  in  establishing  the  diagnosis  and  treatment  of 
diseases  of  the  pancreas  upon  a  sound  basis.  Placed  deeply  in  the 
abdomen,  and  surrounded  by  structures  of  great  importance,  this  organ 
was  long  considered  to  be  beyond  the  reach  of  surgery,  but  more 
accurate  knowledge  of  the  pathology  of  the  pancreas,  and  of  the  special 
surgical  principles  which  must  be  observed  to  attain  success  in  this 
branch  of  surgery,  has  already  done  much  to  change  our  views,  ami 
recent  results  show  that  the  future  is  full  of  promise. 

^Y<•  owe  much  to  Professor  Mikulicz  for  pointing  out  the  best  ways 
of  dealing  with  the  peculiar  dangers  and  difficulties  which  attend 
operations  upon  the  pancreas. 

Difficulties  and  Dangers  and  the  Methods  of  meeting  them. 

(a)  Diagnosis — The  position  of  the  pancreas  makes  it  very  difficult 
for  us  to  feel  and  recognise  any  enlargement  of  it,  unless  the  patient  is 
very  thin  or  the  abdominal  wall  relaxed  under  the  influence  of  an 
anaesthetic. 

The  function  of  the  organ  is  not  influenced  very  much  until  the 
disease  is  too  advanced  or  extensive  for  successful  surgical  treatment 
to  be  undertaken.  Systematic  examinations  of  the  urine  (Cammidge, 
Lancet,  1904,  vol.  i.  p.  782)  and  of  the  faeces  will  very  probably 
provide  us  with  earlier  indications  of  functional  changes,  and  will 
enable  ns  to  arrive  at  a  diagnosis  or  to  explore  earlier  than  hereto- 
fore. Until  recently  wounds  and  contusions  of  the  pancreas  were  more 
serious  than  those  of  any  other  abdominal  organ.  The  chief  reasons 
for  the  high  mortality  were  (a)  the  low  condition  of  the  patient  at  the 
time  of  the  operation,  owing  to  delay  in  diagnosis;  (/;)  haemorrhage 
and  the  difficulty  of  arresting  it;  (c)  escape  of  pancreatic  secretion 
into  the  peritonaeum  ;    (d)   concomitant  injuries. 

(b)  Hamorrhage. — The  pancreas  is  friable,  and  its  vessels  thin- 
walled  and  very  numerous,  so  that  it  is  very  difficult  to  stop  bleeding 
from  it.  It  is  impossible  to  catch  the  individual  blood-vessels  with 
artery  forceps  in  the  usual  way,  and  ligatures  often  do  not  hold,  but 

*  Ann.  of  Surg.,  1903,  vol.  xxxviii.  p.  1. 

t  Hunteriao  Lectures,  Ltmoet,  1904,  vol.  i.  pp.  773,  845,  ami  911. 


OPERATIONS   ()X   THE   PANCREAS.  571 

tear  through  the  delicate  tissues  and  blood-vessels.  It  is  best  to 
Buture  any  wounds  or  Lacerations  with  stout  catgut,  which  must  take  a 
good  bite,  and  must  not  pierce  the  ducts  or  be  drawn  too  tightly. 
Ligaturing  en  masse  will  also  stop  the  bleeding,  but  gangrene  of  the 
isolated  tissues  may  arise  and  be  followed  by  secondary  haemorrhage. 
Gauze  packing  is  usually  successful.  Haemorrhage  is  not  only  serious 
in  itself,  but  the  blood  also  forms  with  the  pancreatic  juice  an  excellent 
culture  material  for  bacteria. 

(r)  Escape  of  Pancreatic  Juice  and  exudation  from  the  injured 
and  inflamed  gland  into  the  peritonaeal  cavity  is  a  very  serious  catas- 
trophe, which  almost  inevitably  leads  to  peritonitis,  whether  the 
contaminating  fluid  is  originally  infective  or  not.  The  pancreas  is 
very  easily  infected  from  the  common  bile-duct,  which  often  contains 
infective  material,  owing  to  the  obstruction  at  the  ampulla  of  Vater, 
which  is  frequently  the  cause  of  the  pancreatic  disease.  Every  effort 
must  therefore  be  made  to  prevent  any  leakage  of  the  pancreatic 
exudate  into  the  peritonaeal  cavity.  This  can  be  done  by  establishing 
free  anterior  drainage,  or  in  some  cases  by  suturing  the  peritonaeum 
over  the  pancreas,  and  establishing  posterior  drainage.  It  is  dangerous 
to  let  the  fluid  escape  and  burrow  in  the  retro-peritonseal  tissues,  for 
infective  cellulitis  may  result  from  this.  Moreover,  the  pancreatic 
juice  dissolves  the  clots  in  and  around  the  severed  blood-vessels,  and 
restarts  hemorrhage.  It  is  essential,  therefore,  to  drain  away  the 
fluids  from  the  injured  or  diseased  pancreas,  and  failure  to  do  this  has 
almost  always  led  to  disaster. 

The  danger  of  wounding  the  pancreas  during  operations  is  shown  by 
the  fact  that  out  of  30  resections  of  the  stomach  in  which  the  pancreas 
was  wounded  either  accidentally  or  intentionally  the  mortality  was 
70  per  cent.,  whereas  the  death-rate  of  91  resections  without  any 
injury  of  the  pancreas  was  27*5  percent.  The  difference  could  not  be 
entirely  or  even  chiefly  due  to  the  more  extensive  or  later  disease,  for  the 
deaths  mostly  occurred  not  from  shock,'Jbut  from  peritonitis,  which  was 
doubtless  due  to  the  escape  of  pancreatic  secretions  into  the  peritonaeum 
(Mikulicz) . 

Various  Methods  of  approaching  the  Pancreas. — There  are  several 
ways  of  reaching  this  deeply  placed  organ,  and  they  may  be  conveniently 
divided  into  anterior  and  posterior  operations. 

The  anterior  route  allows  a  far  more  thorough  exploration,  but  the 
posterior  provides  the  best  drainage  in  some  cases,  and  carries  less 
risk  of  peritonseal  infection  from  escaping  pancreatic  secretions. 

The  Anterior  Route. — The  abdomen  is  opened  by  making  an 
incision  between  the  umbilicus  and  the  ensiform  cartilage,  a  little  to 
one  or  other  side  of  the  middle  line  (vide  Fig.  211,  p.  531).  The  fibres 
of  the  rectus  may  be  either  drawn  out  or  separated.  Better  drainage 
is  provided  by  separating  the  fibres,  and  this  also  gives  less  risk  of 
infection  of  the  abdominal  wall  in  infective  cases.  In  rare  cases, 
where  drainage  is  likely  to  be  quite  unnecessaiy,  a  valvular  incision 
may  be  made  by  displacing  the  rectus  (vide  p.  507).  The  abdomen 
having  been  opened,  there  are  several  ways  of  getting  at  the  pancreas. 
In  some  cases  the  surgeon  has  no  choice,  for  a  swelling,  such  as  a 
cyst  or  abscess,  has  already  approached  the  surface  either  below  or 
above  the  stomach,  and  the  surgeon  should  then    abide  by  nature's 


572 


ol'EKATIOXS    ox    TIIK    A.BDOMEN. 


decision.     When  little  or  qo  swelling  exists   much  may  depend  upon 
the  mobility  and  position  of  the  stomach. 

(a)  Through  the  gastro-colic  ligament  (vide  Fig.  229).  This  should 
he  picked  up  and  incised  below  the  greater  curvature,  and  the  vascular 
arch  that  lies  beneath  it.  A  vertical  incision  should  be  made  to  avoid 
the  omental  blood-vessels,  and  this  should  be  enlarged  to  the  required 
extent  by  tearing.  The  lesser  sac  having  been  opened,  the  anterior 
surface  of  the  pancreas  can  be  examined  after  displacing  the  stomach 
upwards. 

(b)  Through  the  gastro-hepatic  omentum  a  transverse  incision  is 
made  through  this  membrane  where  it  is  thin  above  the  vascular  arch, 

Fig.  229. 


Incision 


Lesser 

omentum 

Arterial  arch 
above  stomach 


Incision 

in  gastro-col 

omentum 


Gastroepiploic 
vessels 


Umbilicus 


The  pancreas  is  best  approached  either  through  the  gastro-colic  ligament  or 
through  the  gastro-hepatic  omentum,  according  to  the  relation  of  the  stomach  to 
the  pancreas  and  to  the  position  of  any  bulging. 


and  to  the  left  of  its  thick  right  border,  which  includes  the  portal  vein, 
hepatic  artery,  and  common  bile-duct.  When  the  stomach  is  drawn 
downward,  the  pancreas  can  be  explored  with  ease. 

(c)  Through  the  transverse  meso-colon  after  displacing  the  colon 
upwards  as  in  gastrojejunostomy.  This  method  does  not  give  such  a 
good  view,  nor  so  direct  an  approach,  and,  lastly,  it  is  unfortunately 
placed  for  establishing  anterior  drainage,  for  any  leaking  fluid  will  at 
once  gravitate  amongst  the  coils  of  small  intestine.  Dr.  Porter,  how- 
ever, used  this  route  in  his  successful  case  of  acute  pancreatitis  ;  he 
used  a  transverse  incision  within  the  arterial  arch  which  supplies  the 
transverse  colon. 

(d)  By  displacing  the  duodenum  after  Kocher's  method  of  incising 
the  parietal  peritonaeum  to   the  right   of  the  descending  part  of  this 


OPERATIONS   ON   THE    PANCREAS.  573 

intestine.  This  method  only  gives  access  to  a  part  of  the  head,  and 
its  adoption  is  difficult  and  may  be  attended  with  profuse  haemorrhage. 
Moreover,  drainage  is  difficult  from  this  situation. 

(e)  Through,  the  duodenum. — The  pancreatic  duct  towards  its  termina- 
tion and  the  ampulla  of  Yater  may  be  reached  through  a  longitudinal 
incision  in  the  anterior  wall  of  the  duodenum  (videYig.  214,  p.  547). 

(/)  Through  the  stomach. — This  method  is  only  mentioned  to  be 
condemned.  Hagen  used  it  successfully  in  one  case,  that  of  a  very 
adherent  pancreatic  cyst  in  a  boy.  It  was  found  to  be  impossible  to 
bring  the  cyst  to  the  abdominal  incision,  and  as  it  lay  directly  behind 
the  stomach,  the  anterior  and  posterior  walls  of  the  latter  were  incised, 
and  the  cyst  emptied.  A  part  of  the  costal  margin  was  then  resected, 
and  the  cyst  wall,  now  more  movable,  was  brought  to  the  parietal 
peritonaeum  after  displacing  the  sutured  stomach.  In  such  a  case  it 
would  be  far  better  to  first  aspirate  the  cyst  below  or  above  the 
stomach,  and  then  to  bring  the  lax  cyst  wall  to  the  surface,  or,  failing 
this,  to  fix  a  tube  in  it  with  a  purse-string  suture.  It  might  also  be 
approached  from  the  left  loin. 

(//)  Post-approach. — Either  an  oblique  or  a  vertical  incision  may  be 
made  in  the  left  loin,  or  in  some  cases  of  disease  of  the  head  of  the 
pancreas  in  the  right  loin.  The  vertical  incision  should  be  parallel 
and  a  little  external  to  the  outer  border  of  the  erector  spinas,  as  advised 
by  Mr.  Cathcart.  An  oblique  incision  closely  resembling  the  one 
employed  in  nephrolithotomy  may  be  used. 

INJURIES. 

The  pancreas  is  not  often  injured,  because  of  its  deep  and  protected 
position,  but  when  it  is  damaged  either  from  contusion  or  penetration, 
other  organs  are  very  frequently  affected  at  the  same  time. 

AVhen  the  abdomen  is  explored  under  these  circumstances,  pancreatic 
lesions  are  very  apt  to  be  overlooked,  with  fatal  consequences.  It  is 
important,  therefore,  to  examine  this  organ  before  completing  all 
explorations  for  injuries  of  the  upper  abdomen. 

Apart  from  wounds,  it  will  be  a  rare  event  for  a  correct  diagnosis  to 
be  arrived  at  before  the  abdomen  is  opened  for  signs  of  internal 
haemorrhage,  abdominal  tenderness  and  rigidity,  indicating  peritonaeal 
irritation  of  uncertain  cause,  but  demanding  immediate  attention.  In 
a  few  cases  a  swelling  may  appear  in  the  epigastrium,  and  in  one  case 
that  I  saw  there  was  glycosuria. 

Even  when  an  injury  of  the  pancreas  is  suspected  the  abdomen 
should  be  explored  through  an  incision  near  the  middle  line,  so  that 
the  other  viscera  may  be  examined  also.  Blood  may  ooze  from  the 
lesser  sac  of  peritonaeum,  or  areas  of  fat  necrosis  may  draw  the 
attention  of  the  surgeon  to  the  pancreas,  which  he  may  then  find  to  be 
enlarged  from  haemorrhage. 

The  gland  may  be  approached  either  through  the  gastro-colic 
ligament,  small  omentum,  or  transverse  mesocolon. 

Haemorrhage  must  be  arrested  by  sutures,  ligatures,  or  gauze  packing, 
and  free  drainage  must  be  established  either  anteriorly,  posteriorly,  or 
both  ways.  When  the  peritonaeum  can  be  sewn  over  the  damaged 
organ  this  should  be  done,  but  this  does  not  abolish  the  need  of 
drainage,  at  least  through  the  loin. 


574  OPERATIONS   ON   THE   ABDOMEN. 

In  cases  of  wounds  from  behind,  it  is  only  necessary  to  explore  the 
abdomen  when  signs  and  symptoms  of  penetration  of  the  peritoneum 
manifest  themselves ;  but  the  patient  should  be  carefully  watched,  so 
thai   abdominal  section  can  be  undertaken  immediately  if  any  indica- 

t  ions  arise. 

Gunshot  wounds  are  generally  penetrating,  and  inflict  injuries  upon 
neighbouring  organs,  such  as  the  stomach,  colon,  or  small  intestine. 
In  any  case  drainage  is  essential. 

Mikulicz  collected  45  cases  of  injury  of  the  pancreas,  21  penetrating 
and  24  subcutaneous  lesions.  Of  the  former  12  were  gunshot  woundsj 
of  which  five  were  treated  by  operation,  with  three  recoveries  ;  and  seven 
were  not  operated  upon,  all  of  these  died. 

Out  of  nine  stab  wounds  only  two  penetrated  the  peritonaeum  ;  no 
drainage  was  employed  in  one  of  these,  who  died ;  the  other  recovered 
notwithstanding  multiple  intestinal  perforations. 

All  of  the  seven  with  retro-peritonaial  stab  wounds  recovered,  but  in 
several  of  these  the  gland  had  prolapsed  into  the  wound  without  being 
seriously  damaged. 

In  some  cases  the  tail  may  be  resected  after  ligation  or  suture  of  the 
gland  near  the  line  of  section  to  prevent  haemorrhage. 

Out  of  24  subcutaneous  injuries  no  operation  was  undertaken  in 
13;  all  of  these  patients  died,  but  as  death  was  the  means  of  the 
discovery  of  the  lesions,  it  is  quite  possible  and  even  probable  that 
some  patients  recover  from  slight  subcutaneous  injuries.  Of  11  treated 
by  operation  seven  recovered. 

It  is  significant  that  out  of  12  operations  for  various  injuries 
drainage  was  employed  in  eight,  with  six  recoveries,  and  that  the 
four  cases  in  which  drainage  was  not  considered  necessary  ended  fatally. 

Dr.  Randall  (Lancet,  1905,  vol.  i.  p.  291)  successfully  operated  011  a  man.  ret.  4S,  who 
bad  been  injured  in  the  epigastrium  by  the  pole  of  a  van,  which  jammed  him  against  a 
stationary  van.  The  operation  was  undertaken  six  hours  after  the  injury,  on  account  of 
gravity  of  the  collapse,  the  site  of  the  injury,  and  dulness  in  the  right  Hank.  The  abdomen 
was  opened  above  the  umbilicus,  and  much  clotted  and  fluid  blood  was  removed.  A  large  tear 
was  found  in  the  small  omentum,  ami  another  in  the  posterior  wall  of  the  loser  sac,  through 
which  a  laceration  two  inches  long  was  discovered  in  the  body  of  the  pancreas,  and  tin' 
aorta  was  felt  in  the  floor  of  the  wound,  which  was  sutured  with  Four  silk  stitches.  I 
was  not  much  trouble  from  haemorrhage.  Drainage  was  established,  and  the  peritonaea] 
cavity  cleansed  and  irrigated.  The  man  ultimately  recovered  completely,  although  he  had 
troublesome  mental  symptoms  for  a  time  and  developed  a  ventral  hernia  at  the  site  of 
drainage. 

ACUTE     PANCKEATITIS  ;      ACUTE     HEMORRHAGIC 
PANCREATITIS. 

This  is  an  acute  inflammation  of  the  pancreas,  usually  associated 
with  and  sometimes  arising  from  profuse  interstitial  haemorrhage,  and 
either  terminating  fatally  in  a  few  days  or  subsiding  into  subacute  or 
chronic  pancreatitis.  In  some  cases  suppuration  or  even  extensive 
gangrene  of  the  pancreas  may  occur. 

The  first  accurate-  account  of  tbis  rare  disease  was  given  by  Fits 
(New  York  Med.  Record,  1889).  Since  then  a  number  of  cases  have 
been  recorded  by  various  observers. 

The  chief  symptoms,  as  summarised  by  fit/.,  are — "  sudden,  severe, 


,\n  TK    PANCREATITIS.  575 

often  intense  epigastric  pain,  without  obvious  cause,  in  most  cases 
followed  by  nausea,  vomiting,  sensitiveness,  ;m<l  tympanitic  swelling  of 
the  epigastrium.    There  is  prostration,  often  extreme,  frequent  collapse, 

low  fever,  and  a  feeble  pulse.      Obstinate   Constipation  for  several   days 

is  the  ride,  hut  diarrhoea  sometimes  occurs.  If  the  case  does  not  end 
fatally  in  the  course  of  a  few  days,  recovery  is  possible,  or  a  recurrence 
i)f  the  symptoms  in  a  milder  form  takes  place,  and  the  characteristics 
of  a  subacute  peritonitis  are  developed." 

Cyanosis  of  the  face  and  a  general  lividity  is  also  a  striking  sign  in 
some  cases  ;  this  was  evident  in  several  patients  that  I  have  seen. 

Very  few  of  the  cases  have  been  correctly  diagnosed,  tin;  majority,  as 
will  he  readily  understood  by  consideration  of  the  ahove-mentioned 
symptoms,  having  heen  thought  to  he  either  acute  peritonitis  (especially 
that  due  to  perforation  of  a  gastric  ulcer)  or  acute  intestinal  obstruc- 
tion,  usually  the  latter.  Recently  a  correct  diagnosis  has  more 
frequently  heen  made. 

In  a  few  instances  the  presence  of  an  epigastric  tumour  has  materially 
aided  the  diagnosis  ;  such  cases  have  heen  recorded  by  Thayer  (Amer. 
Journ.  of  Mr, I.  Sci.,  vol.  ex.),  Pitt  (Clin.  Soc.  Trans.,  vol.  xxxii.),  and 
others.  In  Thayer's  case,  abdominal  section  revealed  the  presence  of 
an  abscess  in  connection  with  the  pancreas,  drainage  of  which  resulted 
in  recovery.  In  Dr.  Pitt's  case,  the  tumour  was  chiefly  due  to  blood 
effusion  in  and  around  the  pancreas. 

Treatment. — The  uncertainty  of  the  diagnosis,  or  the  fact  that  acute 
pancreatitis  was  unsuspected,  has  led,  in  the  majority  of  cases,  to  the 
performance  of  an  exploratory  laparotomy.  Should  such  an  operation 
be  performed  on  a  patient  supposed  to  be  suffering  from  either  acute 
intestinal  obstruction  or  acute  peritonitis  with  a  negative  result,  the 
possibility  of  acute  pancreatitis  must  be  considered.  The  following 
points  will  be  found  useful  under  such  circumstances : 

(1)  Fat  necrosis  may  be  present.  This  occurs  in  the  form  of  small 
patches,  circular  or  oval  in  shape,  and  of  an  opaque  white  or  yellow 
appearance,  scattered  about  the  fat  over  the  pancreas,  the  omentum, 
and  the  mesentery.  If,  on  careful  inspection  with  a  good  light, 
evidence  of  fat  necrosis  is  found,  it  may  be  inferred  that  some  serious 
lesion  of  the  pancreas  is  present.  Absence  of  fat  necrosis,  on  the 
other  hand,  does  not  exclude  the  possibility  of  acute  pancreatitis. 

(2)  Blood-stained  fluid  is  found  within  the  abdominal  cavity. 

(3)  Swelling  of  the  pancreas  on  palpation. — This  may  he  due  to 
inflammatory  exudation,  blood  effusions,  or  a  collection  of  pus.  In 
order  to  further  examine  the  pancreas,  it  must  be  approached  either 
through  the  small  or  great  omentum,  whichever  is  found  to  be  the 
more  convenient.  It  is  then  found  to  be  greatly  swollen,  soft,  and  of 
a  purplish  colour. 

If  a  diagnosis  of  acute  pancreatitis  is  made  either  before  or  after 
exploratoiy  laparotomy,  the  further  treatment  will  depend  upon  the 
particular  condition  of  the  pancreas  that  is  found  to  be  present. 

The  swollen  gland  is  incised  with  due  regard  to  the  large  blood- 
vessels and  the  pancreatic  duct.  Haemorrhage  is  arrested  by  means  of 
tampons  of  gauze,  and  free  drainage  is  established  either  anteriorly  or 
posteriorly.  Mr.  Mayo  Robson  favours  posterior  drainage  through  the 
left  loin.    The  disadvantages  of  this  are  that  (1)  another  incision  will  have 


576  OPERATIONS  ON  THE  ABDOMEN. 

to  be  made,  which  may  lead  to  injury  of  the  splenic  or  renal  vessels 
if  done  hurriedly,  as  may  be  necessary  in  these  patients.  (2)  Posterior 
drainage  does  not  certainly  prevent  leakage  from  the  anterior  surface 
of  the  gland  into  the  peritonaea!  cavity ;  on  the  other  hand,  it  does  prevent 
retro-peritonaeal  extravasation.  A  large  rubber  tube  containing  a  wick 
of  gauze,  and  surrounded  with  layers  of  the  same,  may  be  used  for 
drainage. 

The  peritonaeum  should  be  mopped  quite  dry  of  the  sanious  fluid 
within  it. 

Mikulicz  advocates  irrigation  with  normal  saline  solution. 

Mr.  Mayo  Robson  recommends  that  the  gall-bladder  and  bile-ducts 
be  examined,  and  that  if  a  calculus  be  discovered  at  the  ampulla  it 
should  be  removed  if  the  patient's  condition  allow,  or  if  not,  that  a 
cholecystotomy  be  performed,  with  the  object  of  providing  a  vent  for 
the  retained  and  infective  contents  of  the  biliary  and  pancreatic  ducts. 

Opie  and  Mayo  Robson  have  shown  that  regurgitation  of  septic  bile 
into  the  pancreas  is  at  least  a  common  cause  of  acute  pancreatitis. 
But  the  condition  of  the  patient  is  rarely  such  as  to  allow  any  radical 
operation,  and  it  cannot  be  said  that  even  cholecystotoni}'  is  necessary 
for  recovery,  although  it  may  contribute  towards  it,  if  done  without 
unduly  prolonging  the  operation. 

Owing  to  the  extremely  serious  condition  that  the  patient  is  usually 
in,  every  possible  precaution  must  be  taken  to  avoid  shock,  and  the 
operation  itself  must  be  performed  as  rapidly  as  possible. 

For  a  long  time  acute  pancreatitis  was  regarded  as  an  inevitably 
fatal  disease,  so  that  when  it  was  discovered  during  the  exploration  no 
attempt  was  made  to  deal  with  the  pancreas  directly. 

In  four  cases,  however,  peritonseal  drainage  alone  was  attended  with 
success. 

Dr.  Muspratt,  an  old  Guy's  man,  was  the  first  to  treat  this  disease 
rationally  on  Dec.  2,  1902,  and  his  surgical  instinct  and  courage 
were  rewarded  by  the  recovery  of  the  patient  (Dr.  Muspratt  and  Dr. 
Ramsay,  Brit.  Med.  Journ.,  1904,  vol.  i.  p.  304). 

The  patient  was  a  woman,  40  years  of  age,  who,  after  years  of  abdominal  suffering,  was 
suddenly  seized  with  severe  pain  in  the  abdomen,  attended  by  collapse  and  persist ■  n t 
vomiting.  Laparotomy  was  performed  within  twenty-four  hours,  and  a  swollen,  tense,  and 
purple  pancreas  discovered.  A  free  incision  was  made  into  its  head,  and  free  haemorrhage 
followed,  but  this  was  checked  after  some  trouble,  a  gauze  drain  was  inserted,  and  the 
patient  rapidly  recovered. 

Dr.  Porter,  of  Boston,  soon  afterwards  operated  successfully  upon  the  same  lines,  on 
Feb.  17,  1903  (Mikulicz,  lor.  supra  eit.~).  The  patient  was  a  man,  56  years  of  age,  who 
was  under  treatment  in  October,  1902,  for  dull  pain  in  the  right  hypochondrium.  from 
which  he  had  suffered  for  several  years.  He  also  complained  of  chronic  constipation.  A 
year  before  admission  he  had  Bharp  pain  in  the  epigastrium  and  right  iliac  fossa.  He  had 
never  had  jaundice,  vomiting,  or  rigors.  From  Nov.  5,  1902,  to  Feb.  17,  1903,  he  had 
several  attacks  of  severe  pain  in  the  right  hypochondrium  and  epigastrium,  and  in  January, 
1903,  slight  jaundice  appeared,  and  gall-stones  were  diagnosed.  <>n  Feb.  15  sudden, 
severe  epigastric  pain  developed,  and  extended  to  the  right  iliac  fossa.  The  pain  continued 
inspit  of  temporary  relief  with  morphia,  and  later  it  became  general  all  over  the  abdomen, 
and  it  was  accompanied  with  vomiting  and  constipation  which  waB not  complete.  The 
man  was  emaciated,  very  restless  From  mnch  pain  and  distress;  the  vomit  was  neither 
faecal,  nor  did  it  contain  blood.  Abdominal  distension  and  rigidity  was  moderate,  and 
there  was  no  visible  peristalsis.  Shifting  dulness  was  noticed.  The  temperature  was 
ioo°,  the  pulse  100  and  weak,  the  respiration  30  per  minute.     A  diagnosis  of  intestinal 


SUBACUTE    PANCREATITIS.  577 

obstruction  due  to  a  band  was  made:  the  band  being  considered  to  be  secondary  to  gall- 
bladder or  appendicular  disease.     An  incision  was  made  Ei 3  inches  below  the  en 

cartilage  to  within  2  inches  of  the  pubis.     A  Large al  of  brownish  red  fluid  escaped  ■ 

this  proved   to   be  Bterile.*     No  obstruction   i Id    be    discovered,   the  appendix    was 

congested  an. I  was  removed,  the  Eal  in  its  mesentery  was  necrosed.    The  gall-bladder  was 
full  of  bile,  the  pancreas  was  (wire  the  normal  size,  hard  and  tense.     The  abdomen  was 
irrigated  and  the  wound  closed.     A  second  incision  was  now  made  parallel  to  the  Lefi 
costal  margin,  which  was  retracted,  and  the  stomach  an. I  small  intestines  were  pa 
away  with  gauze,  and  the  pancreas  approached  through  the  transverse  meso-colon  ;  ij 
very  large,  tense,  oedematous,  and  deep  purple  in  colour.     No  stones  could  befell  in  the 

pancreatic  duct.      The  pancreas  was  freely  incised  along  H  3  anterior  surface,  and   drai 

was  established.  The  patient  improved  rapidly.  In  April  il  was  considered  to  be  neci 
to  re-operate  on  accouni  of  recurrence  of  pain.  A  small  cavity  was  found  in  the  pancreas 
containing  sterile  debris.  The  gall-bladder  was  stitched  to  the  wound,  but  not  opened. 
The  duodenum  was  turned  forwards  for  examination  of  the  head  and  duct  of  the  pancreas. 
Pneumonia  followed,  but  the  patient  rceovered  in  spite  of  this  and  gained  ten  pounds  in 
weight. 

Mikulicz  analysed  the  records  of  75  cases  of  operation  for  acute 
pancreatitis,  of  $J  of  these  in  which  the  pancreas  itself  was 
involved  in  the  operative  interference,  25  recovered.  Of  41  where  the 
pancreas  was  not  tackled,  4  recovered  with  peritonseal  drainage,  and 
after  csecostomy  for  paralytic  distension  in  one  case  (Henle). 

Mayo  Robson  (loc.  supra  cit.)  has  operated  upon  6  cases  with 
two  recoveries.  He  states  that  after  59  operations  undertaken  in  the 
acute  stage,  23  recoveries  took  place. 

If  all  the  cases  were  published  the  results  would  not  be  so  favourable, 
but  every  recovery  means  a  life  saved,  for  few,  if  any,  patients  ever 
recover  spontaneously  from  acute  pancreatitis. 

It  has  been  suggested  that  the  operation  should  be  deferred  until 
the  subacute  stage  of  the  disease,  but  this  is  inadvisable,  for  the  large 
majority  of  the  patients,  if  untreated,  die  in  the  acute  stage,  and  only 
the  milder  cases  ever  reach  the  more  favourable  subacute  stage  of 
suppuration. 

SUBACUTE     PANCREATITIS. 

Here  the  inflammation  is  less  acute  from  its  commencement,  and 
the  patient  survives  long  enough  for  suppuration  or  gangrene  to 
occur.  The  abscess  may  burst  into  the  stomach,  colon,  duodenum,  or 
peritonaeum,  or  it  may  reach  or  bulge  forwards  into  the  epigastrium  or 
umbilical  region,  or  backwards  into  the  loin  generally  on  the  left  side. 

Spontaneous  recovery  may  occasionally  occur  from  rupture  into  the 
alimentary  canal,  or  upon  the  surface,  but  if  the  condition  is  not 
treated  surgically,  death  usually  occurs  from  septicaemia,  sub-diaphrag- 
matic abscess,  wasting,  or  pulmonary  complications. 

Operation. — The  abdomen  is  opened  by  separating  the  fibres  of  the 
rectus  abdominis,  above  the  umbilicus,  and  to  either  side  of  the  middle 
line  according  to  the  position  of  the  swelling  which  may  usually  be 
discovered,  especially  when  the  patient  is  anaesthetised.  The  abscess 
may  bulge  forwards  either  below  or  above  the  stomach,  and  therefore 
it  may  be  approached  through  either  the  gastro-colic   ligament   or  the 

*  Hlava  and  others  had  previously  shown  that  the  sa n ions  peri tonaeal  fluid  and  a lso 
the  exudation  within  the  pancreas  are  sterile  in  at  least  some  eases  early  in  their  course. 
S. VOL.  II.  37 


578  OPERATION'S   ON    Till!    ABDOMEN. 

small  omentum  (Fig.  22g),  the  most  direct  route  being  selected  in  each 
case,  after  carefully  protecting  tin-  peritonaeum  by  gauze  packing. 
Drainage  may  be  established  by  means  of  a  rubber  tube  containing 
a  wick  and  surrounded  with  a  layer  or  two  of  gauze.  The  wound  is 
then  partly  closed. 

Mr.  Mayo  Bobson  (Brit.  Med.  Journ.,  .May  ii,  1901)  recommends  a 
vertical  posterior  incision  in  the  left  costo-vertebral  angle  for  this 
purpose.  Such  an  incision  would  certainly  be  more  favourably  placed 
for  the  purposes  of  drainage;  great  care,  however,  would  have  to  be 
exercised  in  carrying  out  this  plan  in  view  of  the  important  structures 
which  might  be  injured.  This  plan  is  especially  suitable  for  large 
collections. 

If  the  surgeon  has  not  opened  the  abscess  in  front,  he  can  then 
dispense  with  anterior  drainage  and  close  the  wound  completely  so  as 
to  avoid  the  risk  of  ventral  hernia. 

In  the  majority  of  cases  anterior  drainage  alone  will  be  both 
necessary  and  sufficient,  and  there  is  little  risk  of  contaminating  the 
peritonaeum  if  care  be  taken  to  pack  around  before  opening  the  abscess. 

Either  immediately  or  later,  characteristic  grey  or  greyish  black 
sloughs  of  the  pancreas  may  come  away,  as  in  a  case  that  I  saw  under 
the  care  of  my  colleague,  Mr.   Dunn,  in  1898. 

This  patient,  a  middle  aged  stout  woman,  had  suffered  such 
agonising  pain  in  the  epigastrium  and  right  hypochondrium,  that 
she  had  acquired  the  morphia  habit.  In  the  last  attack  a  vague 
swelling  appeared  above  the  umbilicus  and  to  right  of  the  middle  line, 
vomiting  became  very  troublesome,  and  constipation  almost  complete. 
The  abscess  was  opened  through  the  right  rectus  muscle  and  gastro- 
colic ligament.  This  gave  immediate  relief,  and  the  patient  gradually 
made  a  complete  recovery. 

In  one  case  Mr.  Mayo  Robson  performed  a  gastrojejunostomy 
successfully  after  an  abscess  had  burst  into  the  stomach  and  continued 
to  discharge  its  foul  contents  into  the  latter. 

Mr.  Mayo  Robson  has  recorded  7  operations  with  5  recoveries,  and 
has  collected  7  others  with  4  recoveries.  Two  of  Mr.  Robson's  5  patients 
who  recovered  from  the  operation  died  later ;  one  after  a  few  weeks 
from  pulmonary  complications,  and  the  other  from  exhaustion  and 
wasting  after  a  few  months. 

CHRONIC    PANCREATITIS. 

Riedel  first  pointed  out  the  relation  of  this  condition  to  cholilithiasis, 
but  to  Mr.  Mayo  Robson  belongs  the  credit  of  defining  and  drawing 
the  attention  of  the  profession  to  this  important  subject  (loc.  supra  cit.). 
In  the  great  majority  of  cases,  chronic  pancreatitis  is  secondary  to 
impaction  of  a  calculus  within  the  ampulla  of  Vater  or  in  the  lower 
part  of  the  common  bile-duct  or  the  pancreatic  duct.  But  when  an 
operation  is  undertaken  the  calculus  may  have  already  sloughed  out 
or  passed  on  into  the  duodenum  or  may  not  be  discovered. 

It  is  due  essentially  to  infection  ascending  along  the  pancreatic  duct, 
and  it  has  followed  typhoid  fever  as  in  a  case  recorded  by  Mr. 
Moynihan. 

The  result  is  a  chronic  interstitial  and  parenchymatous  inflammation 


CIIIIO.XIC    PANCIJKATITIS.  57g 

which  usually  and  chiefly  concerns  the  head  of  the  pancreas,  which 
becomes  enlarged  and  hard,  so  that  it  closely  resembles  malignant 
disease,  for  which  it,  lias  heen  very  frequently  mistaken  during  explora- 
tory operations  tor  jaundice  and  other-  signs  of  obstruction  of  the 
common  bile-duct ;  under  these  circumstances  cholecystostomy  has  heen 
performed  and  the  patient  has  recovered,  much  to  the  surprise  of  all 
concerned. 

If  left  too  long  untreated,  the  patient  may  die  of  obstructive  jaundice 
or  rapid  emaciation.  Long  continued  obstruction  to  the  flow  of 
pancreatic  juice  may  lead  to  such  an  amount  of  destruction  of  the 
pancreatic  tissue  as  to  lead  to  diabetes,  and  similarly  the  liver  may 
become  cirrhotic  from  obstruction  to  the  biliary  flow.  As  far  as 
possible  the  diagnosis  between  carcinoma  and  chronic  pancreatitis 
must  be  made  before  an  operation  is  undertaken,  for  operative  inter- 
ference does  no  good  in  cases  of  carcinoma  of  the  head  of  the  pancreas, 
and  even  an  exploration  may  prove  fatal.  A  careful  consideration 
of  the  clinical  history,  especially  the  history  of  cholelithiasis,  and  a 
careful  examination  of  the  urine,  will  often  lead  to  a  correct 
conclusion. 

Mr.  Mayo  Robson  believes  that  Dr.  Cammidge's  reaction  is  of  great 
value  in  these  cases,  but  others  are  not  so  sanguine  (Lancet,  1906, 
vol.  i.  p.  756). 

Treatment. — A  thorough  exploration  should  be  undertaken  through 
the  right  rectus,  and  a  decision  made  between  carcinoma  and  chronic 
pancreatitis  from  palpation  of  the  pancreas,  and  the  presence  or  absence 
of  any  calculous  obstruction  of  the  bile  or  pancreatic  duct,  especial 
attention  being  paid  to  the  ampullary  region. 

Any  calculus  that  may  be  discovered  is  removed  {vide  p.  558),  and 
this  may  be  enough  in  some  cases,  but  if  there  be  much  sclerosis  of 
the  pancreas,  or  if  no  calculus  be  discovered,  free  drainage  of  the 
infective  contents  of  the  pancreatic  and  bile-ducts  must  be  established 
by  performing  cholecystostomy,  or  cholecystenterostomy,  or  if  the 
cystic  duct  be  obstructed  the  common  bile-duct  must  be  drained  (vide 
PP-  555,  556). 

Cholecystostomy  is  easier,  safer,  and  better  than  cholecystenteros- 
tomy ;  for  infection  of  the  ducts  may  take  place  through  the  fistula 
into  the  duodenum,  but  the  danger  of  this  has  been  exaggerated,  as 
shown  by  the  researches  of  Radziewski  (Mikulicz,  loc.  cit.). 

Mayo  Robson  (loc.  supra  cit.)  records  5T  cases  with  two  deaths  from 
operation,  a  mortality  of  3*9  per  cent.  Out  of  62  published  cases 
eight  died,  giving  a  death-rate  of  12*9  per  cent. 

In  27  cases  of  calculous  obstruction,  recorded  by  the  same  surgeon, 
choledochotomy  was  performed  in  19,  cholecystostomy  in  five,  and 
cholecystenterostomy  in  three. 

Some  time  afterwards  all  these  patients  were  well,  except  one  who 
had  died  from  bronchitis,  one  who  was  suffering  from  cirrhosis  of  the 
liver,  and  one  who  had  glycosuria  8£  years  after  the  operation. 

Out  of  24  cases  in  which  no  calculus  was  found  cholecystostom}r  was 
performed  in  12,  cholecystenterostomy  in  nine,  and  in  two  adhesions 
were  separated  only.  Twenty-two  of  these  patients  recovered,  and 
some  time  afterwards  replies  were  received  from  18  of  them ;  all  of 
these  were  well  except  one,  who  had  glycosuria. 

37—2 


58o         OPERATIONS  ON  THE  ABDOMEN. 

It  need  hardly  be  pointed  out  that  these  results,  obtained  by  a 
Burgeon  of  unusual  experience  of  this  branch  of  surgery,  are  tar  more 
favourable  than  the  average  for  all  Burgeons  who  may  he  called  upon  to 
undertake  these  operations,  but  they  serve  to  show  what  can  be  done 
by  careful  work  based  upon  a  sound  knowledge  of  the  pathology  of 
chronic  pancreatitis. 

PANCREATIC    CALCULI. 

Mr.  Pearce  Gould  removed  a  pancreatic  calculus  in  March,  1896, 
hut  the  patient  died  twelve  days  later.  Mr.  Moynihan  was  the  first  to 
correctly  diagnose  and  successfully  remove  a  stone  from  the  duct  of 
Wirsung  in  May,  1902  (Lancet,  1902,  vol.  ii.  p.  355). 

The  patient  "  was  a  lady,  aged  57,  who  had  suffered  for  several  months  from  symptoms 
which  may  be  briefly  described  as  follows  : — There  was  steady  Loss  of  health,  gradual  wasting, 
irregular  pigmentation  of  the  skin,  in  patches  of  the  colour  of  cafe"-au-lait  (very  closely 
resembling  the  pigmentation  of  molluscum  fibrosum),  persisting  attacks  of  epigastric  pain, 

and  uneasiness  of  the  type  of  hepatic  colic,  though  less  severe,  and  unattended  until 
very  late  in  the  history  by  jaundice,  which  was  then  always  trivial,  though  unmis- 
takable, and  pain  passing  through  from  the  front  of  the  abdomen  to  the  middle  of  the 
back.  There  was  no  rigor  or  any  complaint  of  sensation  of  heat  or  cold.  The  stools  were 
occasionally  frothy  and  greasy.  On  examination  under  chloroform  some  indefinite 
swelling  could  be  felt  above  the  umbilicus  and  a  little  to  both  sides  of  the  median  line 
though  chiefly  to  the  right." 

Mr.  Moynihan  diagnosed  chronic  pancreatitis,  due  probably  to  a  pancreatic  calculus, 
which  had  produced  the  epigastric  colic  during  its  transit  along  the  duct  of  Wirsung,  and 
had  later  caused  some  inflammatory  obstruction  of  the  common  bile-duct.  The  abdomen 
was  opened  by  separating  the  fibres  of  the  right  rectus  muscle,  and  the  diagnosis  was  con- 
firmed. "  The  head  of  the  pancreas  was  very  much  enlarged  and  hard,  the  body  was  less 
so,  but  still  larger  and  denser  than  the  normal."  A  small  lump  was  felt  between  the 
duodenum  and  the  pancreas,  and  upon  opening  the  duodenum  and  the  ampulla  of  Vat.-r  a 
small  soft  stone  was  discovered  at  the  end  of  the  duct  of  Wirsung.  whence  it  was  removed 
with  a  scoop.     The  patient  made  a  complete  recovery  and  was  quite  well  in  March,  1905. 

Mr.  Mayo  Robson,  Dalziel,  and  L.  W.  Allen  have  also  removed  stones 
from  the  pancreas. 

Mayo  Kohson  (Lancet,  1904,  vol.  ii.  p.  113)  successfully  removed 
four  pancreatic  stones,  two  from  the  ampulla  after  opening  the 
duodenum,  and  one  each  from  the  ducts  of  Santorini  and  Wirsung. 
The  ducts  and  the  pancreas  were  sutured  and  no  drainage  was 
employed. 

Pancreo-Lithotomy. — Pancreatic  calculi  may  he  removed  (a)  from 
the  duodenum,  and  through  the  ampulla  of  Vater  by  a  slight  modi- 
fication of  the  operation  of  diiodeiio-choledochotomy  (riilc  \t.  558). 

(h)  If  this  is  impracticable,  the  pancreas  may  be  approached  through 
the  gastro-hepatic  or  gastro-colic  omentum,  and  an  incision  made 
directly  over  the  stone  and  parallel  to  the  duct.  When  the  stone  has 
been  removed  both  the  duct  and  the  pancreas  should  he  carefully 
sutured,  but  drainage  should  be  established  from  the  line  of  suture  to 
avoid  any  possible  leakage  and  peri  ton  seal  contamination.  A  sandbag 
under  the  back  is  of  great  value  in  bringing  the  duodenum  and  the 
pancreas  much  nearer  the  surface. 


PANCREATIC   CYSTS    AND    PSEUDO-CYSTS.  581 


PANCREATIC   CYSTS  AND  PSEUDO-CYSTS. 
Mr.  Moynihan  (Abdominal  Operations,  p.  612)  gives  the  following 

Classification  of  these  cysts:  — 

(1)  Retention  cysts. 

,  v    T->    ,.f      ,.  I Cystic  adenoma. 

(2)  Proliferation  cyst     1  ,-r    ,  • 

•  I  Cystic  carcinoma. 

(3)  Hydatid  cysts. 

(4)  Congenital  cystic  disease. 

(5)  Hemorrhagic  cysts. 

(6)  Pseudo-cysts. 

Effusions  into  the  lesser  sac  of  the  peritonaeum  were  for  long 
mistaken  for  pancreatic  cysts,  partly  hecause  the  fluid  withdrawn  from 
these  pseudo-cysts  often  contained  pancreatic  secretion,  and  partly 
because  the  pancreas  formed  a  part  of  the  wall  of  the  cyst. 

Mr.  Jordan  Lloyd  first  drew  attention  to  the  true  nature  of  the 
so-called  cysts  which  followed  injuries  of  the  upper  part  of  the  abdomen 
(Brit.  Med.  Journ.,  1892,  vol.  ii.  p.  1085).  They  generally  take  the 
characteristic  shape  of  the  lesser  peritoneal  cavity,  and  if  the  pancreas 
has  been  injured,  their  fluid  contents  may  have  "  the  property  of 
converting  starch  into  sugar." 

Mr.  McPhedran  (Brit.  Med.  Journ.,  1897,  voL  *•  P-  I400)  records  an 
interesting  example  of  this  condition,  and  later  a  true  pancreatic  cyst 
developed  in  this  patient,  and  was  probably  due  to  obstruction  of  the 
pancreatic  duct. 

Mr.  Kellock  {Clin.  Sue.  Trans.,  vol.  xxxix.  p.  63)  describes  another  instance  of 
"  traumatic  pancreatic  pseudo-cyst "  and  refers  to  seven  more.  In  four  out  of  these  eight 
cases  the  injury  was  a  kick  from  a  horse.  In  Mr.  Kellock' s  case  the  collection  of  fluid 
became  evident  after  a  month.  The  patient  suffered  much  from  pain,  vomiting,  dyspnoea, 
and  became  thin,  pale,  and  weak.  The  temperature  was  about  ioo°  F.,  and  the  pulse 
became  120,  the  respirations  36.  Dulness  extended  from  the  left  loin  to  the  middle  line  and 
downwards  as  far  as  the  umbilicus,  and  a  thrill  could  be  obtained  over  it.  An  exploratory 
puncture  through  the  ninth  interspace  in  the  scapular  line  was  made  and  some  turbid 
fluid  was  withdrawn.  A  portion  of  the  ninth  rib  was  resected  in  the  axillary  line,  and 
the  lesser  peritoneal  sac  opened  through  the  diaphragm,  and  88  ounces  of  fluid  were 
collected,  and  found  later  to  contain  an  active  diastatic  and  also  a  peptonising  ferment, 
acting  in  an  alkaline  medium.  No  micro-organisms  were  present.  "  Considerable  difficulty 
was  experienced  in  keeping  the  cavity  drained,"  although  a  rubber  tube  had  been  sewn  in, 
and  a  few  days  later  the  wound  had  to  be  explored,  and  70  ounces  of  fluid  were  liberated, 
and  another  opening  was  made  further  back  below  the  ribs.  Large  drainage  tubes  were 
inserted  in  the  openings,  "  but  seven  days  later  the  fluid  had  again  reaccumulated  "  ; 
100  ounces  were  withdrawn  by  means  of  a  Boudin's  glass  tube.  Ultimately  a  gum-elastic 
catheter  was  inserted  and  drainage  established  into  a  bottle  at  the  side  of  the  bed,  and  an 
average  of  28  ounces  of  fluid  was  collected  every  day.  After  about  four  weeks  from  the 
operation  the  discharge  ceased  and  the  patient  made  a  rapid  and  complete  recovery. 

Diagnosis  of  Pancreatic  Cysts. — Attention  to  the  following  points 
will  generally  lead  to  a  correct  conclusion.  A  rounded,  elastic,  deeply 
fixed  swelling,  which  may  date  to  an  accident,  appears,  usually  in  an 
adult,  in  the  epigastric  and  left  hypochondriac  regions,  is  generally 
accompanied  (especially  when  its  increase  is  rapid)  by  "  cceliac 
neuralgia" — i.e.,  pains  probably  arising  in  the  solar  plexus — often 
colicky,    or    even    agonising,    and    leading    to    collapse.      Dyspepsia, 


.Vs-"  OPKKATIONS    ().\     TIIK    A  111  ><  >M  K\. 

marasmus,  and  mental  depression  are  often  present  to  a  marked  decree. 
The  position  of  the  cyst,  behind  the  Btomach  and  transverse  colon,  is 
important.  This  relationship  may  be  demonstrated  by  percussion  with 
or  without  inflation  of  the  Btomach  and  colon  with  gas,  mid  also  with 
the  aid  of  a  rubber  tube  containing  an  emulsion  of  bismuth,  and  the 
shadow  thrown  by  this  upon  the  X-ray  screen  (Dalton).  Both  side  to 
side  and  front  to  back  shadows  should  he  taken. 

The  resonance  of  the  stomach  is  often  ahove  the  cyst,  and  that  of  the 
colon  below  it,  the  centre  or  most  prominent  part  being  dull. 

The  cyst  may  present  and  he  dull  ahove  the  stomach,  or  below  the 
transverse  colon  towards  the  left  loin.  I  have  known  such  a  cyst 
mistaken  for  hydronephrosis.  The  segregator  will  help  to  distinguish 
the  two  conditions,  for  equal  amounts  of  urine  should  issue  from  the 
two  ureters  if  the  cyst  is  pancreatic,  whereas  the  amount  and  the 
characters  of  the  separated  urines  will  be  different  in  hydronephrosis, 
even  if  any  comes  from  the  left  ureter.  The  urine  may  contain  sugar 
with  pancreatic  cyst.  The  feces  may  contain  an  excess  of  fat  or 
muscle  fibre  in  a  few  cases. 

Treatment. — Dr.  Senn  showed  that  the  wisest  course  was  incision 
of  the  cyst  by  abdominal  section.  The  results  of  attempting  to 
extirpate  the  cyst  have  been  so  unsuccessful  as  to  entirely  justify  his 
condemnation  of  this  course  except  in  quite  exceptional  cases. 
Aspiration  is  not  to  he  recommended  because  it  is  never  successful, 
and  is  not  without  danger.  It  is  not  even  advisable  to  employ  it  for 
diagnostic  purposes  (vide  foot-note,  p.  583)  or  for  the  temporary  relief 
of  tension. 

(1)  Evacuation  and  drainage. — The  cyst  is  approached  as  already 
described  at  p.  577.  Generally  it  is  best  to  incise  the  gastro-colic 
ligament. 

The  following  case,*  in  which  I  operated  at  the  request  of  Dr.  Newton 
Pitt,  is  a  good  instance  of  a  pancreatic  cyst  treated  by  laparotomy, 
incision,  and  drainage  : — 

I  received  the  following  history  when  asked  to  see  the  case,  August  21,  1889  :  The 
patient  was  21.  He  had  received  a  kick  in  the  abdomen  three  years  before  which  had 
confined  him  to  bed  for  three  weeks.  Ever  since  he  had  been  Liable  to  severe  attacks 
of  epigastric  pain.  Be  had  been  markedly  jaundiced,  was  emaciated,  and  Buffered  a 
good  deal  from  nausea  and  depression.  The  swelling  in  the  epigastric  region  was  convex 
and  uniform  and  reached  from  below  the  tip  of  the  ensiform  cartilage  to  just  above  the 
umbilicus,  and  laterally  to  near  the  ends  of  the  eleventh  ribs.  The  tumour  gave  the 
impression  of  being  attached  to  some  deep-seated  structure.  There  was  transmitted 
impulse  synchronous  with  the  pulse,  but  not  expansile.  As  the  swelling  had  refilled  after 
two    previous    tappings. ■(    and,  as    the    swelling    and    the    patient's  distress  were  steadily 

*  My  colleague  and   I   reported   this  caBe  fully  (Trans.  Med.-Chir.  8oo.fvo\.  Lxxiv. 

P«  455)-  References  are  given  to  30  cases  which  will  be  found  summarised  there  by 
Dr.  Pitt.  Keferences  are  also  made  to  13  case-  by  Mr.  Cathcart  in  his  instructive 
paper  (AV////.  Med.  Journ.,  July  1890). 

t  The  fluid  was  alkaline,  sage-green,  sp.  gr.  1013,  albuminous,  and.  under  the  micro- 
scope. Bhowing  innumerable  collections  of  globular  masses  of  tyrosin  crystals.  No 
leucin  could  be  detected.  The  fluid  in  these  cysts  varies  a  good  deal — sometimes 
colourless  and  serous,  at  others  it  is  red  and  viscid.  It  will  be  seen  from  the  account  th.it 
follows  that  on  each  occasion  the  aspirating  needle  must  have  transfixed  the  stomach.  The 
same  thing,  with  like  harmlessness,  happened  in  one  of  Karewsky's  two  cases  (Deut.  Med 


['AVIMvVTIc    CYSTS    AND    I'S KUDO-CYSTS.  583 

Increasing,  laparotomy  was  perfor d,  Augusi  22,  with  strict  antiseptic  precautions,    kv 

incision,  three  inches  long,  was  made  over  the  most  prominent  pari  of  the  cyst,  an  inch 
and  a  half  to  the  lefl  of  the  middle  Line,  extending  to  within  an  inch  of  the  umi.il 
The  parietal  peritonaeum  having  been  stitched  to  the  margins  of  the  wound,  the  lower 
edge  of  the  liver  could  be  seen  moving  with  respiration  in  the  upper  angle,  while  thi 
of  the  incision  was  occupied  by  a  smooth  reddish  surface,  which  bulged  si  rongly  Forwards. 
Taking  this  to  be  the  fronl  of  the  cyst,  and  having  ascertained  before  the  operation  thai 

tin'  cysl  was  dull  on  percussion,  I  was  about  to  leave  (his,  for  twenty-four  limns,  to  1 ome 

adherent  before  ii  was  incised.  The  resull  proved  t  hat,  if  I  bad  done  so,  <  he  scalpel  would 
have  passed  through  both  walls  of  the  stomach.  Before  dressing  the  wound,  I  again 
scrutinised  the  surface  of  the  supposed  cyst,  and  thoughl  I  found  evidence  of  involuntary 
muscular  fibre,  which  threw  doubts  upon  the  swelling  being  a  pancreatic  cyst.     When  the 

supposed  cyst  was  examined  between  the  lingers,  it  proved  to  be  the  empty  stomach. 
stretched  very  tightly  over  the  subjacent  cyst.  To  get  at  this,  the  stomach  was  drawn 
upwards,  that  it  might  be  packed  away  above  under  the  liver.  But  here  an  embarrassing 
difficulty  arose.  As  1  pulled  up  the  stomach,  which  was  tightly  jammed  between  the 
bulging  cyst  behind  and  the  parietes  in  front,  the  omentum  came  up  into  the  wound  in 
front  of  the  cyst.  The  tension  of  the  parts  was  so  great,  owing  to  the  rapid  increase  in  the 
cyst,  that  there  was  no  room  above  in  which  to  pack  away  the  omentum.  Pushing  this 
to  either  side,  already  fully  occupied,  pulled  down  the  stomach  again.  I  accordingly  drew 
the  greater  part  of  the  omentum  out  of  the  wound.*  Some  of  it  was  tied  with  catgut,  and 
cut  away  ;  much  of  it  was  left  heaped  up  on  the  abdominal  walls  on  either  side  of  the 
incision.  One  or  two  fine  catgut  sutures  retained  the  omentum  in  position.  I  next 
scratched  through  the  two  layers  of  omentum,  and  exposed  the  surface  of  the  cyst  for 
a  space  the  size-  of  a  shilling.  There  was  thus  a  somewhat  conical  passage  leading 
from  the  abdominal  incision,  through  a  mass  of  omentum,  down  to  the  anterior  surface 
of  the  cyst.  This  last  was  very  vascular,  and  so  tense  that  it  was  not  thought  advisable 
to  put  in  a  guide-suture.  The  patient  passed  through  the  next  twenty-four  hours  fairly 
well.  At  midnight,  August  23,  symptoms  of  collapse  set  in  (haemorrhage  probably  took 
place  at  this  time  into  the  cyst,  a  complication  which  must  always  be  probable,  owing  to 
the  very  vascular  surroundings).  The  patient's  pulse  at  2  A.M.  had  run  up  to  163,  and 
his  condition  pointed  to  a  fatal  ending  at  no  distant  date.  At  3  A.M.  I  passed  a  fine 
trocar  into  the  cyst,  and  drew  off  12  oz.  of  deeply  blood-stained  fluid,  which  was  under  very 
high  tension.  The  sac  was  then  incised  and  a  large  drainage-tube  inserted.  A  marked 
improvement  at  once  set  in.  A  slight  discharge  of  dark  treacly  fluid  necessitated  changing 
the  dressing  twice  a  day  at  first.     The  wound  was  all  healed  in  two  months  {vide  infra). 

On  another  occasion  I  should  prefer  to  pack  around  and  empty  the  cyst 
at  once  either  by  aspiration  or  by  a  large  trocar  and  tubing,  or  by  a  small 
incision,  keeping  the  cyst  well  forwards  by  means  of  Spencer  Wells's 
forceps  attached  to  the  cut  edges.  Then,  as  the  cyst  emptied,  a 
finger  as  a  guide  having  been  introduced  into  the  cyst  and  pushed 
downwards  and  outwards  below  the  left  infra-costal  margin,  a  counter- 
opening  might  be  made  and  a  large  drainage-tube  inserted  into  the 
cyst  from  behind.  This  would  be  shortened  from  time  to  time,  as 
gradual  contraction  of  the  cyst  took  place.  The  anterior  opening  in 
the  cyst  could  be  either  sutured,  or  attached  to  the  margins  of  the 
abdominal  incision.  Mr.  Cathcart  left  the  opening  in  the  front  of 
the  cyst  open,  Mr.  A.  P.  Gould  closed  his  by  suture. 


Wbch.,  No.  46, 1890).  In  two  cases  the  preliminary  puncture  was  followed  by  evidence  of 
peritonitis,  and  in  two  by  grave  collapse  attending  the  escape  of  fluid  from  the  cyst  into 
the  peritonasal  sac.  Another  possible  danger  is  puncture  of  the  transverse  colon,  which 
may  be  tightly  stretched  over  the  cyst.  If  fluctuation  can  be  detected  in  the  infra-costal 
region  behind,  or  if  a  thrill  can  be  obtained  here  from  the  front,  it  will  be  safer  to  aspirate 
from  behind. 

*  On  another  occasion  I  should  divide  the  omentum  above  the  transverse  colon. 


584  OPERATIONS    ON    THE    ABDOMEN. 

Mr.  Caird  (Edin.  Med.  Journ.,  Feb.  [896)  acting  <>n  Mr.  Cathcart's 
plan  of  making  a  counter-opening  behind,  opened  one  of  these  cysts  a1 
tlir  back,  and  not  through  the  anterior  abdominal  wall,  as  is  usually 
done.  The  incision  was  made  along  the  outer  border  of  the  erector 
spina'  just  below  the  twelfth  rib,  and  a  tube  inserted.  This  was  kept 
in  for  four  months,  and  later  on  iodine  was  injected  occasionally  to 
promote  obliteration  of  the  cyst.  The  patient  was  ultimately  dis- 
charged, with  the  opening  closed.  The  administration  of  liquor 
pancreaticua  with  the  food  was  thought  to  have  been  beneBcial.  All 
will  agree  with  what  Mr.  Cathcaii  claims  for  the  posterior  incision, 
viz.,  (r)  that  the  cyst  can  here  he  reached  extra-peritonaeally ;  (2)  that 
this  incision  gives  better  drainage;  ami  (  ;)  that  by  it  there  is  less  risk 
of  a  ventral  hernia,  but  the  anterior  incision  is  tar  better  for  explora- 
tory purposes,  and  moreover  anterior  drainage  has  been  found  to  suffice 
in  most  cases.  I  have  seen  one  pseudo-cyst  drained  successfully 
through  the  anterior  part  of  an  incision  made  tor  the  exploration  of  a 
supposed  hydronephrosis. 

The  after-history  of  any  case  of  pancreatic  cyst  reported  as  cured  by 
drainage  must  he  carefully  watched.  It  is  clear  that  under  certain 
conditions — e.g.,  where  the  cyst  is  very  large,  where  it  has  thick  walls, 
and  above  all  where  the  duct  communicates  with  the  cyst  and  where 
much  of  the  tissue  of  the  pancreas  remains — recurrence  is  almost 
certain  and  complete  obliteration  by  drainage  probably  impossible. 
As  in  most  of  these  cases  the  intimate  relation  of  these  cysts  with  x<-ry 
vital  parts  does  not  admit  of  their  being  dissected  out,  we  must  he 
prepared  to  fail  sometimes  in  our  efforts  to  secure  a  radical  cure.  This 
i-  shown  by  the  si  quel  to  Dr.  Newton  Pitt's  and  my  case,  which  was 
brought,  as  one  treated  successfully  by  drainage,  before  the  Medico- 
Chirurgical  Society  (vide  supra).  About  a  year  later  I  heard  that  the 
swelling  had  reappeared  and  that  the  man  was  about  to  be  operated  on 
again.  Later  on  I  was  given  to  understand  that  the  swelling  had 
reappeared  a  second  time,  hut  I  have  been  unable  to  obtain  the  needful 
information.  Dr.  M.  II.  Richardson,  of  Boston,  drew  attention  to  this 
tendency   of  pancreatic  cysts  to  recur  after   drainage.      "  Pancreatic 

its  apparently  cured  by  Incision  and  Drainage;  Recurrence;  Per- 
foration of  the  Stomach  :  Death  ;  Autopsy"  (Boston  Med.  and  Surg. 
Journ.,  vol.  cxxvi.  1892,  p.  441).  At  the  necropsy  it  was  found  that 
the  head  of  the  pancreas  was  normal,  and  that  a  tube  could  be  passed 
from  the  pancreatic  duct  into  the  cyst  ;  about  two  inches  of  normal 
pancreatic  tissue  were  found  lying  between  the  cyst  and  the  spleen. 
From  this  also  a  duct  could  be  traced  into  the  cyst.  It  was  very 
difficult  and  even  impossible  at  the  time  of  the  necropsy  to  dissect  out 
the  cyst  from  the  parts  to  which  it  was  adherent.  J  >r.  Richardson 
thinks  that  in  some  cases  the  permanent  use  of  a  tube  will  be  needful. 
Mr.  A.  P.  Gould  published  (Lancet,  vol.  ii.  1891,  p.  290)  a  case  of 
pancreatic  cyst  which  had  been  treated  by  drainage,  a  sinus  persisted 
in  spite  of  treatment,  and,  three  years  later.  Became  the  site  of 
epitheliomatous  infiltration.  Dr.  <).  Ramsey,  of  Baltimore,  in  a  case 
of  a  large  pancreatic  cysl  treated  by  drainage,  was  obliged  to  continue 
the  use  of  a  drainage-tube  seven  months  after  the  operation,  as  the 
discharge  was  still  free  {Ann.  of  Surg.,  Dec.  1895).  Dr.  Ramsey  thinks 
that  in  addition  to  persistence  of  secretion  the  large  siz,.  «,f  the  cyst 


PANCREATIC   CYSTS   AND    PSEUDO-CYSTS.  585 

and  the  tension  under  which  the  fluid  escapes  when  the  cysl  is  opened, 
point  to  gland  substance  being  present  and  still  functionally  active. 
The  last  two  features,  it  will  be  noticed,  were  present  in  Dr.  X.  Pitt's 
and  my  case,  which  recurred  after  an  apparent  cure.  Some  of  these 
recurrences  may  have  been  due  to  the  adenomatous  or  primarily 
malignant  nature  of  the  cyst,  and  for  this  reason  it  is  always  advisable 
to  remove  some  of  the  wall  of  the  cyst  for  microscopical  examination. 

Extirpation. — On  account  of  the  slow  recovery  and  occasional  recur- 
rence alter  evacuation  and  drainage,  extirpation  has  been  practised 
and  recommended,  but  it  is  not  often  either  advisable  or  practicable  on 
account  of  the  extensive  adhesion  to  vital  parts,  and  the  large  blood- 
vessels in  and  around  the  cyst. 

Even  Mikulicz  had  to  abandon  two  attempts,  and  the  splenic  vessels 
had  to  be  tied  in  two  instances  (Mikulicz  and  Billroth).  When  the 
cyst  is  peduncled  or  chiefly  concerns  the  tail,  it  may  be  safely  and  very 
properly  excised,  the  pedicle  being  ligatured,  sutured,  or  clamped. 

Mayo  Robson  (loc.  supra  cit.)  collected  the  records  of  160  operations 
for  pancreatic  cysts  ;  140  of  the  patients  recovered  from  the  operation 
or  were  presumed  from  the  records  to  have  recovered.  Four  of  the 
cases  were  doubtful  in  this  respect.  Out  of  138  patients  treated  by 
incision  and  drainage  16  died — a  death-rate  of  n*6  per  cent.  Out  of 
13  complete  excisions  three  died  (20  per  cent.).  Out  of  seven  partial 
excisions  one  died  (14*3  per  cent.). 

It  must  be  remembered,  however,  that  only  the  most  movable  and 
comparatively  small  cysts  were  excised,  so  that  the  figures  do  not 
represent  the  comparative  danger  of  drainage  and  extirpation,  the 
latter  of  which  is  only  suitable  for  occasional  cases.  It  is  interesting 
to  notice  that  eight  of  the  patients  died  of  peritonitis,  two  from  shock, 
one  from  collapse,  one  from  intestinal  obstruction,  and  one  from 
gangrene  of  the  pancreas.  Out  of  the  patients  who  survived  the 
operation  one  died  later  of  diabetes,  one  from  tuberculosis,  and  one 
from  haemorrhage  after  a  year-and-a-half. 

GROWTHS   OF  THE  PANCREAS. 

Very  few  operations  have  been  undertaken  for  new  growths  of  the  pan- 
creas. The  most  common  malignant  neoplasm  is  carcinoma,  especially 
of  the  head  of  the  gland  ;  but  occasionally  fibro-sarcoma  occurs. 

Mr.  Mayo  Robson  (Hunterian  Lectures,  loc.  cit.)  collected  records  of 
16  operations  for  the  removal  of  solid  tumours  of  the  pancreas,  with 
eight  recoveries  from  the  operation,  but  the  prolongation  of  life  was  of 
short  duration. 

Mr.  Malcolm  removed  an  enormous  fibro-sarcoma  of  the  pancreas 
from  a  child,  but  the  patient  died  of  shock  soon  after  the  operation, 
and  the  portal  vein  was  found  at  the  autopsy  to  be  full  of  growth 
(Trans.  Path.  Soc,  vol.  liii.  p.  420). 

Mr.  Mayo  Robson  records  the  results  of  28  operations  for  malignant 
disease  of  the  head  of  the  pancreas.  These  were  undertaken  chiefly 
with  a  view  of  making  a  diagnosis  between  chronic  pancreatitis  and 
carcinoma.  Of  15  cholecystostomies  eight  recovered,  but  the  longest 
survived  only  for  eight  months,  and  the  average  duration  of  life  after 
the  operation  was  only  four  months.  Out  of  six  cholecystenterostomies 
only  two  recovered,  and  they  only  survived  for  a  few  weeks. 


586  OPERATIONS    <>\    TIIK    A  lilxi.M  K\. 

Out  of  12  cholecystenterostomies  for  malignant  disease  undertaken 
by  Dr.  Murphy  only  two  recovered  from  the  operation. 

It  may  be  concluded  that  it  is  not  worth  while,  nay,  that  it  is  even 
wrong  to  perform  palliative  operations  for  malignant  growths  of  the 
pancreas,  and  that  radical  operations  are  very  rarely  possible,  and  so 
far  have  not  been  attended  with  sufficient  success  to  justify  their 
performance. 

Very  rarely  it  may  be  possible  to  remove  a  growth  of  the  tail  or 
body  if  discovered  very  early.  Malignant  cysts  may  be  occasionally 
drained  with  temporary  relief.  Growths  of  other  organs  such  as  the 
stomach  or  the  colon  which  trespass  upon  the  pancreas  are  nearly  always 
best  left  alone  ;  and  if  the  pancreas  is  either  accidentally  wounded  or 
a  part  of  it  purposely  resected,  it  is  essential  to  drain  the  wound  to 
prevent  contamination  of  the  peritonaeum  with  the  secretion  that  oozes 
from  wounds  of  the  pancreas. 


CHAPTER  XL 
OPERATIONS  ON  THE  BLADDER. 

REMOVAL  OF  GROWTHS  OF  THE  BLADDER.— OPERATIVE 
TREATMENT  OF  TUBERCULAR  ULCERATION.  —  LA- 
TERAL LITHOTOMY.  —  SUPRA-PUBIC  LITHOTOMY.  — 
MEDIAN  LITHOTOMY.— LITHOTRITY  AND  LITHOLA- 
PAXY.— PERINEAL  LITHOTRITY.— REMOVAL  OF  STONE 
IN  THE  FEMALE.— CYSTOTOMY.— RUPTURED  BLADDER. 

REMOVAL    OF    GROWTHS    OF    THE    BLADDER. 

Chief  Varieties. 

I.  New  Growths  from  the  Mucous  or  Sub-Mucous  Coat: — 

(i)  Papilloma  (including  the  two  varieties  of  Sir  Henry  Thompson), 
viz.,  (a)  The  fimbriated  papilloma  or  villous  growth ;  (b)  Fibro- 
papilloma,  which  is  much  rarer,  and  is  almost  smooth  upon  the 
surface  as  seen  with  the  naked  eye. 

(2)  Fibrous  polypi. 

(3)  Myxoma. 

(4)  Sarcoma. 

(5)  Angioma. 

II.  New  Growths  from  the  Muscular  Coat : — 
Myoma. 

III.  New  Growths  arising  from  the  Epithelial  and  Glandular  Tissues: — 

(1)  Adenoma. 

(2)  Carcinoma,  either  squamous  or  spheroidal-celled :  (a)  Villous 
variety  ;  and  (b)  Flattened  variety,  infiltrating  early,  and  very  malignant 
and  difficult  to  remove  satisfactorily. 

(3)  Dermoids. 

Sir  Henry  Thompson  has  also  described  a  transitional  form  of 
papilloma,  characterised  by  vascularity  and  cell  infiltration.  It  is  not 
at  all  easy  to  tell,  either  with  the  naked  eye,  the  cystoscope,  or  even 
with  the  microscope,  whether  any  given  villous  tumour  is  or  is  not 
certainly  innocent  or  malignant,  for  the  one  merges  into  the  other, 
without  any  sharp  line  of  demarcation.  Growths  from  neighbouring 
tissues  may  invade  the  bladder  especially  from  the  prostate  and 
rectum. 

Practical  Points  in  the  Diagnosis. — Early  and  accurate  diagnosis  is 
here  of  the  utmost  importance. 

(1)  Hemorrhage. — This  is  of  much  importance  both  in  diagnosis 
and  in  its  bearing  upon  an   operation.      Symptomless  hematuria  of 


588         OPERATIONS  ON  THE  ABDOMEN. 

ical  origin  is  very  characteristic  of  growth   of  the   bladder.     Sir 
Benry  Thompson  laid  much  n  the  facl  that,  in  these  cases,  the 

stream  often  begins  without  any  or  with  little  blood,  and  cuds  of  a 
bright  red  colour.  Pore  blood  may  be  expressed  by  the  final  efforts  of 
the  bladder  as  it  closes  upon  and  compresses  the  growth.  Bleeding 
forms  the  initial  symptom  in  a  large  number  of  cases,  especially  when 
the  growth  is  of  the  villous  type.  Mr.  Hurry  Fen  wick  (Tumours  of 
the  Urinary  Bladder,  1901)  Btates  that  hematuria  is  the  first  sign  in 
about  84  per  cent,  of  benign  papillomata,  and  in  about  75  per  cent,  of 
the  cases  of  villous  carcinoma,  and  about  60  per  cent,  of  the  bald 
malignant  growths. 

In  villous  growth  or  fimbriated  papilloma  haemorrhage  alone  may 
kill,  and  it  may  he  the  only  symptom  throughout.  In  these  growths 
the  chief  point  is  that  the  haemorrhage  extends  over  a  long  time,* 
occurs  spontaneously  and  suddenly,  and  without  any  allied  symptoms; 
it  ceases  in  the  same  way;  the  periods  of  intermission  gradually 
become  less,  till  tie  bleeding  is  constant,  either  rendering  the  patients 
utterly  anaemic  or  adding  to  their  misery  by  bringing  about  cystitis. 
1  hese  two  last  conditions  may  be  so  marked  as  to  demand  an  opera- 
tion. This  symptom  is  most  frequent  in  tie-  villous  growth  (fimbriated 
papilloma),  less  so  in  the  fibro-papilloma  or  in  tie-  "transitional" 
growths.  In  the  Hat  carcinomatous  or  epitheliomatous  growths 
hematuria  is  more  frequently  associated  with  other  symptoms  and  it  is 
less  profuse  ;  but  repeated  small  haemorrhages  with  only  short,  if  any, 
intermissions,  occur  and  exhaust  the  strength  of  the  patient;  and  the 
blood  i-  often  dark  from  decomposition  and  is  more  diffused  throughout 
the  urine. 

(2)  Sudden  arrestof  the  Stream  of  Urine. — M.  Guyon  (Ann.  de  Mai. 
des  Org.  Gen.-Urin.,  1889,  p.  449)  points  out  that  in  a  few  cases  a 
pedunculated  growth  situated  near  the  neck  may  cause  obstruction  and 
other  micturition  troubles,  before  haemorrhage  appears. 

Mr.  Hurry  Fenwick  estimates  that  Budden  arrest  of  the  stream  occurs 
as  the  initial  symptom  in  about  8  per  cent,  of  the  benign  villous,  and 
about  10  per  cent,  of  the  malignant  villous  growths:  whereas  it  is  very 
rarely  noticed  with  the  flat  or  bald  variety  of  carcinoma. 

Any  tumour  which  grows  quite  near  or  infiltrates  the  tis.-u<-.>  around 
the  urethral  orifice  of  the  bladder  may  cause  obstruction  to  the  flow 
of  urine  sooner  or  later,  and  this  may  simulate  carcinoma  or  even 
senile  enlargement  of  the  prostate. 

(3)  Unilateral  Renal  Pain. — Growths  are  so  very  frequently  situated 
at  or  quite  near  to  one  or  other  ureteral  orifice,  that  they  often 
obstruct  it  either  by  dragging,  or  compression  from  infiltration.     Hence 

*  Mr.  It.  Hani-. 11  (Intern.  Encycl.  >»■>■:/..  vol.  vi.  p.  38)  Btates  that  in  the  Museum  <.f 
age's  Hospital  there  i-  a  specimen  of  a  villous  tumour  attached  to  the  neck  of  the 
bladder  of  a  gentleman  aged  81.     The  first  attack  of  haemorrhage  had  occurred  twenty 
-  before  death,  and  had  lasted  for  eight  months.     An  interval  of  four  years  had  fol- 
lowed this,  and  then  a  recurrence  of  haemorrhage,  which  ultimately  proved  fatal.     Sir 
I;.  Brodie  also  Btates  that  the  du  donally  exte  In  a 

f  the  late  Mr.  \V.  An  -  e.  Trans.,  vol.  xviii.  p.  313),  of  papilloma,  the 

first  hematuria  had  taken  place  tw.  then  came  an  interval  of  a  year, 

followed  by  recurrence  of  the  hematuria,  the  next  interval  being  shortened  t-j  six  monl 
after  which  recurrence  took  place  fairly  regularly  every  three  months. 


REMOVAL    OF   GROWTHS   OF    THE    BLADDER.  589 

dilatation  of  the  ureter   and   renal  pelvis  or  pyelitis  may  develop  and 
cause  pain  in  the  corresponding  loin. 

This  may  he  the  initial  symptom  of  vesical  growth  occasionally, 
and  the  kidney  has  heen  needlessly  explored  in  some  cases  under  these 
circumstances.  This  symptom,  which  may  serve  to  localise  the  growth, 
is  noticed  earlier  with  benign  papilloma  than  with  villous  carcinoma, 
which  obstructs  by  infiltration  around  the  ureteral  end. 

(4)  Frequency  of  Micturition  and  other  symptoms  of  vesical  irrita- 
tion are  most  frequently  associated  with  the  infiltrating  fiat  growths, 
and  they  are  least  common  with  benign  villous  tumours.  Fenwick 
estimates  that  these  symptoms  are  the  initial  ones  in  about  30  per 
cent,  of  the  bald  carcinomata,  15  per  cent,  of  the  villous  carcinomata, 
and  only  8  per  cent,  of  the  simple  villous  papilloinata.  Pain  is  more 
frequent  and  most  severe  with  infiltrating  carcinoma. 

(5)  Examination  of  the  Urine. — This  aid  has  been  too  much  neglected 
because  the  naturally  present  "transitional"  epithelium  of  the  bladder 
may  so  easily  be  mistaken  for  growth  cells.  But,  in  the  case  of  villous 
growths  especially,  careful  examination  of  the  urine  should  be  fre- 
quently made,  and  the  patients  directed  to  bring,  at  once,  any  white 
or  shreddy  particles  passed.  The  delicate  papillae,  with  their  connec- 
tive-tissue basis  supporting  hosts  of  columnar  cells  with  large  delicate 
capillaries,  are  most  characteristic.  Recognisable  fragments  are  more 
rarely  cast  off  the  malignant  villous  growths,  and  when  any  are  found, 
they  give  no  indication  of  the  nature  of  the  base  of  the  tumour;  the 
villi  may  be  innocent  in  appearance,  and  yet  the  base  may  be  malignant. 
It  is  uncommon  for  the  bald  or  flat  growths  to  shed  any  pieces  until 
the  late  sloughy  stage,  but  when  seen  microscopically,  the  fragments 
are  characteristic  enough.  It  is  very  important  to  ascertain  the  total 
amount  of  urea  passed  in  the  24  hours,  for  if  the  excretion  is  seriously 
lowered,  no  operation  should  be  undertaken  on  account  of  the  danger  of 
death  from  uraemia.  Marked  wasting  is  very  characteristic  of  malignant 
disease  of  the  bladder. 

(6)  Rectal  Examination. — This  should  never  be  omitted,  for  with 
the  bladder  empty  of  urine,  the  finger  may  detect  a  thickening,  hardness 
or  rigidity  of  the  base  above  the  prostate,  indicating  an  infiltrating 
growth.  Usually  the  mass  is  separate  from  the  prostate,  but  in  late 
cases  the  latter  may  not  be  distinct  from  the  growth.  A  benign  growth 
cannot  be  felt  per  rectum,  and  the  villous  carcinoma  may  only  indicate 
its  presence  by  an  unusual  fulness  or  heaviness  of  the  bladder,  but  a 
carcinoma  which  infiltrates  the  vesical  wall  soon  becomes  palpable, 
and  Fenwick  states  that  quite  50  per  cent,  of  these  growths  are 
palpable  per  rectum,  within  a  year  of  their  origin.  A  rectal  examina- 
tion may  thus  enable  the  surgeon  to  dispense  with  cystoscopic  or  other 
examinations  of  the  interior  of  the  bladder,  for  in  these  cases  an  opera- 
tion is  nearly  always  futile,  and  a  mere  cystoscopic  examination  is  not 
free  of  danger  in  them.  The  patient  should  be  examined  in  the  kneel- 
ing attitude  as  well  as  in  the  supine  position,  for  the  former  posture 
enables  the  surgeon  to  feel  higher  up  the  posterior  wall  of  the  bladder. 
Bimanual  examination  with  the  patient  supine,  and  the  abdominal  wall 
relaxed,  may  discover  infiltrating  growths  placed  in  unusual  positions 
such  as  at  the  fundus  or  on  the  anterior  wall.  In  the  female  vaginal 
examination  should  be  conducted  in  a  similar  way. 


590 


OPERATIONS    ON    THE    AHDo.MKN. 


At  the  present  day  it  is  quite  unnecessary  and  unjustifiable  to  sound 
any  patient  suffering  from  hematuria  only,  for  a  stone  is  extremely 
unlikely  to  be  the  cause,  and  to  try  to  detach  i>ieces  of  growth  for 
examination  is  foolish.  When  this  method  was  used  before  the  days 
of  the  cystoscope,  it  often  failed  in  its  purpose,  and  seriously  aggravated 
the  haemorrhage,  and  not  uncommonly  it  was  followed  by  cystitis,  even 
when  all  care  had  been  taken  in  ensuring  asepsis. 

(7)  Th e  Cystoscope. — In  skilful  hands  the  cystoscope  is  of  great 
value  in  the  detection  and  examination  of  vesical  growths,  and  it 
enables  the  surgeon  to  decide  for  or  against  an  operation. 

It  serves  to  exclude  renal  causes  of  the  hematuria,  and  to  define  the 
nature,  size,  number,  position,  and  character  of  the  basal  attachment 
of  the  growths,  and  also  the  presence  or  absence  of  infiltration  of  the 
vesical  wall. 

Hence  the  knowledge  gained  through  the  cystoscope  may  indicate 
the  exact  nature    and  degree    of   surgical  interference   that   may  be 


Max  Nitze's  cystoscope  (No.  21,  French  gauge),  with  Pardoe's  eyepiece. 

required,  so  that  the  surgeon  can  adopt  the  most  suitable  method 
without  waste  of  time  during  the  actual  operation. 

There  are  certain  precautions  to  be  carefully  observed  in  using  the 
cystoscope,  and  there  are  limitations  to  its  use  and  value. 

It  is  not  enough  for  the  surgeon  to  be  able  to  see  abnormal  condi- 
tions in  the  bladder,  but  he  must  be  acquainted  with  the  many  varieties 
•of  normal  bladders,  and  also  able  to  interpret  what  he  sees.  For  this 
considerable  practice  is  required,  and  a  sound  knowledge  of  the 
pathology  of  the  bladder. 

It  is  imperative  to  conduct  the  examination  asepticallv,  and  with 
all  gentleness,  so  that  neither  cystitis  nor  haemorrhage  may  follow. 
In  many  cases  with  infiltration  of  the  bladder-base,  which  is  palpable 
from  the  rectum,  it  is  not  necessary  to  examine  the  interior  of  the 
bladder,  for  the  time  for  radical  operative  interference  has  already  passed. 

In  certain  cases  haemorrhage  may  be  so  profuse  in  spite  of  all  gentle- 
ness, injections  of  adrenalin,  nitrate  of  silver,  &c,  that  the  cystoscope 
may  fail  to  give  any  information  of  value. 

It  is  wise  to  wait  for  an  interval  in  these  cases,  the  patient  being 
kept  at  rest  in  bed,  and  when  the  urine  has  become  clear,  the  bladder 


REMOVAL   OF    GROWTHS    OF   THE    BLADDER. 


59i 


may  be  examined  through  this  medium  to  avoid  the  risk  of  setting  up 
fresh  haemorrhage  by  irrigation. 

To  check  the  bleeding  three  or  four  ounces  of  a  yoooo  solution  of 
adrenalin  chloride  may  be  introduced  and  left  in  the  bladder  for  a  few 
minutes.  In  other  cases  a  weak  solution  of  silver  nitrate  (grs.  ii  to 
the  ounce)  may  succeed  after  adrenalin  has  failed.  An  irrigating 
cystoscope  may  be  of  great  value  when  oozing  persists  in  spite  of  all 
endeavours  to  (heck  it ;  quick  work  with  an  ordinary  cystoscope  will 
succeed  unless  the  bleeding  is  profuse. 

Haemorrhage  is  likely  to  be  troublesome  with  friable  growths  which 
surround  or  grow  near  the  vesical  orifice  of  the  urethra  ;  bleeding  from 
over-distension  and  rough  handling  is  avoidable. 

A  very  large  growth  may  not  allow  proper  illumination,  the  beak  of 
the  instrument  being  more  or  less  surrounded  by  villous  processes,  or 
prevented  from  entering  the  main  vesical  cavity. 

I  only  occasionally  use  a  general  anaesthetic,  and  then  only  for 
young  women  or  for  painful  conditions.     A  10  per  cent,  solution  of 

Fig.  231. 

•isc 


Guterbock's  cystoscope  (modified  by  Mr.  Hurry  Fenwick)  for  irrigation.  The 
outer  canula  is  introduced  with  the  help  of  pilot,  or  snugly-fitting  flexible  catheter 
to  close  the  opening  ;  the  bladder  is  then  washed  out  with  syringe  or  syphon,  and 
filled  with  clear  medium  ;  finally  the  cystoscope  is  pushel  inside  the  outer 
cannula  for  examination  of  the  bladder. 

cocaine  milked  back  along  the  urethra  of  the  male,  or  injected  into  the 
urethra  of  the  female,  generally  suffices.  A  drachm  of  a  20  per  cent, 
solution  of  cocaine  may  be  added  to  the  medium  for  painful  conditions 
and  nervous  patients  if  the  examination  is  likely  to  be  difficult  or 
prolonged  (Fenwick).  This  makes  a  tender  bladder  relax  sufficiently 
to  admit  enough  fluid,  and  enables  the  patient  to  retain  the  liquid 
without  much  discomfort  during  the  examination. 

The  urethral  orifice  is  covered  with  cotton  wool  soaked  with  cocaine 
solution. 

An  aseptic  soft  silk  catheter*  with  a  very  large  but  smooth  eye 
is  then  passed  gently,  and  the  bladder  is  washed  out  very  thoroughly 

*  1  generally  use  a  child's  evacuator  when  haemorrhage  is  not  anticipated  ;  this  is  a 
little  smaller  than  the  cystoscope,  and  has  the  same  shape,  so  that  it  is  as  easily  introduced 
as  the  cystoscope.  It  has  the  advantage  of  being  certainly  aseptic,  for  it  can  be  boiled 
just  before  use,  and  it  possesses  a  very  large  eye,  which  greatly  facilitates  and  accelerates 
the  washing  out.  When  gently  used,  and  only  introduced  just  within  the  bladder,  it  is 
not  likely  to  induce  haemorrhage — no  more  likely  than  the  cystoscope. 


592  OPERATIONS  ON  THE  ABDOMEN. 

and  carefully  with  warm  sterile  boracic  lotion.  Hydrostatic  pressure 
is  the  best  to  use,  for  it  can  be  so  well  regulated  by  depressing  or 
elevating  the  graduated  funnel.  Directly  the  patient  feels  the  bladder 
to  be  full,  the  funnel  is  depressed,  and  a  mental  note  is  made  of  the 
capacity  of  the  bladder.  When  the  escaping  Quid  becomes  quite  clear, 
from  six  to  eight  ounces  of  the  solution  are  run  in,  if  the  bladder  can 
comfortably  hold  as  much.  A  satisfactory  examination  cannot  lie  made 
with  less  than  about  four  ounces,  and  the  upper  part  of  the  bladder 
becomes  invisible  if  too  much  fluid  is  injected.  In  any  case  it  is 
absolutely  essential  for  the  medium  to  be  quite  transparent. 

The  patient  may  be  either  lying  down  with  the  thighs  separated,  or 
placed  in  the  lithotomy  position.  I  prefer  the  former  attitude  except 
for  very  stout  patients.  The  external  genitals  are  thoroughly  cleansed 
with  soap  and  water  and  a  weak  solution  of  lysol,  and  an  aseptic 
towel  with  a  central  slit  in  it  is  applied  so  that  the  examination  can  be 
conducted  aseptically.  The  surgeon's  hands  are  cleansed  as  for  an 
operation.  The  cystoscope,  which  has  been  previously  tested  and 
found  to  be  in  good  working  order,  has  its  beak  and  stem  immersed  in 
a  jQ-g-  solution  of  lysol  during  the  preparation  of  the  bladder  and  the 
cleansing. 

The  beak  and  stem  are  lubricated  with  glycerine,  and  the  instru- 
ment is  gently  introduced.  The  light  must  not  be  turned  on  until  the 
beak  has  reached  the  bladder,  and  care  must  be  taken  not  to  touch  the 
vesical-wall  with  the  beak,  for  the  contact,  if  prolonged,  may  cause  a 
burn. 

The  ureteral  orifices  and  the  trigone  are  first  sought  and  examined, 
for  in  the  great  majority  of  cases  growths  and  other  pathological 
conditions  are  to  be  observed  at  these  situations.  The  knob  upon  the 
rim  of  the  cystoscope  indicates  the  direction  of  the  light,  and  when  it 
is  turned  downwards  and  outwards  to  either  side  the  corresponding 
ureter  is  seen.  If  the  circle  of  rotation  be  compared  to  the  face  of  a 
clock,  the  ureters  will  be  found  when  the  indicator  points  towards  five 
and  seven  o'clock,  if  the  beak  is  neither  too  far  from  or  too  near  to 
the  urethral  orifice.  Normal  urine,  blood,  pus,  or  methylene  blue  may 
be  seen  to  be  discharged  at  intervals  from  the  ureters,  or  a  tumour 
may  be  seen  near  them  or  upon  the  trigone.  The  beak  is  turned 
downwards  and  backwards  to  examine  the  lower  part  of  the  base  ;  the 
pouch  behind  an  enlarged  prostate  cannot  be  easily  seen.  When  the 
base  has  been  thoroughly  examined,  other  parts  are  scrutinised  in 
turn.  The  light  can  he  regulated  to  a  nicety  by  means  of  a  rheostat 
placed  at  one  of  the  terminals  of  the  battery.  If  the  medium  becomes 
cloudy  the  instrument  should  be  withdrawn  and  the  bladder  irrigated 
again,  unless  an  Irrigating  cystoscope  is  used.  When  the  examination 
has  been  completed  the  light  is  turned  off  and  alter  a  few  seconds  the 
instrument  is  withdrawn.  If  the  bladder  is  uncomfortably  distended, 
and  the  patient  cannot  empty  it,  a  catheter  should  be  passed  at  once. 

For  the  safe  use  of  the  cystoscope  it  is  essential  to  conduct  the 
examination  aseptically,  and  for  the  evidence  which  it  affords  to  be 
reliable,  it  is  necessary  for  the  surgeon  to  have  acquired  skill  both  in 
the  use  of  the  instrument,  and  a  considerable  experience  of  normal 
and  abnormal  cystoscopic  views.  For  the  introduction  of  the  instru- 
ment  the  urethra  must  be  huge  enough   to  admit   a  No.   jj   French 


REMOVAL    OF   GROWTHS    <>F   THE   BLA I  >l  >Ki;.  593 

catheter,  so  that  when  a  stricture  is  present  it  is  necessary  to  dilate 
or  divide  this  first,  and  when  the  meatus  IS  unusually  small  it  must  be 
enlarged.     For  obtaining  a  proper  viewthe  medium  must  be  absolutely 

clear,  and  the  bladder  must  be  capable  of  holding  at  least  four  ounces 
of  it.  Growths,  tuberculous  and  simple  ulcerations,  diverticula?, 
calculi,  vesical  projections  from  an  enlarged  prostate,  and  a  variety  of 
other  conditions,  may  he  seen  through  it,  as  well  as  valuable  localising 
signs  ot  renal  disease.  It  must  he  used  with  judgment,  and  not  indis- 
criminately, for  any  of  these  conditions.  In  many  cases  of  enlargement 
of  the  prostate,  for  instance,  tbe  introduction  of  the  instrument  may 
be  impossible  or  may  be  attended  with  considerable  difficult}',  so  that 
more  harm  than  good  may  follow  its  use  under  these  circumstances, 
and  especially  if  there  is  mucli  cystitis.  The  diagnosis  is  frequently 
clear  enough  without  the  cystoscope,  although  in  certain  cases,  with 
little  or  no  enlargement  to  be  discovered  from  the  rectum,  the 
instrument  is  of  great  value. 

(8)  Dilatation  of  the  Female  Urethra  with  Kelly's  dilators  and  either 
visual  or  digital  examination  of  the  bladder  is  valuable.  The  former  is 
by  far  the  best,  for  it  needs  less  dilatation  of  the  urethra,  and  avoids 
any  risk  either  of  laceration  of  its  mucous  membrane  or  of  incon- 
tinence of  urine.  Above  all,  sight  is  infinitely  more  accurate  and 
reliable  than  touch.  Electric  cystoscopy,  however,  disturbs  the  patient 
less  than  either,  and  is  therefore  to  be  preferred  for  the  purpose  of 
diagnosis,  except  in  the  rare  cases  where  this  method  fails  on  account 
of  haemorrhage,  and  where  treatment  is  to  follow  the  diagnosis 
immediately. 

(9)  Supra-pubic  Cystotomy. — In  males,  where  the  cystoscope  fails  or  is 
not  available,  I  strongly  advise  supra-pubic  cystotomy  to  clear  up  the 
doubt  in  these  cases.  If  a  removable  growth  be  discovered,  it  should 
be  removed  at  once. 

(10)  Exclusion  of  other  Conditions — e.g.,  stone,  tubercular  and  other 
forms  of  cystitis,  also  haemorrhage — from  the  prostate  or  kidney.  In 
none  of  these  cases,  save  in  the  last,  is  there  the  spontaneous  character 
which  often  marks  the  bleeding  of  bladder  growths.  In  renal 
hematuria  due  to  growth  the  bleeding  may  be  spontaneous,  and 
unaccompanied  by  other  evidence.  Here  the  renal  region  should  be 
thoroughly  examined  at  regular  intervals,  but  the  cystoscope  and  the 
segregator  will  clear  up  the  diagnosis,  as  in  the  case  related  at  p.  160. 
In  tubercular  disease  of  the  bladder  the  bleeding  is  never  as  severe  as 
in  growth,  and  for  a  long  time  occurs  only  at  the  end  of  micturition. 
Other  evidence  will  also  be  present,  and  so,  too,  with  the  haemorrhage 
of  enlarged  prostate,  which  will  very  likely  be  preceded  by  a  chill  or 
by  retention. 

Indications  for  Operation. — Growths  of  the  bladder  being  nearly 
always  fatal,  whether  from  haemorrhage,  or  pain,  or  tbe  results  of 
obstruction,  or  from  these  combined,  the  surgeon  is  entirely  justified 
in  urging  an  early  cystoscopic  examination  to  clear  up  the  diagnosis, 
and  to  decide  the  question  of  removal.  If  the  cystoscope  fail,  which  it 
rarely  does,  digital  and  visual  exploration  should  be  advised.  Supra- 
pubic cystotomy  should  be  performed  in  the  male,  and  urethral 
dilatation  in  the  female.  While  it  remains  as  yet  uncertain  how  many 
of  the  cases  published  as  cures  are  really  and  permanently  so,  even  in  the 

s. — vol.  11.  38 


594 


nl'KRATInNS    ox    THK    AUDOMKX. 


case  of  the  villous  growth,  it  is  an  undoubted  fact  that  an  operation 
may  result  in  arresting  the  haemorrhage  completely  for  years.  In 
other  cases,  haemorrhage,  pain,  and  frequency  of  micturition  may  all 
be  very  Largely  relieved.  Where  little  or  nothing  can  be  dune  in  the 
way  of  removal,  the  free  escape  given  to  the  urine  by  a  supra-pubic  opera- 
tion or  by  dilating  the  neck  of  the  bladder  in  a  woman  may  give  great 
relief;  where  even  this  fails,  the  diagnosis  has,  at  least,  been  cleared  up. 
If  in  doubt  as  to  recommending  cystoscopic  examination  or  explora- 
tion, the  practitioner  should  remember— (i)  that  the  long  intervals 
between  the  bleedings  teach  strongly  that  growths  of  the  bladder  often 

Fig.  232. 


Nodules   of 

growth. 

Ulcerated  growth 

/ 

iw^ 

—  J! 

~  ~~^tk^^^^^^^^  Rods  in  ureters 

Flat  and  infiltrating  epithelioma  of  the  bladder.     The  central  part  of  the  extensive 
growth  has  ulcerated.     (Guy*s  Hospital  Museum.) 

pass  through  a  long  first  stage,  during  which  the  growth  is  connected 
with  the  mucous  membrane  only  :  (2)  that,  following  on  the  above, 
infiltration  of  the  deeper  coats,  and  thus  glandular  infection,  is  often 
here  long  delayed.  AVhile  the  long  intervals  between  the  bleedings, 
and  the  comparative  slightness  of  the  other  symptoms,  may  make  the 
surgeon  unwilling  to  urge  operative  interference,  it  is  right  that  it 
should  be  \evy  clearly  put  before  the  patient  that  it  is  in  this  stage 
only  that  any  hope  of  a  radical  cure  can  be  given,  and  that  later  on, 
when  the  stage  of  infiltration  is  reached,  not  only  is  radical  cure 
almost  out  of  the  question,  but  the  risk  of  attempting  it  is  vastly 
increased.  The  points  that  a  careful  and  skilful  cystoscopic  examina- 
tion or  a  Bupra-pubic  exploration  will  clear  up  about   the  growth   are 


REMOVAL   OF   GROWTHS    OF   THE    BLADDER.  595 

the  number,  site,  whether  accessible  or  not,  and  its  relation  to  the 
ureter,  how  far  pedunculated  or  sessile,  how  far  it  seems  attached  to 
the  coats  of  the  bladder.  There  is  a  general  belief,  I  think,  that 
pedunculated  growths  are  usually  benign.     This  is  a  very  dangerous 

belief.  Malignant  growths  or  transitional  ones  becoming  malignant 
form  the  very  great  majority  of  bladder  growths.  It'  the  growth  is  at 
all  thick  or  succulent,  if  it  is  at  all  infiltrating — i.<\,  not  a  merely 
implanted  pedicle — the  odds  are  greatly  in  favour  of  recurrence, 
however  thoroughly  the  growth  is  removed.  Of  28  cases  of 
pedunculated  growths  examined  by  Albarran  15  were  malignant.* 
In  apparently  simple  cases  recurrence  may  take  place  in  spite  of  the 
most  complete  operation  {ibid.).  The  more  the  growth  approximates 
to  the  worst  of  all  types  of  bladder  growth — viz.,  the  low-lying,  broad- 
based,  fixed,  sessile  lump,  especially  if  with  a  sloughy  surface  encrusted 
with  phosphatic  debris — the  more  hopeless  is  operative  interference 
(vide  Fig.  232).  If  the  renal  function  is  seriously  impaired,  or  if  there  is 
any  sign  of  metastases  or  extensive  local  infiltration  palpable  from  the 
rectum  or  vagina,  no  operation  should  be  undertaken,  except  for 
drainage  as  a  palliative  measure  in  some  cases  of  obstruction  of  the 
urethra. 

Choice  of  Operation. — In  my  opinion,  in  all  cases,  but  especially 
where  the  surgeon  is  uncertain  as  to  the  size  or  the  number  of  growths, 
where  the  perinseum  is  very  deep,  where  the  prostate  is  enlarged,  or 
the  perinseum  small  and  the  pelvic  outlet  contracted,  the  supra-pubic 
method  will  be  safest,  gives  by  far  the  best  view  and  most  room.  So, 
too,  in  the  case  of  a  recurrent  growth,  this  method  should  be  employed, 
as  it  cannot  be  told  how  far  the  recurrence  is  widely  diffused.  The 
supra-pubic  operation  is  always  to  be  preferred  as  enabling  one  to  see 
as  well  as  to  touch  the  growth,  as  alone  giving  more  room  for  necessary 
manipulations,  e.g.,  the  use  of  an  electric  lamp  in  what  may  be  a  very 
difficult  operation.! 

The  perineal  route  has  been  advocated  for  single  small  growths 
near  the  neck  of  the  bladder,  and  also  for  arresting  haemorrhage  in  a 
few  desperate  cases,  in  which  perinseal  section  is  the  quickest  method. 

*  It  is  always  worth  while  to  remember  the  vast  preponderance  of  malignant  over 
benign  growths  of  the  bladder  (Wallace,  Edin.  Mid.  Jui/rn.,  1893,  p.  735).  Thus  out  of 
88  cases  which  Albarran  personally  examined  71  were  malignant,  and  17  simple.  Out  of 
22  cases  Guyori  found  19  to  be  malignant. 

t  It  is  noteworthy  that  all  the  surgeons  of  widest  experience  have  declared  for  the 
supra-pubic  method — viz.,  Sir  H.  Thompson,  Guyon,  Volkmann,  Dittel,  von  Antal,  &c. 
Sir  Henry  Thompson  thus  drew  attention  to  the  great  risk  of  making  strong  supra-pubic 
pressure  while  forceps  are  being  used  through  a  perinatal  wound:  ;' If  that  pressure  is 
considerable,  it  forces  the  upper  wall  of  the  bladder  into  its  own  cavity,  and  thus  gives 
the  growths  a  larger  contour  than  they  possess,  ami  makes  them  apparently  salient  to  a 
mucli  greater  extent  than  they  really  are.  Thus  an  eager  or  inexperienced  operator, 
unaware  of  the  effects  of  strong  supra-pubic  pressure,  might  be  led  to  seize  the  mass 
offered  to  the  forceps  through  the  influence  of  this  pressure,  and,  under  the  belief  that  it 
was  a  large  growth,  he  might  inflict  a  fatal  wound  by  crashing  a  double  fold  of  the  coats 
of  the  bladder,  and  so  make  an  opening  in  the  peritonaeum.  To  avoid  such  a  catastrophe, 
it  is  only  necessary,  first,  to  decline  the  attempt  to  destroy  any  growth  which  is  clearly 
not  sufficiently  saline  to  admit  of  complete  or  nearly  complete  removal.'  and,  secondly, 
never  to  employ  the  forceps  while  forcible  supra-pubic  pressure  is  made — at  least,  no  more 
pressure  than  is  desirable  just  to  steady  and  fcujiport  the  bladder  and  the  parts  adjacent." 

38-2 


596 


OPK  RATIONS    ON    THE   ABDOMEN. 


Fig.  233. 


4Sc 


In  such  cases  the  bladder  hns  been  explored  from  the  perineum  l>v 
opening  the  membranous  urethra,  and  dilating  the  vesical  neck.  Bui 
even  here  I  do  not  recommend  it. 

In  some  cases  it  will  be  advisable  to  combine  both  operations,  as  the 
perinaial  opening  enables  the  surgeon  to  use  two  index-lingers  in  the 
bladder  at  the  same  time,  and  also  favours  drainage,  especially  where 
the  urine  is  foul. 

In  cases  where,  owing  to  complete  removal  having  been  an  impossi- 
bility, it  is  desired  to  give  relief  by  a  permanent 
opening,  a  supra-pubic  one  kept  patent  by  a 
short  curved  tube  and  plate  (somewhat  like 
a  tracheotomy-tube)  will  be  preferable  to  a 
perineal  opening,  owing  to  the  tendency  of  the 
latter  to  close,  and  the  basal  position  of  the 
growth  in  nearly  all  cases,  and  the  comparative 
freedom  of  the  anterior  wall  until  very  late  in 
the  disease. 

Operation. — Usually  the  surgeon  determines 
to  perform  a  supra-pubic  cystotomy  for  the 
reasons  already  given.  The  bladder  is  carefully 
and  thoroughly  washed  out,  and  then  filled  with 
boracic  lotion  ;  a  vertical  supra-pubic  opening  is 
then  made,  with  the  precautions  given  at  p.  623  ; 
a  transverse  incision  gives  a  better  view,  but  in- 
flictsmoredamageboth  to  the  abdominal  wall  and 
to  the  bladder.  When  the  bladder  is  distinctly 
reached,  some  advise  that  one  or  two  sutures 
of  sterilised  silk  be  passed  across  the  site  of 
the  intended  opening  into  the  bladder  with  a  curved  needle  in  a  handle. 
The  opening  into  the  bladder  is  then  made  (carefully,  so  as  not  to  divide 
the  underlying  silk),  and  the  silk  is  hooked  up  and  divided  ;  by  ibis 
means  two  or  four  sutures  are  present,  which  will  serve  to  raise  up  the 
bladder  as  required,  and  to  keep  it  well  open  and  within  reach  during 


Caisson  for  examination 
of  the  bladder  through  a 
supra-pubic  wound. 


Fig.  234. 


Forceps  for  seizing  bladder  growths.     (Hurry  Fenwick.) 


the  manipulations  required  for  the  removal  of  the  tumour.*  I  prefer  the 
use  of  two  fine  tissue-forceps  on  either  lip  of  the  wound,  held  by  assis- 
tants, the  threads  when  pulled  upon  being  liable  to  tear  the  delicate 
tissue  of  the  bladder.  Suitable  tissue  forceps  inflict  no  serious  damage. 
The  finger  of  an  assistant  in  the  rectum  serves  to  push  the  base  oi  the 
bladder  up  in  difficult  cases,  and  is  far  safer  than  a  rectal  bag.      This 

*  In  difficult  cases  the  position  of  Trendelenburg  (p.  612)  is  always  to  be  employed. 

The  intestines  gravitating  towards  the  diaphragm  drag  upwards  the  peritonaea] ad  thus 

the  bladder  slightly.  The  deeper  parts  of  the  viscus  can  now  be  better  brought  into  view, 
especially  with  an  electric  lamp. 


REMOVAL    OK    CIJONTIIS    OK    TIIK    BLADDER. 


597 


assistanl  must  aot  take  any  other  part  in  the  operation.  In  opening 
out  and  exposing  the  cavity  of  the  bladder,  specula*  of  wire  (solid- 
bladed  ones  taking  too  much  room)  will  be  found  very  useful,  and  a 
caisson  illuminated  with  a  forehead  lamp  is  invaluable,  for  a  clear 
view  oi  the  growth  ami  operation  area  can  he  thus  obtained  without 

Fig.  235. 


.    , 


Rod  in  right 
ureteral  orifice 


Small 

villous  growth. 


Villous 
papilloma 


Incision 


Urethra 


Simple  villous  papillomata  of  the  bladder.  (Guy's  Hospital  Museum.)  The 
mucous  membrane  around  the  base  is  removed  as  indicated  in  the  figure.  The 
ureteral  orifices  were  free  of  growth  in  this  case. 

the   need    of  frequent    sponging.      The  parietal    wound    is    also    less 
exposed  to  contamination  and  bruising  (vide  Fig.  233). 


*  Of  these  special  instruments  the  bladder-speculum  with  two  wire  blades  in/ented  by 
Watson,  of9Bostonl(Za«ce£,  Oct.  18,  1890),  and  the  three-jawed  speculum  of  Bruce  Clarke 
{Brit.  Med.  Journ.,  July  4,  1891),  are_the  best. 


598 


nPKUATinxs    "N    THE    ABDOMEN. 


To  minimise  haemorrhage  and  tlms  improve  the  view,  a  solution 
(toVo)  of  adrenalin  chloride  or  of  hemisine  can  be  applied  through  the 
caisson  before  the  base  of  the  growth  is  excised.  The  removal  of 
tin-  growth  is  effected  in  different  ways  according  to  its  size  and 
structure. 

Appropriate  forceps,  Btraight  and  curved,  those  with  serrated  blades 
introduced  by  Sir  Henry  Thompson  or  those  of  Fen  wick,  may  be  used 
to  seize  the  pedicle  of  the  growth  (vide  Figs.  234,  236).  If  the  tumour 
isa  large  one  it  is  a  great  convenience  to  gel  rid  of  the  bulk  of  it  at  once 
after  dividing  the  pedicle  in  front  of  the  clamp,  which  prevents 
hemorrhage.  The  division  is  made  with  the  curved  scissors  passed 
down  towards  the  concavity  of  the  twisted  jaws  of  the  forceps,  the  left 
forefinger  being  used  as  a  guide.  The  tumour  is  then  removed  with 
forceps,  and  attention  turned  to  the  stump.  This  and  the  adjacent 
mucous  membrane*  must  be  deliberately  removed  with  blunt-pointed 
scissors,  curved  upon  the  flat  (Fig.  235).  To  prevent  haemorrhage 
Mr.  Hurry  Fenwick  first  applies  a  narrower  curved  clamp  forceps 
between  the  fir>t  one  and  the  bladder  wall,  and  then  cuts  between  the 
two  forceps.      The  haemostatic  clamp  is  left  on  for  twenty-four  hours. 


[Fig.  236. 


il  forceps  for  seizing  the  pedicles  of  villous  growths.     (R.  Harrison.) 

The  second  (damp  may  be  dispensed  with  if  a  continuous  mattress 
suture  of  fine  catgut  can  be  placed  between  the  first  clamp  and  the 
vesical  muscle  ;  the  base  of  the  tumour  is  then  excised  between  the 
suture  and  the  clamps.  Very  fine  catgut  does  no  harm,  and  i>  very 
soon  absorbed  after  it  has  answered  its  purpose,  but  it  is  often  impossible 
to  insert  it.  It  is  rarely  wise  to  try  to  pull  the  pedicle  into  the  wound 
with  the  forceps,  for  the  traction  may  tear  off  the  stump  and  lead  to 
profuse  haemorrhage,  which  is  difficult  to  get  under  control.  It  is 
better  to  grasp  the  bladder  mucosa  near  the  tumour  with  tenaculum 
forceps  and  to  bring  the  growth  well  into  view  with  them.  In  any  1 
the  interior  of  the  bladder  must  be  thoroughly  examined  with  the  aid 
head  light  and  the  caisson  before  the  operation  is  completed,  so 
that  no  early  and  small  growth  may  perchance  be  overlooked. 

In  more  doubtful  cases — cases  transitional  between  innocent  and 
malignant — the  following  test  of  Albanian's  may  be  useful:  "The 
gliding  or  otherwise  of  the  mucous  membrane  ought  to  regulate  the 


*  ■•  Even  in  the  must  simple  cas._s  the  removal  of  the  growth  should  be  more  exten- 
sively performed  than  is  the  custom,  anil  all  the  mucous  membrane  in  contact  with  the 
th  should  be  removed.     We  have  Been  the  possibility  of  infection  by  contact  with  the 
mucous  membrane,  and  the  plan  I  propose  is  to  eradicate  the  epithelial  neoplasms  that 
may  exist  around  the  growth"  (Albarran,  loc.  tupra  < 


IIKMOVAL    OF    (illOWTHS    OF    THF    IH,AI>DKK.  599 

depth  of  the  removal  of  the  growth.  Wherever  the  mucous  membrane 
seems  fixed  to  the  sub-mucous  coat  it  would  be  better,  even  in  pedun- 
culated growths,  to  resect  the  entire  wall,  ;i  step  still  more  essential  in 

small  sessile  tumours"  {vide  infra,"  Partial  Resection  of  the  Bladder," 
p.  604).  When  the  growth  is  of  firmer  consistence  and  more  of  the 
sessile  type,  it  should  he  clipped  away  with  scissors,  punched  out  if  firm 
bit  by  hit  with  Jessop's  prostatectomy  forceps,  or  Fenwick's  scoop 
forceps  (Fig.  237).*  This  procedure  only  affords  temporary  relief, 
and  is  not  to  be  employed  when  partial  resection  of  the  bladder  is 
practicable. 

If  we  are  to  progress  in  our  surgery  here,  a  radical  cure  can  only  be 
hoped  for  in  growths  that  infiltrate  the  bladder  wall  by  treating  them 
as  we  do  malignant  disease  elsewhere  —  i.e.,  operating  early  and 
removing  the  whole  thickness  of  the  tissues  affected,  as  long  as  this 
step  is  not  foolhardy  (see  "1'artial  Resection,"  p.  604).  Further  two 
warnings  of  Mi-.  Fenwick's  must  be  remembered  by  those  who  trust 
to  forceps  and  nibbling  or  twisting  :  "  Munching  the  surface  of  a 
carcinoma  and  leaving  the  base  is  tantamount  to  an  increase  in  the 
rapidity  of  its  growth.  I  have  reason  to  believe  that  the  munching 
or  squeezing  of  the  healthy  mucous  membrane  in  the  neighbourhood 
of  the  growth  fosters  the  appearance  subsequently  of  growth  in  the 
traumatized  areas  "  (Brit.  Med.  Journ.,  1895,  vol.  ii.  p.  906). 

Fig.  237. 


Fenwick's  scoop  forceps. 


Dr.  F.  S.  Watson  in  a  valuable  paper  in  the  Ann.  of  Surg.,  1905 
(vol.  xlii.,  p.  805),  gives  the  results  of  his  careful  analysis  of  the  records  of 
653  operations  for  various  growths  of  the  bladder.  This  number 
includes  the  cases  published  by  Albarran  in  1892,  and  others  collected 
or  observed  by  Watson  since  that  time ;  243  of  the  operations  were  for 
benign  and  410  for  malignant  growths.  From  this  study  Watson 
concludes  that  "  the  sum  and  substance  of  the  result  of  operative 
interference  up  to  the  present  time  may  be  stated  thus  :  If  the  operative 
deaths  and  rapid  recurrences  are  combined  under  the  one  heading  of 
operative  failures,  such  failures  are  seen  to  have  occurred  in  the  28*6 
per  cent,  of  the  benign  tumours,  exclusive  of  myxoma,  and  in  40  per 
cent,  of  the  cases  of  carcinoma.  .  .  .  The  very  large  percentage  of 
recurrence  seems  to  point  logically  to  the  necessity  of  more  radical 
measures  in  benign  as  well  as  in  cases  of  malignant  tumours,  if  we  are 
to  hope  for  better  results." 

Dr.  Watson  even  goes  so  far  as  to  suggest  "  that  total  extirpation  of 
the  bladder  and  of  the  prostate,  if  it  be  involved  in  the  pathological 
process,  be  done  at  the  outset  in  all  cases  of  carcinoma  that  have  not 

*  Whatever  method  is  used,  the  surface  left  should  be  as  smooth  as  possible,  in  order 
to  diminish  the  risk  of  phcsphatic  deposit, 


6oo 


OPERATIONS    ON    THE    ABDOMEN. 


extended  beyond  the  limits  of  the  above-named  structures,  and  in 
which  it  is  believed  that  there  are  no  metastases,  and  that  the  same 
measures  shall  be  applied  in  all  cases  of  benign  growths  in  which 
recurrence  has  taken  place  alter  a  primary  operation  fortheir  removal." 
While  fully  conscious  of  the  need  of  adopting  more  radical  measures  in 
all  cases,  especially  of  the  wisdom  of  partial  resection  and  even  complete 

Fig.  238. 


Carcinomatous 
growth. 


Rod  in 
ureteral  orifice 


Carcinoma  of  the  bladder  surrounding  the  right  ureteral  orifice     (Guy's 
Hospital  Museum.) 

resection  in  suitable  cases  by  very  skilful  and  experienced  surgeons, 
I  cannot  endorse  Dr.  Watson's  recommendations  in  their  entirety  for 
the  following  reasons: — 

(1)  The  immediate  mortality  of  total  extirpation  has  been  as  high 
as  56  per  cent,  in  the  25  cases  collected  by  Wats. .11,  as  compared  with 
18-6  per  cent,  in  91  partial  resections  ;  but  it  is  likely  that  the  death- 
rate  of  both  operations  will  be  very  considerably  diminished  in  the 
hands  of  skilful  surgeons,  from  improvements  of  technique  and  a  better 


REMOVAL   OF   GROWTHS   OF   THE    BLADDER.  601 

selection  which  increasing  experience  may  enable  them  to  make.  The 
greater  risk  is  compensated  to  some  extent  by  more  freedom  from 
recurrence  after  total  extirpation  than  alter  partial  resection  and  other 
less  radical  removals  of  malignant  growth.  Recurrence  is  also  much 
rarer  after  partial  resection  than  after  less  radical  operations  for  so- 
called  benign  papilloma. 

(2)  The  primary  difficulties  and  dangers  of  ureteral  transplantation 
of  every  kind  and  the  unsatisfactory  character  of  the  ultimate  results 
as  regards  want  of  proper  control  of  the  urine,  and  the  liability  to 
ascending  infection*  and  ureteral  obstruction. 

It  seems  to  me  that  more  is  to  be  expected  from  partial  but  earlier 
and  more  extensive  resections  than  hitherto  adopted,  but  leaving 
enough  bladder  for  implantation  of  one  or  both  ureters  according  to 
the  situation,  nature,  and  extent  of  the  growth. 

Haemorrhage. — This  may  be  met  by  pressure,  suture,  or  occasionally 
by  ligature,  the  ends  of  the  latter  being  brought  out  through  the 
meatus  in  the  female  or  the  supra-pubic  wound  in  the  male.  Sutures 
of  very  fine  catgut  may  be  used.  Hurry  Fenwick  with  sessile  growths 
catches  the  bleeding  points  through  the  caisson  with  artery  clips,  and 
then  removes  the  handles  of  the  latter,  and  withdraws  the  caisson, 
leaving  the  clips  on  for  twenty-four  hours. 

Hot  saline  solution  at  a  temperature  unpleasantly  hot  for  the  hand 
may  be  tried  if  the  bleeding  persists  in  spite  of  the  above,  and  if  the 
bleeding  point  is  on  the  floor  or  above  the  neck.  A  solution  of 
adrenalin  chloride  (xuoo")  snou^  De  applied  on  the  bleeding  part  through 
the  caisson,  and  followed  if  necessary  by  gauze  tamponnading.  A 
subcutaneous  injection  of  aseptic  ergot  or  emutin  may  be  required  in 
some  cases.  Care  must  be  taken  not  to  leave  any  bits  of  growth  or 
clots  in  the  bladder  to  become  the  nuclei  of  stones,  and  for  this  reason 
the  bladder  must  be  irrigated  before  attempting  to  close  the  wound 
either  partly  or  completely. 

When  the  operation  is  completed  the  question  will  arise  as  to  the 
advisability  of  suturing  the  bladder.  In  the  after-treatment  of  all 
supra-pubic  cystotomies,  the  chief  nuisance,  and  a  very  great  one,  is 
constant  soakage  of  the  dressings  by  the  urine.  This  should  be 
avoided  whenever  the  following  conditions  make  the  use  of  sutures 
safe  :  (1)  efficient  suturing  of  the  vesical  wound  :  a  continuous  Lembert 
suture  of  catgut  is  employed,  care  being  taken  to  secure  a  sufficient 
hold  and  inversion  without  piercing  the  mucosa ;  (2)  efficient  empty- 
ing of  the  bladder ;  (3)  arrest  of  bleeding,  otherwise  the  catheter  will 
be  blocked,  the  distress  great,  and  much  tension  will  be  thrown  on  the 
stitches ;  (4)  an  aseptic  condition  of  the  urine  ;  (5)  an  operation  in 
which  the  manipulations  have  not  been  veiy  prolonged  and  difficult, 

*  Dr.  Watson  proposes  to  get  over  these  difficulties  and  dangers  by  performing  bilateral 
nephrostomy  with  ligation  of  the  ureters  some  four  or  six  weeks  before  the  radical  opera- 
tion. This  provides  freer  drainage  than  any  transplanting  operation,  and  Watson  believes 
that  the  immediate  risk  even  of  the  bilateral  operation  would  be  much  less  than  that  of 
ureteral  implantation.  He  also  states  that  the  annoyances  and  dangers  of  bilateral  renal 
fistulas  are  small,  and  avoidable  to  a  large  extent.  Obviously  this  method  is  not  suitable 
even  as  a  palliative  measure  for  irremovable  vesical  growth,  except  in  the  well-to-do,  who 
can  provide  the  needful  apparatus  for  drainage,  and  obtain  the  services  of  a  capable  nurse 
permanently. 


602 


OPKRATIONS  ON  THE  ABDOMEN. 


and  one  especially  in  which  there  has  not  heen  much  disturbance  of 
the  cavuni  E&etzii. 

In  any  case  a  small  drainage  tube  containing  a  wick  of  gauze  should 
pass  through  the  lower  angle  of  the  parietal  wound  down  to  the  line  of 
suture,  so  that,  if  any  leak  occur  in  the  first  day  or  two,  urine  may  not 
extravasate  in  the  loose  cellular  tissues  of  the  pelvis,  but  drain  away 
alongthe  tube  and  gauze.  These  can  be  safely  removed  after  three  days. 
If  the  surgeon  is  wisely  cautious  about  suturing  the  whole  of  the 
bladder  wound,  he  will  suture  it  almost  completely,  and  leave  in  a 
small  closely  fitting  drainage  tube,  putting  in  one  or  two  provisional 


Fig.  239. 


Fig.  240. 


u 


sect:oh 

Colt's  supra-pubic  dressing,  round 
or  cylindrical  pattern.  A  water- 
tight joint  is  made  between  the 
patient's  skin  and  the  rubber  sheet 
by  unpins  of  a  solution  of  rubber 
in  naphtha.  The  upper  pari  of  the 
glass  capsule  is  open,  so  that  air 
may  enter  it,  and  syphonage  be 
thus  avoided. 


Supra-pubic  dressing,  oval  pattern. 


sutures,  which  he  will  tighten  up  in  a  few  days,  when  the  risk  of 
haemorrhage  and  extravasation  has  passed  away.  When  the  conditions 
given  above  are  not  present,  and  suturing  the  bladder  involves  too 
much  risk,  the  cut  edges  of  the  bladder  should  be  united  to  those  of 
the  deeper  and  lower  part  of  the  parietal  wound  with  catgut. 

A  No.  12  soft  and  large-eyed  catheter  is  passed  through  the  urethra 
so  that  its  eye  lies  just  within  the  bladder,  where  the  point  can  do  no 
harm. 

A  medium-sized  drainage  tube  is  passed  into  the  bladder.  The  part 
that  lies  within  the  latter  should  be  fenestrated,  and  the  other  end 
should  project  a  little  beyond  the  lips  of  the  parietal  wound,  to  which 
it  is  fixed  by  means  of  a  salmon-gut  suture.  Another  method  of 
draining  is  to  use  an  india-rubber  catheter,  lengthened  by  a  piece  of 


IIFMOVAL    OF    GROWTHS    OF    THK    IJLADDKH.  603 

drainage  tube,  passed  along  the  urethra,  and  out  at  the  supra-pubic 
wound.  Several  holes  should  be  cut  in  the  part-  that  is  to  Lie  within 
the  bladder.  Bringing  the  tube  out  above  the  pubes  facilitates  washing 
out  the  bladder  both  ways. 

If  the  urine  does  not  drain  through  the  catheter,  although  its  end 
lias  been  properly  placed  just  above  the  vesical  orifice,  and  the  distal 
end  of  the  rubber  tube  attached  to  it  is  kept  under  some  carbolic 
lotion,  a  little  boracic  lotion  should  be  run  through  the  catheter,  for  this 
may  serve  to  dislocate  a  clot  from  within  it. 

li'  the  patient  still  gets  wet  syphonage  should  be  employed,  but  this 
is  easier  to  write  about  than  to  establish  and  maintain  efficiently.* 
Colt's  improved  supra-pubic  drainage  apparatus  if  carefully  applied 
works  admirably  (vide  Figs.  239,  240). 

Ureteral  drainage  is  only  mentioned  to  be  condemned  on  account  of 
the  danger  of  ascending  suppurative  nephritis!,  for  in  many  of  these 
patients  the  kidneys  are  already  damaged. 

The  Removal  of  Vesical  Growths  in  Women. — Supra-pubic  cysto- 
tomy is  not  necessary  for  the  removal  of  pedunculated  benign  growths 
from  the  female  bladder,  for  these  can  be  removed  through  the  dilated 
urethra  witli  less  risk,  and  with  little,  if  any,  more  chance  of 
recurrence.  Malignant  and  sessile  growths  must  be  removed  supra- 
pubically,  as  in  the  male.  When  the  surgeon  has  decided  to  remove  a 
growth  through  the  urethra,  the  bladder  is  washed  out,  and  the 
urethra  is  dilated  with  Kelly's  conical  dilators.  A  large  Kelly's 
speculum  is  then  introduced,  and  the  growth  is  sought  and  brought 
into  view,  and  removed  as  described  above  (p.  598). 

Removal  of  papillomatous  growths  with  the  operating  cystoscope  of 
Nitze  is  not  to  be  recommended,  for  it  is  only  practicable  for  very  few 
experts,  and  even  for  them  the  hemorrhage  obstructs  the  view  imme- 
diately after  the  removal  of  perhaps  a  part  of  the  growth,  and  it  is 
impossible  to  tell  whether  the  removal  has  or  has  not  been  complete. 
The  operation  can  certainly  he  repeated  if  necessary  with  less  dis- 
turbance than  a  supra-pubic  cystotomy  involves,  and  the  operative 
mortality  is  very  small  in  the  hands  of  the  very  few  who  can  really 
employ  the  method. 


*  The  best  means  of  draining  the  bladder  is  one  described  by  my  friend  Mr.  Cathcart, 
of  Edinburgh  (Brit.  Med.  Jouni.,  1895,  vol.  ii.  p.  968).  Besides  a  douche-can,  some  india- 
rubber  tubing,  and  a  pail,  a  screw  clamp,  a  small  glass  Y  or  T  tube,  a  second  piece  of  glass 
tubing  bent  like  a  capital  S,  and  a  third  piece  bent  at  a  right  angle  to  go  into  the  bladder, 
are  required.  The  can,  filled  with  water,  is  fixed  over  the  patient's  bed ;  the  Y  tube  is 
fastened  with  a  large  safety-pin  to  the  edge  of  the  mattress  opposite  the  patient's  pelvis. 
To  one  limb  of  the  Y  tube  is  attached  about  a  foot  of  tubing  which  is  connected  with  the 
can,  to  the  other  a  right-angled  glass  tube,  which  dips  into  the  bladder.  To  the  stalk  of 
the  Y  tube  a  third  bit  of  tubing  is  attached,  which  is  fixed  below  to  the  S  glass  tube,  which 
by  means  of  another  bit  of  tubing  should  end  under  some  aseptic  lotion.  The  apparatus 
being  in  position,  the  screw-clamp  which  controls  the  rubber  tubing  between  the  irrigator 
and  one  arm  of  the  Y  tube  is  then  relaxed,  so  as  to  allow  the  water  to  run  very  slowly,  in 
fact,  only  by  drops.  It  accumulates  in  the  S  tube,  and  as  it  tends  to  run  out  produces  a 
negative  pressure  in  the  other  arm  of  the  Y  tube — i.e.,  the  one  connected  with  the  tube  in 
the  bladder,  thus  withdrawing  the  urine. 

t  Schede  has  thus  kept  a  tube-catheter  in  one  ureter  for  several  days  without  any  harm 
resulting. 


604  OPERATIONS   ON   THE   ABDOMEN. 

Whichever  way  the  vesical  growths  are  removed,  it  is  absolutely 
necessary  to  keep  the  patients  under  observation  for  a  long  time. 
Cystoscopic  examinations  should  be  made  at  regular  intervals  of  about 
two  months,  and  in  this  way  a  recurrence  may  be  discovered  long 
before  symptoms  arise  or  the  tumour  has  become  inoperable.  Intra- 
vesical injections  of  nitrate  of  silver  solution  may  do  something 
towards  preventing  recurrence  (Herring,  Brit.  Med.  Journ.,  Xov.  28 

im- 
partial Hesection  of  the  Bladder  for  Growths. — A  good  many  cases 
have  been  recorded  with  a  sufficient  amount  of  success  to  justify  a 
repetition  of  the  operation  in  selected  cases.  Watson's  collected  cases 
included  17  partial  resections  for  papilloma,  with  one  death,  tour  for 
myoma,  with  one  death,  making  a  total  of  21  partial  resections  for 
innocent  growths,  with  two  deaths,  a  mortality  of  9-5  per  cent. 

For  carcinoma  there  were  91  of  these  operations,  with  17  deaths — a 
mortality  of  i8'6  per  cent.  It  is  interesting  that  this  death-rate  was 
less  than  that  for  the  222  supra-pubic  operations  without  resection,  for 
the  latter  were  attended  by  a  mortality  of  28  per  cent. 

There  was  a  freedom  from  recurrence  for  over  a  year  in  37*5  of  the 
cases  of  papilloma,  as  compared  with  an  immunity  for  over  a  year  in 
only  27*5  per  cent,  after  supra-pubic  operations  without  resection.  It  is 
hardly  necessary  to  mention  that  recurrence  may  frequently  occur  after 
a  year,  hut  this  does  not  spoil  the  value  of  the  figures  tor  the  purpose 
of  comparison. 

The  growth  can  be  most  readil}'  resected  when  it  is  situated  some- 
where in  the  upper  or  middle  zones  of  the  bladder,  whereas  it  is  most 
difficult,  and  frequently  impossible,  to  excise  widely  enough  when  the 
tumour  arises  from  the  region  of  the  trigone  without  destroying  one 
or  both  ureteral  orifices  or  the  sphincter  vesicas.  Unfortunately  all 
growths  of  the  bladder  are  infinitely  more  common  at  or  mar  the  trigone 
than  anywhere  else.  When  it  is  necessary  to  remove  a  portion  of  one 
ureter  the  latter  may  be  implanted  into  the  reconstructed  bladder,  and 
in  some  cases  both  ureters  may  be  so  treated,  as  in  Dr.  Han 
patient  (p.  605). 

Where  the  vertex  or  neighbourhood  is  the  seat  of  the  growth  Antal's 
extra-peritonaeal  method  should  he  followed.  By  this  a  large  amount 
of  the  upper  part  of  the  bladder  may  be  removed,  but  the  farther  the 
resection  is  carried  the  greater  is  the  difficulty  of  stripping  off  the 
peritonaeum,  and,  of  course,  in  closing  the  gap. 

The  peritonaeum  is  much  more  easily  peeled  oil'  when  the  bladder  is 
full  than  when  it  is  empty.  The  edges  of  the  wound  in  the  bladder 
should  be  closed  with  catgut  sutures  as  completely  as  possible.  When 
the  resection  has  been  so  complete  that  the  gap  cannot  be  closed,  its 
edges  must  be  united  to  those  of  the  parietal  wound,  and  the  opening 
closed  later  on  by  a  plastic  operation. 

A  good  account  of  a  case  of  resection  of  part  of  the  lateral  wall  and 
disease  of  the  bladder  is  given  by  Mr.  IT.  Fenwick  (Clin.  Soc.  Trans., 
vol.  xxvii.  p.  164)  : 

The  patient  was  a  man  aged  46.  The  growth,  an  epithelioma,  had  been  removed 
twice  before,  the  first  time  by  the  perinseal  route,  the  second  time  Bopra-pubically, 
from  a  spot  to  the  left  of  the  orifice  of  the  left  meter.  "On  opening  the  bladder 
supra-pubieally    the  growth   was  found   to  have  recurred    in    the  -ear   of    the  previous 


REMOVAL   OF    (JROWTITS    OF    TUB    BLADDER.  605 

operation.  Ii  was  now  a  smooth,  sessile  epithelioma,  one  inch  and  a  half  bj  one  inch. 
The  base  was  indurated,  and  the  infiltration  bad  involved  the  muscular  and  Bub-mucous 
layers,  for  they  wen-  glued  to  the  tumour,  in  order  to  gain  free  access  to  the  left 
lateral  wall  of  the  bladder,  I  drew  my  knife  horizontally  through  the  left  lower 
abdominal  muscles,  the  incision  commencing  al  the  Bupra-pubic  opening,  and  ending 
point  above  the  inner  third  of  Poupart's  ligament.  Stripping  off  the  peritonaeum 
from  the  front  wall  of  the  left  pelvis,  I  kepi  it  packed  up  with  sponges.  I  then  rese 
the  growth  by  cutting  away  with  scissors  it  and  the  entire  thickness  of  thai  pari  of  the 
bladder  which  was  subjacent  to  it.  The  bladder  incision  commenced  al  the  median 
ing,  ami  passed  directly  to  the  left  until  the  upper  margin  of  the  growth  was  reached.  It 
then  proceeded  round  the  tumour.  The  left  side  of  the  trigone  was  almost  involved,  bnl 
the  ureteral  orifice  was  not  encroached  upon.  The  hemorrhage  was  nol  severe,  and  was 
easily  controlled  by  a  couple  of  dozen  Spencer  Wells's  forceps."  The  edges  of  the  bladder 
wound  were  drawn  together  by  catgut  sutures  which  traversed  only  the  muscular  la 
a  small  Bupra-pubic  opening  being  left  for  drainage.  This  wound  and  that  in  the 
abdominal  wall  healed  quickly,  and  two  years  later  (Brit.  Med.  •Toum.,  1895,  v°l-  '•■  P- 
907)  Mr.  Fenwick  stated  that  the  patient  was  at  work  in  good  health. 

All  will  agree  with  the  three  conditions  which  Mr.  Fenwick 
considers  necessary  before  such  operations  are  undertaken  :  (1)  a 
single  growth,  slow  and  dense;  (2)  absence  of  cystitis;  (3)  suffi- 
cient vitality  on  the  "part  of  the  patient  to  bear  so  serious  an 
operation. 

Dr.  Malcolm  Harris,  of  Chicago  (Ann.  of  Surg.,  1902,  p.  509),  success- 
fully resected  the  prostate  and  the  greater  part  of  the  bladder  extra- 
peritonaeally  in  a  man  aet.  53  for  carcinoma  involving  the  trigone  and 
invading  the  prostate.  The  upper  end  of  the  bladder  was  saved,  and 
the  ureters  were  implanted  into  it. 

The  operation  was  performed  on  Oct.  5,  1901.  A  long  median  supra-pubic  incision 
was  made,  and  the  peritonaeum  displaced  upwards.  The  sides  and  front  of  the  bladder  and 
prostate  were  cleared  down  to  the  base,  and  the  urethra  was  divided  just  above  the 
triangular  ligament.  Beginning  from  below,  the  prostate  and  the  bladder  were  gradually 
separated  from  the  rectum.  "This,  which  was  the  most  difficult  part  of  the  operation,  was 
facilitated  by  an  assistant  introducing  two  fingers  into  the  rectum,  thus  raising  all  the 
parts  well  forward.  The  haemorrhage  during  this  part  of  the  operation,  though  consider- 
able, was  not  as  severe  as  was  anticipated,  and  was  materially  lessened  by  keeping  the 
bladder  well  drawn  forward,  that  is  toward  the  supra-pubic  opening,  as  fast  as  it  was 
separated  from  the  rectum.  The  ureters,  as  soon  as  they  came  into  view,  were  easily 
divided  beyond  the  disease.  The  right  ureter  was  considerably  enlarged  and  tortuous, 
owing  to  the  obstruction  which  the  growth  had  produced  at  the  ureteral  opening.  Some 
small  enlarged  lymph  glands  which  were  found  in  the  connective  tissue  to  the  side  of  the 
bladder  were  removed.  As  the  vertex  of  the  bladder  was  not  involved  in  the  diseased  process, 
a  portion  of  it,  six  to  seven  centimetres  in  diameter,  was  retained.  The  remainder  of  the 
bladder  and  the  prostate  were  removed.  Small  slits  were  made  in  the  remnant  of  the  bladder, 
and  the  ureteral  ends  drawn  through  and  stitched  with  catgut.  The  small  portion  of  the 
bladder  was  then  stitched  by  its  edge  to  the  inner  edge  of  the  supra-pubic  opening,  except 
at  the  lower  part.  The  cavity  in  the  pelvis  was  packed  with  gauze,  and  a  large  rubber 
drainage  tube  inserted  to  the  bottom  of  the  cul-de-sac.  The  peritonaaal  cavity  was  not 
opened.  Time  of  operation,  about  one  hour  and  thirty  minutes.  There  was  considerable 
shock  following  the  operation,  but  this  was  slowly  recovered  from,  and  in  about  two  weeks 
the  patient  was  able  to  sit  up.  The  cavity  filled  in  quite  rapidly,  and  the  tube  was  soon 
dispensed  with.  In  about  a  month  the  patient  had  gained  in  strength  so  as  to  be  up  and 
around.  The  ureteral  openings  in  the  small  practically  exstrophied  bladder  were  easily 
seen,  and  the  urine  escaping  from  them  was  clear,  and  on  analysis  normal,  with  the 
exception  of  a  small  amount  of  pus  from  the  surrounding  parts. 

11  On  drawing  the  edges  of  the  supra-pubic  opening  together  the  lower  part  of  the  small 


606  OPERATIONS   ON   THE    ABDOMEN. 

bladder  wonld  dip  slightly  behind  the  upper  edge  of  the  symphysis  pubis.  A  catheter 
introduced  through  the  penis  reached  tin- small  bladder,  and  nearly  all  the  nrine  drained 
off  through  the  catheter.  It  was,  therefore,  retained  permanently  in  position."  The 
man  was  going  about  and  improving,  when  he  developed  lobar  pneumonia  and  died  early  in 
ober,  1901. 

Dr.  Harris  was  led  to  retain  ;i  portion  of  the  bladder,  with  a  view  of 
its  ultimate  regeneration  into  a  serviceable  receptacle  by  noticing  the 
remarkable  way  in  which  the  base  and  a  small  part  of  the  posterior  wall 
of  the  bladder  had  enlarged  in  a  man  who  had  lost  the  upper  and 
greater  part  of  his  bladder  from  sloughing  as  the  indirect  result  of  an 
accident.  The  man  gradually  regained  the  power  of  retaining  his 
urine  quite  well. 

The  upper  part  of  the  bladder,  however,  is  never  likely  to  develop  the 
power  of  retaining  much  urine,  and  this  fact  alone  will  militate  against 
its  enlargement.  Still  Dr.  Harris's  ingenious  operation  is  capable  of 
further  development  and  modification. 

Vaginal  Resection  of  a  Part  of  the  Bladder. — In  the  female,  when 
the  growth  is  situated  at  or  near  the  trigone  as  usual,  the  vaginal 
route  is  safer,  and  better  for  partial  resection.  A  longitudinal  incision 
is  made  in  the  anterior  vaginal  wall,  and  the  growth  resected;  the 
bladder  is  reconstructed,  and  the  vagina  carefully  sutured.  The 
bladder  must   be   drained   by  means   of  a   soft   catheter. 

Intra-peritonseal  Resection  of  a  Part  of  the  Bladder. — This  may  be 
necessary  when  the  growth  arises  in  or  invades  the  postero-superior 
part  of  the  bladder,  where  it  is  covered  with  peritonaeum.  It  is  not 
necessary  to  adopt  such  mutilating  procedures  as  resection  of  a  part  of 
the  symphysis  pubis,  as  advised  by  Hellerich  ;  but  the  Trendelenburg 
posture,  a  large  incision,  and  good  retraction,  give  plenty  of  room  and 
a  good  view. 

Along  median  incision  is  made,  and  the  bladder  freely  opened  in 
front,  the  escaping  liquid  being  carefully  removed  with  gauze  sponges. 
The  peritonaeal  sac  is  then  opened,  and  the  field  of  operation  carefully 
isolated  with  gauze  tampons,  which  protect  the  intestines  which  have 
fallen  away  from  the  pelvis.  If  the  growth  extends  at  all  near  either 
ureter  a  bougie  must  be  passed  into  this,  as  a  guide  during  the  subse- 
quent steps.  The  part  to  be  removed  is  taken  away  from  within,  a 
hand  introduced  into  the  peritonaea]  sac  and  behind  the  bladder, 
keeping  touch  of  the  catheterised  ureter  and  guiding  the  scissors. 

The  wound  in  the  bladder  is  then  sewn  up,  beginning  from  the  pos- 
tero-inferior  angle.  Catgut  is  used  lor  the  suture  which  does  not 
pierce  the  mucosa,  and  is  reinforced  by  a  Lembert  or  Cushing  con- 
tinuous suture  tor  greater  security.  An  oblique  perforation  is  then 
made  through  the  wall  of  the  reconstructed  bladder  at  the  most 
accessible  part  for  the  ureter,  which  is  drawn  through  the  puncture  by 
means  of  narrow-bladed  forceps.  The  ureter  should  tit  snugly  in  the 
oblique  canal,  which  should  be  about  an  inch  long.  Tin-  part  of  the 
duct  which  now  projects  into  the  cavity  of  the  bladder  is  slit  for  a 
short  distance  and  sewn  to  the  vesical  mucosa  with  tine  catgut.  If 
possible  one  or  two  sutures  should  also  be  inserted  t<>  strengthen 
the  point  of  junction  with  the  bladder  upon  the  peritonaea]  surface.  A 
catheter  is  passed  into  the  ureter  and  brought  out  through  the  supra- 
pubic drainage  tube.     The  vesical  wound   is  partly  closed  around  the 


REMOVAL   OF  GROWTHS   OF   THE    BLADDER.  607 

tube,  and  the  space  between  the  bladder  and  the  pubea  is  drained  with 
gauze. 

Complete  Extirpation  of  the  Bladder.* — This  operation  lias  been 
performed   by   Bardenheuer  and   Gussenbauer.      The  first  successful 

case  was  by  l'awlik,  of  Prague.  Cliido  has  had  a  second.  Both  of 
these  were  in  women.  In  each  case  the  operation  was  done  in  two 
stages,  the  ureters  being  first  diverted  to  and  secured  in  the  vagina, 
and  then,  about  three  weeks  later,  the  bladder  removed.  The  vagina 
by  the  second  operation  was  converted  into  a  pseudo-bladder,  the 
mine  being  voided  through  the  urethra.     Pawlik's  patient,   was  alive 

two  years  and   a  half  after  the  operation,  and  in  fair  c fort.      Drs. 

Tuffier  and  Dujarier  (Rente  de  Chirurgie,  April,  1898)  described  a 
successful  case  of  complete  extirpation  of  the  bladder  in  a  man  in  one 
operation,  the  ends  of  the  ureters  being  implanted  into  the  rectum. 
Two  months  after  the  operation  the  man  was  able  to  do  his  work. 
Dr.  Watson  has  collected  the  records  of  25  cases  of  total  extirpation 
of  the  bladder  for  carcinoma,  with  14  deaths,  a  mortality  of  56  per 
cent.  ;  out  of  the  11  that  recovered,  six,  or  54*5  per  cent.,  were  known 
to  be  free  of  recurrence  a  year  later.! 

In  some  cases,  in  which  the  growth  has  not  invaded  the  part  of  the 
bladder  which  is  covered  with  peritonaeum,  it  may  be  possible  to  perform 
the  operation  extra-peritonaeally,  but  in  the  majority  of  patients  in 
whom  total  extirpation  is  indicated  at  all  the  peritonaeum  must  be 
opened,  and  most  of  the  serous  covering  of  the  bladder  sacrificed,  in 
order  to  get  well  beyond  the  disease,  and  for  the  same  reason  the 
prostate  should  be  removed  with  the  bladder.  Moreover,  it  is  easier 
to  do  this  than  to  leave  it  and  have  to  deal  with  the  comparatively 
broad  pedicle  formed  by  the  base  of  the  bladder. 

The  ureters  have  been  diverted  into  the  rectum,  vagina,  urethra,  or 
brought  to  the  skin.  In  the  female  the  vagina  is  the  best  to  choose, 
and  in  the  male  the  rectum  or  sigmoid  is  on  the  whole  the  best,  although 
there  is  more  danger  of  ascending  nephritis  than  with  urethral  and 
cutaneous  implantation,  but  the  control  of  the  urine  acquired  by  the 
rectum  is  a  great  advantage,  and  the  ureters  may  not  be  long  enough 
to  join  to  the  urethra.  When  the  intestine  is  selected,  the  perforations 
should  be  made  as  obliquely  as  possible,  and  ureteral  catheters  fixed 
in  and  brought  out  at  the  anus,  to  prevent  distension  of  the  rectum 
before  the  union  is  complete. 

The  bladder  may  be  separated  either  (a)  from  above  downwards  (Lund), 
or  (b)  from  below  upwards  (Harris).  The  former  method  is  most  suitable 
when  the  peritonaeum  need  not  be  opened,  and  it  also  has  the  advan- 
tage of  allowing  the  surgeon  to  tie  the  larger  blood-vessels  and  secure 
the  ureters  very  early  in  the  operation.  The  latter  method  has  the 
advantage  that  the  main  part  of  the  operation  can  be  conducted  extra- 
peritonaeally  in  all  cases,  even  when  some  of  the  serous  coat  has  to  be 
sacrificed. 


*  A  paper  by  M.  Chevalier  (Arch.  Gen.  de  Med.,  t.  ii.  1894)  contains  much  information 
on  partial  and  complete  resection  of  the  bladder. 

f  Watson  (Ann.  of  Surg.,  vol.  xlii.  p.  805)  gives  a  valuable  table  of  the  recorded  cases 
of  total  extirpation  for  growth.  Hartley  (Med.  News,  Aug.  29,  1903)  also  collected  and 
discussed  23  cases  of  total  excision  of  the  bladder  for  malignant  growth. 


608  OPKRATIOXS    OX    THK    AIJDOMKX. 

(a)  Mr.  Herbert  Lund  (Lancet,  1902,  vol.  ii.  p.  1624)  removed  the 
whole  bladder  for  extensive  papillomatous  growth,  but  the  patient  died 
three  days  after  the  operation  of  pre-existing  renal  suppuration.  The 
following  excellent  description  of  the  operation  is  taken  from  the 
Lana  1 : 

Operation. — The  patient  was  placed  "  in  the  dorsal,  and  not  in 
Trendelenburg's,  position.  The  bladder  was  washed  out  and  then 
moderately  distended  with  boric  lotion.  A  vertical  incision  was  made 
in  the  middle  line  about  four  inches  long,  and  the  recti  muscles  were 
separated  but  not  divided  either  transversely  or  at  their  attachments 
into  the  pubes.  Great  care  was  taken  not  to  open  the  peritoneal 
cavity.  The  bladder  was  then  easily  exposed  and  opened,  and  a  digital 
examination  was  made.  The  growth  was  chiefly  confined  to  the 
trigone  and  lower  half  of  the  bladder,  the  fundus  being  fairly  free; 
some  of  the  papillomata  were  long  and  branching.  To  the  right  of 
the  fundus  was  a  pouch.  Mr.  Lund  at  once  determined  to  remove  the 
whole  bladder.  Commencing  at  the  fundus,  the  peritonaeum  was  stripped 
off,  and  in  doing  this  two  small  rents  occurred,  neither  of  them  half 
an  inch  in  length,  and  they  were  at  once  repaired  with  a  continuous 
catgut  suture.  The  stripping  was  tedious,  but  not  difficult.  Then 
working  at  each  side  alternately  and  clamping  and  ligaturing  numerous 
fibrous  attachments,  the  left  ureter  was  exposed  and  divided  close  to 
the  bladder,  the  cut  renal  end  being  for  the  time  held  in  catch  forceps. 
The  bladder  being  now  fairly  free,  it  was  easier  to  locate  the  right 
ureter,  and  after  this  was  accomplished  and  dealt  with  the  viscus  was 
rapidly  turned  forwards  and  downwards  until  the  upper  border  of  the 
prostate  came  into  view.  Gentle  dissection  with  the  finger  separated 
the  rectum,  and  all  that  now  remained  was  the  neck  of  the  bladder. 
After  freeing  it  as  close  up  as  possible  to  the  triangular  ligament  a 
stout  silk  ligature  was  passed  round  it,  and  the  neck  was  divided.  The 
haemorrhage  was  never  great,  any  vessel  seen  being  divided  between 
double  ligatures. 

"  The  ureters  were  next  dealt  with.  Through  each  cut  end  a  fine 
catgut  ligature  was  passed  and  looped  to  facilitate  subsequent  drawing 
down  into  the  rectum.  A  finger  being  passed  per  anum,  sinus  forceps 
were  guided  along  it  as  far  up  the  bowel  as  possible,  probably  about 
four  inches,  and  were  then  made  to  perforate  the  bowel.  In  this  way, 
by  drawing  upon  the  catgut  ligatures,  the  ureters  were  pulled  down- 
wards through  the  perforation,  and  as  far  as  could  be  judged  about  one 
inch  of  each  ureter  lay  tree  in  the  rectum.  No  attempt  was  made  to 
iix  the  ureters  by  suture  to  the  rectum,  but  the  transfixing  ligatures, 
being  brought  out  per  anum,  were  tied  round  a  large  piece  of  rubber 
tubing.  The  operation  had  occupied  two  hours,  and,  in  spite  of  skilful 
administration  of  chloroform  and  ether,  the  patient  was  much  collapsed. 
A  Keith's  tube  was  placed  in  the  lower  angle  of  the  supra-pubic  wound, 
and  the  cavity  was  lightly  packed  with  iodoform  gauze.  N  >  tube  was 
used  for  draining  the  rectum.  Mr.  Lund  thought  that  the  urine  would 
easily  find  its  way  out  along  the  ligatures  attached  to  the  ureters,  but 
in  this  he  was  mistaken." 

Urine  accumulated  in  the  rectum  and  leaked  through  the  supra- 
pubic wound  until  a  rectal  tube  was  introduced  on  the  second  day. 
The  patient  died  from  suppurative  nephritis  and  uraemia. 


REMOVAL    OF   GROWTHS    OF    THE    BLADDER.  609 

(5)  The  following  is  a  modification  of  Dr.  Harris's  method  of  partial 
extirpation,  in  which  he  was  able  to  leave  the  upper  part  of  the  bladder, 

where  it  was  covered  with  peritonaeum  (ride  p.  605). 

Operation. — The  bladder  having  been  washed  out  as  usual  and 
distended  with  air,  a  long  vertical  or  transverse  incision  is  made  above 
the  pubes,  exposing  the  bladder  extra-peritonaeally.  The  bladder  is 
opened,  and  the  exact  extent  of  the  disease  determined,  especially  as 
regards  the  freedom  or  otherwise  of  the  prostate.  The  interior  is  then 
cleansed,  and  a  pack  of  gauze  left  within  it  for  collecting  the  urine, 
which  is  usually  septic,  as  it  issues  from  the  ureters. 

The  surgeon  then  separates  the  bladder  from  the  pelvic  wall  by  blunt 
dissection  as  far  as  the  prostate,  or  if  the  latter  is  involved  as  far  as  the 
triangular  ligament.  This  procedure  is  easily  carried  out  on  the  anterior 
and  lateral  aspects,  but  difficulty  will  be  experienced  in  separating  the 
bladder  and  prostate  from  the  rectum  ;  and  an  assistant  should  pass 
two  fingers  into  the  rectum  as  guides.  If  the  prostate  is  to  be  removed 
the  urethra  should  be  first  divided  just  above  the  triangular  ligament, 
as  recommended  by  Dr.  Harris.  The  separation  of  the  prostate  and 
bladder  from  the  rectum  can  then  be  carried  out  far  more  easily  by 
working  from  below  upwards  and  backwards,  the  bladder  being  mean- 
while pulled  forwards  and  upwards  as  far  as  possible  to  provide  a  better 
view  and  to  control  haemorrhage.  The  ureters  are  sought,  clamped, 
and  divided  above  or  beyond  the  disease.  The  peritonaeum  is  now 
opened  above  the  bladder,  the  Trendelenburg  posture  adopted,  and  the 
field  of  operation  carefully  isolated  b}r  gauze  packing.  The  peritonaeal 
covering  of  the  bladder  is  incised  and  separated  from  the  bladder,  but  if 
any  of  it  is  involved  or  adherent,  it  should  be  excised  with  the  bladder. 
The  remaining  flaps  of  peritonaeum  may  be  sewn  together  if  possible 
after  carefully  drying  the  pelvis,  in  which  a  drain  may  be  left.  The 
ureters  are  then  implanted  into  the  vagina,  rectum,  or  urethra.  A  drain 
is  passed  into  the  extraperitonaeal  space  from  which  the  bladder 
has  been  removed.  The  upper  part  of  the  parietal  wound  is  then 
closed. 

Causes  of  Death  after  Removal  of  Bladder  Tumours. 
1.  Shock.  Mr.  R.  Harrison  (Lancet,  1884,  vol.  ii.  p.  678)  records  a 
case  of  a  man,  aged  42,  who  died  somewhat  suddenly,  apparently 
from  shock,  twelve  hours  after  removal  of  a  villous  tumour  by  the 
perinaeal  method.  The  haemorrhage,  which  had  begun  four  years 
before,  had  for  a  year  been  persistent  and  considerable.  Mr.  Harrison, 
in  illustration  of  the  sudden  and  excessive  bleeding  to  which  villous 
tumours  are  liable,  even  when  they  appear  comparatively  quiescent,  has 
published  (Liverpool  Med.-Chir.  journ.,  July,  1884)  a  case  where  death 
took  place  from  this  cause  in  nine  hours.  In  this  instance  slight 
haematuria  had  existed  for  some  months  previously,  but  no  operation 
had  been  performed.  Mr.  Morton  has  drawn  attention  (Lancet,  1896, 
vol.  i.  p.  480)  to  the  possibility  of  secondary  haemorrhage.  In  his  case 
a  papilloma  had  been  removed  supra-pubically,  the  pedicle  being  cut 
through  with  scissors.  Severe  bleeding  took  place  on  the  third  day, 
necessitating  opening  up  the  wound.  The  patient  recovered. 
2.  Collapse  from  haemorrhage  before,  during,  or  after  the  operation, 
or  from  exhaustion.  3.  Uraemia  is  a  very  common  cause,  and  may  be 
secondary  to  pre-existing  obstruction  of  one  or  both  ureters,  and  the 
s. — vol.  11.  3g 


610  OPERATIONS  ON  THE  ABDOMEN. 

superadded  trauma  of  the  operation,  with  or  without  sepsis.  The 
anesthetic  also  has  a  bad  effect.  Evidence  of  chronic  or  impending 
uraemia  wiU  of  course  be  sought  for  before  any  operation  is  undertaken, 
the  urine  being  thoroughly  examined.  4.  Ascending  suppurative 
nephritis.  5.  Cellulitis.  6.  Injury  to  the  bladder  and  peritonitis. 
Mr.  Bryant  (Lancet,  1886,  vol.  ii.  p.  1077)  mentioned  a  case  in  which 
a  fibrous  polypus  was  drawn  from  the  fundus  into  the  perineal  wound 
and  snipped  off.  The  man  died  of  peritonitis,  and  a  small  hole  was 
found  in  the  bladder  at  the  site  of  the  removed  polypus.  7.  Recurrence. 
This  may  appear  first  in  the  cicatrix  of  the  wound.  8.  Abscess  in  the 
track  of  the  apparently  healed  wound,  bursting  into  the  peritoneal  sac 
(Sir  H.  Thompson,  Clin.  Soc.  Trails.,  vol.  xxi.  p.  46). 

OPERATIVE     INTERFERENCE     IN"     TUBERCULAR     DISEASE 
OP    THE    BLADDER. 

It  should  be  remembered  that  tuberculous  cystitis  is  uncommon  as  a 
primary  disease,  and  every  effort  should  be  made  to  discover  a  possible 
source  in  the  kidney,  epididymis,  vesiculae  seminalis,  lungs,  or  elsewhere. 
A  careful  cystoscopic  examination  may  show  that  the  vesical  disease  is 
limited  to  the  neighbourhood  of  one  or  other  ureteral  orifice,  which 
may  be  itself  dilated,  ulcerated,  or  retracted,  or  discharge  pus  indicating 
disease  of  the  corresponding  kidney  or  ureter. 

If  the  diagnosis  is  confirmed  by  a  lumbar  exploration,  and  the 
opposite  kidney  has  been  proved  to  be  normal  in  function  (p.  149), 
nephro-ureterectomy  is  indicated,  and  maybe  followed  by  complete  and 
permanent  recovery  of  the  bladder. 

It  is  not  wise  to  use  the  cystoscope  when  the  diagnosis  is  certain 
from  the  symptoms  and  from  the  presence  of  obvious  tuberculous 
disease  elsewhere,  especially  in  the  genito-urinary  organs,  for 
instrumentation  of  any  kind  is  to  be  avoided  as  far  as  possible. 

My  own  experience  in  several  of  these  cases  and  a  study  of  what 
others  have  published  leave  me  strongly  of  opinion  that  operative  inter- 
ference in  the  form  of  cystotomy  is  rarely  justifiable  here.  My  reason 
for  this  opinion  will  be  gathered  from  the  following  Indications  and 
Cautions,  (i)  It  is  an  accepted  fact  by  all  careful  surgeons  that  in 
tubercular  affections  in  which  it  is  not  possible  to  remove  the  mischief 
operative  interference  may  do  more  harm  than  good.  Under  such 
conditions  the  manipulations  only  irritate  early  tubercle  into  activity, 
and  light  up  again  obsolete  or  quiescent  tubercle,  besides  causing 
certain  dangers*  peculiar  to  this  viscus — viz.,  cystitis  and  pyelitis. 
Again,  to  show  how  useless  and  even  harmful  will  be  operative  inter- 
ference in  the  early  stage  of  tubercular  mischief,  a  stage  in  which 
alone  can  such  treatment  be  expected  to  be  curative,  let  us  con- 
sider what  are  the  conditions  present  at  this  early  stage.  To  put 
it  briefly,  it  is  not  one  suitable  for  curetting,  &c,  as  is  often  the  case 

*  Another  ill  result  which  is  very  possible  here  is  rupture  by  even  a  moderately  dis- 
tending injection  of  a  contracted,  rigid  bladder  the  seat  of  long-standing  tubercular 
mischief,  and  one  emptied  for  some  time  by  irritability  and  incontinence.  I  would  refer 
my  readers  to  two  such  cases  candidly  published  by  Mr.  H.  Fenwick  in  his  instructive 
book  Cardinal  Symptoms  of  Urinary  Diseases,  p.  200. 


OPERATIVE    INTERFERENCE   IN   TUBERCULAR    BLADDER.     611 

with  tubercular  mischief  elsewhere.*  The  mucous  membrane  is  swollen, 
very  vascular,  velvety,  at  times  gelatinous.  Any  ulcers  present  are 
often  small,  even  minute  and  numerous,  so  that  it  is  impossible  to 
make  sure  of  efficient  curetting,  especially  when  anyone  familiar  with 
the  interior  of  the  bladder  knows  how  quickly  a  little  bleeding  hides 
the  field  of  operation,  and  the  fact  that  the  mischief  is  usually  most 
marked  on  the  posterior  wall,  trigone,  and  neck.  The  following  is  a 
good  description  of  a  condition  often  present  in  these  cases  (  :  "  The 
trigone  and  a  band  of  about  an  inch  in  depth  around  the  urethral 
orifice  were  the  seat  of  many  superficial  ulcers,  varying  in  size  from 
that  of  a  split  pea  to  irregular  patches  as  large  as  a  five-cent  piece. 
The  mucous  membrane  of  the  whole  fundus  of  the  bladder  was  also 
studded  with  small  tubercles  which  had  not  advanced  to  the  stage  of 
ulceration  nor,  indeed,  even  to  the  length  of  showing  signs  of  caseation. 
The  ulcerated  patches  were  scraped  and  cauterised,  but  the  little  non- 
ulcerated  tubercles  were  left  untouched.  They  were  so  numerous  that 
it  would  have  been  impossible  to  deal  with  each  one  singly."  Mr. 
Battle's  case  (Clin.  Soc.  Trans.,  vol.  xxiii.  p.  201),  which  was  greatly 
benefited  by  scraping  after  other  treatment  had  failed,  owes  its  success 
largely  to  the  condition  found,  which  was,  I  think,  a  very  rare  one. 
The  ulcerated  surface  was  single,  though  very  extensive,  spreading  over 
the  left  lateral  and  posterior  wall,  from  the  trigone  almost  to  the 
summit,  with  the  bladder  relaxed.  After  the  ulcer  had  been  scraped 
it  was  dabbed  over  with  a  solution  of  chloride  of  zinc  (30  gr.  to  3J). 
The  patient  was  seen  nearly  a  year  later,  soundly  healed  and  able  to 
hold  her  water  for  three  hours  at  a  time.  It  is  not  stated  whether 
pyrexia  was  then  present,  (ii)  For  these  reasons  I  am  strongly  of 
opinion  that  in  the  earlier  stages  we  should  treat  tubercular  disease 
of  the  bladder  not  by  operation,!  but  by  improving  the  hygienic  sur- 
roundings, especially,  whenever  it  is  possible,  getting  the  patient  to  be 
much  in  the  open  air,  if  possible  by  the  sea.  Injections  of  Koch's  new 
tuberculin  promise  to  be  of  considerable  value  in  suitable  cases, 
although  it  is  not  claimed  that  a  cure  may  be  obtained  from  its  use. 
It  should  not  be  resorted  to  unless  the  disease  is  limited  to  the  bladder, 
and  except  after  the  tubercle  bacilli  have  been  found  in  the  urine.  It 
relieves  the  pain,  diminishes  the  frequency  of  micturition  and  the 
haemorrhage.  In  some  patients,  however,  the  symptoms  have  been 
aggravated  by  the  injections  (Fenwick,  Wright,  and  others,  Lancet, 
1904,  vol.  i.  p.  935).  This  method  is  certainly  worthy  of  a  thorough 
trial  with  the  precautions  and  restrictions  mentioned.  Intra-vesical 
injections  of  iodoform  emulsion,  solutions  of  perchloride  of  mercuiy, 

*  Prof.  Guyon  reported  {Ann.  des  Malad.  des  Votes  Vrin.,  November,  1889)  very  fully 
four  cases  which  he  treated  by  curetting  and  the  cautery  after  a  supra-pubic  cystotomy. 
One  of  the  four  died  two  years  after  the  operation,  the  patient  having  a  persistent  sinus 
and  being  bedridden  most  of  the  time.  One  died  within  the  year,  and  one  within  about 
three  months  of  the  operation.     The  fourth'had  survived  four  years. 

t  J.  Bell,  M.D.,  of  Montreal,  "  Treatment  of  Tuberculosis  of  the  Bladder  by  a  Supra- 
pubic Section,"  Journ.  Cutan.  and  Gen'it.  IJvin.  Bis.,  1892,  p.  298. 

X  Dr.  L.  Bolton  Bangs,  of  New  York,  whose  experience  in  diseases  of  the  genito- 
urinary organs  is  a  very  wide  one,  thus  expresses  himself  on  this  matter  :  "  After  faithful 
and  zealous  efforts  to  relieve  by  surgical  interference  the  local  symptoms  of  these  cases, 
I  have  been  forced  to  the  conclusion  that  the  less  instrumentation  we  resort  to  the  better." 

39—2 


6l2 


<>IT.l!.\Tln\S    on    THE    ABDOMEN. 


chloride  of  zinc,  or  nitrate  of  silver,  are  disappointing  and  troublesome, 
and  may  aggravate  the  disease.  Internal  administration  of  urinary 
antiseptics,  such  as  urotropine,  helmitol,  and  others,  is  useless,  (iii)  The 
cases  that  call  for  operative  interference  are  those  in  which  what  I  may 
be  allowed  to  call  hygienic  treatment  has  failed,  or  in  which  the  i 
has  goi  beyond  tins,  where  pain  is  incessant,  micturition  frequent — 
e.g.,  every  half-hour  day  and  night — with  much  tenesmus,  and  where 
opiates  are  required  to  afford  sleep.  There  should  he  no  advanced 
disease  present  of  the  other  urino-genital  organs,  kidneys,  lungs,  &c. 
If  a  single  ulcer  is  discovered  by  cystoscopic  examination,  it  may  be 
excised  in  some  cases,  although  this  is  not  an  easy  matter,  for  the 
solitary  ulcer  is  nearly  always  situated  at  the  trigone,  (iv)  The  supra- 
pubic operation  is  always  to  be  preferred.  The  perinatal  gives  very 
little  room,  and,  moreover,  has  the  great  drawback  that  a  tube  thus 
introduced  will  very  likely  press  upon  the  neck  or  trigone,  parts  very 
liable  to  be  attacked  by  tubercle.     Again,   this  opening  has  a  great 


Fig 


Trendelenburg's  position.     (R.  Harrison.) 

tendency  to  close  before  the  full  benefit  of  drainage  has  been  secured  ; 
but  I  have  seen  several  patients  considerably  relieved  by  perineal 
drainage.  The  vaginal  opening  seems  to  me  to  be  liable  to  the  same 
objection  as  the  perinasal — viz.,  that  the  vesical  end  of  a  tube  thus 
introduced  is  very  likely  to  rest  against  an  ulcerated  surface,  (v)  The 
tube  should,  if  possible,  be  withdrawn  in  about  three  weeks,  and,  as 
soon  as  the  wound  is  closed,  every  effort  should  again  be  made  to  place 
the  patient  under  the  best  hygienic  surroundings,  to  the  necessit}'  of 
which  I  have  alluded  above.  Hospital  patients  should  be  got  into 
better  air  at  once.  But  too  often  the  after-treatment  of  supra-pubic 
cystotomy  for  tubercular  cystitis  resolves  itself  into  the  following 
dilemma.  If  the  opening  is  closed  all  the  pain,  &c,  soon  recurs  ;  if  it 
is  kept  open  there  is  much  difficulty  in  preventing  noisome  soaking. 
A  tube  and  plug  worn  in  the  supra-pubic  sinus  rarely  acts  well  in 
these  cases,  where  the  bladder  is  often  small,  contracted,  and  thicdv- 
walled.  Mr.  Colt's  supra-pubic  drainage  apparatus  is  the  most  efficient 
means  of  keeping  the  patient  dry  {vide  p.  602).  (vi)  The  patient  may 
enjoy  years  of  fairly  active  and  happy  life  after  a  supra-pubic  cystotomy, 
if  the  opening  has  closed  within  a  reasonable  time  of  the  operation,  but 


OPERATIVE    INTERFERENCE    IN    TtJBERCULAB    BLADDER.    6]  ; 

he  will  be  Liable  to  other  outbreaks  of  tubercular  mischief  secondary  to 
disease  which  was  probably  present,  though  quiescent,  at  the  time  of 
the  cystotomy — e.g.,  tubercular  testis  and  kidney. 

When  the  disease  is  secondary  to  unilateral  renal  tuberculosis,  or  to 
a  tuberculous  testis,  nephrectomy  or  orchidectomy  may  be  followed  by  a 
gradual  cure  of  the  secondary  disease  in  the  bladder  (vide  pp.  195). 

Operation. — The  details  of  a  supra-pubic  cystotomy  are  so  fully  given 
at  pp.  622 — 624,  that  it  is  needless  to  repeat  them  here.  I  will  only  add 
the  caution  that  great  care  must  he  taken  in  distending  these  bladders. 
Four  to  six  ounces  will  he  as  much  as  can  usually  be  injected  with 
safety.  The  bladder  is  first  opened,  and  its  interior  exposed  with  some 
suitable  speculum  (p.  596),  aide*d,  if  needful,  by  the  Trendelenburg  posi- 
tion (Fig.  241).  A  single  ulcer  may  be  excised  in  some  cases.  Any 
ulcers  should  he  carefully  and  thoroughly  curetted  or  cauterised  with  a 
fine  point  of  the  Paquelin's  thermo-cautery,  iodoform  rubbed  over  the 
surface  or  left  in,  in  the  shape  of  the  emulsion.  To  any  very  vascular, 
gelatinous-looking  mucous  membrane,  not  ulcerated,  a  solution  of 
AgN03  5ij — 3J*  should  be  applied  on  a  small  sponge  on  a  holder. 

The  following  is  a  good  instance  of  the  relief  which  supra-pubic 
cystotomy  may  give  in  a  very  obscure  case  : — 

In  May,  1890,  I  was  asked  by  Dr.  Cock  and  Dr.  Hodgson,  of  Exmouth,  to  explore  the 
bladder  of  a  gentleman,  aged  57,  suffering  from  painful  cystitis,  hematuria,  and 
frequent  micturition,  to  which  general  treatment,  washing  out  the  bladder  and 
drainage  by  a  catheter,  had  failed  to  give  any  relief.  Calculus  being  excluded  by 
sounding,  and  there  being  no  rectal  enlargement  of  the  prostate,  I  expected  to  find 
a  small  malignant  growth,  as  the  symptoms  were  too  urgent  for  prostate  trouble,  and 
as  this  gland  was  not  enlarged  either  to  the  finger  or  the  sound.  The  bladder,  having 
been  opened  and  emptied  by  the  supra-pubic  method,  at  first  appeared  normal  save  for 
some  subacutely  inflamed  ruga?  which  stood  out  very  distinctly  on  the  right  lateral  aspect 
of  the  neck  of  the  bladder.  A  small  electric  lamp  at  once  showed  amongst  these  folds  two 
ulcers  each  about  one  inch  by  a  quarter  of  an  inch,  oval  in  shape,  with  muscular  fibre 
clearly  exposed  on  their  floors,  their  edges  neither  thickened  nor  indurated.  They  were 
scraped  with  a  sharp  spoon,  and  iodoform  was  then  rubbed  into  their  surfaces.  The  patient 
made  an  excellent  recovery,  and  now,  six  years  later,  remains  quite  well.  In  this  patient, 
with  a  deep,  fat  perinseum,  I  should  never  have  detected  the  ulcers  by  the  perineal  route. 

If  the  operation  is  performed  with  the  object  of  securing  long- 
continued  drainage,  only  a  small  incision  is  made  into  the  bladder, 
and  the  edges  of  this  are  carefully  sutured  to  the  skin,  so  that  the 
fistula  may  not  close  so  readily.  In  some  intractable  cases  with 
painful  micturition  extirpation  of  the  bladder,  with  transplantation  of 
ureters  into  the  rectum  or  sigmoid  colon,  may  be  considered. 

Hartley  (loc.  supra  tit.)  has  removed  the  whole  bladder  for  tuber- 
culous disease  ;  he  joined  the  ureters  with  a  part  of  the  bladder  to  the 
sigmoid  colon.  The  operation  gave  great  relief,  and  the  patient  was 
well  and  working  as  a  clerk  nine  months  later.  She  voided  urine 
about  three  times  during  the  day  and  once  or  twice  in  the  night. 
Total  extirpation  can  be  rarely  indicated  for  tuberculosis,  and  should 
not  be  contemplated  until  hygienic  treatment  and  injections  of 
tuberculin  have  been  well  tried  (vide  p.  607.) 

*  This  may  appear  strong,  but  it  gives  very  marked  relief.  In  women  it  may  be 
applied  at  repeated  intervals  after  dilatation  of  the  urethra.  If  it  should  give  much  pain, 
which,  in  my  experience,  it  rarely  does,  a  solution  of  sodium  chloride  may  be  injected. 


f)i4  OPERATIONS   ON    TIIK    ABDOMEN. 


LATERAL  LITHOTOMY   (Figs.  160,  l6l,  162). 

Owing  to  the  introduction  and  perfection  of  the  crushing  operation 
for  Btone,  lateral  Lithotomy  is  now  seldom  called  for.  The  chief 
indications  are — (1)  In  children,  when  the  stone  is  a  small  one,  and 
when  the  surgeon  is  inexperienced  in  the  nse  of  the  lithotrite,  it  is 
the  operation  of  choice.     (Vide  also  the  remarks   on  pp.  646 — 648.) 

(2)  In  the  case  of  a  large  stone  with  which  it  has  been  decided  to  deal 
by  perinseal  lithotrity  (p.  C45)  the  bladder  is  opened  by  the  same  steps 
as  in  lateral  lithotomy.  (3)  In  certain  cases  of  stricture  of  the  nrethra 
and  enlarged  prostate,  where  a  staff  can  he  passed.  In  the  majority 
of  the  cases  of  enlarged  prostate,  however,  the  supra-pubic  method  is 
to  he  preferred,  as  by  this  means  the  prostatic  hypertrophy  can  be 
more  readily  dealt  with  at  the  same  time,  and  the  bladder  more 
thoroughly  examined,  especially  as  regards  the  presence  or  absence  of 
diverticula  which  may  contain  stones  (p.  621). 

The  lateral  operation  will  be  descrihed  under  the  following  heads: 

A.  Preparatory  Treatment. 

B.  Passing  the  Staff.    Possible  Difficulties. 

C.  Finding  the  Stone.    Possible  Difficulties. 
I).  Entering  the  Bladder.    Possible  Difficulties. 
E.  Extracting  the  Stone.    Possible  Difficulties. 

A.  Preparatory  Treatment. — For  a  week  or  so  before  the 
operation  the  diet  should  be  bland,  so  as  to  tax  as  little  as  possible 
jaded  kidneys — e.g.,  milk,  barley-water,  light  puddings,  and  a  little 
fish.  If  alcohol  is  needed,  some  sound  spirit,  well  diluted,  should  be 
given.  Baths  should  be  taken  regularly,  the  bowels  well  moved,  and 
an  enema  given  on  the  morning  of  the  operation,  and  care  should  be 
taken  that  all  this  has  come  away. 

B.  Passing  the  Staff.  —  This  step,  however  simple  and  easy 
usually,  presents  occasional  difficulties,  the  more  trying  because 
perhaps  unlooked  for;  they  are  — 

(1)  Spasm,  from  the  urethra  not  being  used  to  instruments ;  (2) 
stricture  ;  (3)  a  false  passage  ;  (4)  an  enlarged  prostate  ;  (5)  an 
enlarged  prostatic  sinus,  into  which  the  end  of  the  sound  passes.  Mr. 
Buckston  Browne's  staff  meets  the  last  two  admirably. 

C.  Finding  the  Stone  with  Sound  or  Staff.  Possible 
Difficulties. 

(1)  The  stone  ma}'  have  been  passed.*  This  is  not  impossible  in 
children  with  small,  smooth,  narrow  calculi,  and  their  sudden,  strenuous 
micturition.  (2)  The  stone  may  lie  behind  an  enlarged  prostate. 
Here    the  finger  of   an    assistant   passed   into   the   rectum   may    help. 

(3)  The  stone  may  be  enveloped  in  folds  of  mucous  membrane. 
Injection  of  the  bladder  is  here  indicated.  (4)  The  stone  may  be 
encysted.  This  is  so  rare  as  to  have  been  called  "  The  refuge  of 
young  lithotomists."  The  following  case  of  Sir  G.  Humphry  (Some 
Cases  of  Operation,  pamphlet,  1856)  shows  well  how  embarrassing  this 
condition  may  be : 

A  man.  aged  51,  was  cut.  then  submitted  twice  to  lithotrity.  then  again  cut  in  the 
old  scar  three  times,  all  within   six   years,  for  an   encysted   calculus.     On   the   fourth 

*   Cf.  the  case  mentioned  by  Mr.  Holmes.  Clin.  Su\  Trans.,  vol.  ii.  p.  67. 


LATERAL    LITHOTOMY. 


615 


occasion  of  lateral  lithotomy  the  nature  of  the  case  was  made  out  accurately.     The 

was  now  fell    behind   the   prostate  attached  to  the   bladder  by  a  pedicle  which 

seemed  to  penetrate  the  coats  of  the  viscus,  and  to  be  attached  to  another  mass  beyond 

it.     It  was  evidently  a  stone  of  hour-glass  Bhape,  part  being  in  the  bladder  and  part 
in    the    sac.       At    each    of    the    previous    operations    the    part    within    the    bladder    had 

Fig.  242. 


Anus. 


Lateral  lithotomy.     (After  Fergusson.) 


broken  off,  the  rest  not  being  extracted,  owing  to  the  size  of  the  prostate.  The 
symptoms  recurring,  urethro-rectal  lithotomy  was  performed.  The  stone  being  now 
■within  reach,  the  edge  of  the  mucous  membrane  around  it  was  incised  with  a  hernia 
knife,  and  a  stone  the  size  of  a  walnut,  and  with  a  truncated  stalk,  extracted.     Death 


Prostate 
Lateral  lithotomy.     (After  Fergusson.) 

took  place  in  two  days,  from  pelvic  cellulitis.  Though  the  bladder  was  otherwise  but 
little  diseased,  the  cyst  seemed  to  have  originated  from  the  protrusion  of  mucous 
membrane  between  the  muscular  fibres,  as  another  one  existed,  though  without  a 
stone.  The  cyst  communicated  by  a  considerable  opening  with  the  foul,  infiltrated 
tissues.  Sir  George  points  out  that  these  cysts  may  be  quite  out  of  reach  in  lateral 
lithotomy.     As  their  walls    consist    only  of    cellular  tissue,   mucous    membrane,    and 


6i6 


OPERATIONS    OX    THK    Al'.DO.MKX. 


perhaps  a  thin  layer  of  muscular  fibre,  they  are  easily  lacerated  during  an  operation, 
an  accident  almost  certain  to  be  fatal.  The  diagnosis  is  usually  to  be  made  if  the 
stone  is  always  -truck  by  the  sound  at  one  spot,  especially  if,  per  rectum,  a  lump  is 
detected  corresponding  to  that  spot.*  The  supra-pubic  operation  is  indicated  here. 
See  footnote,  p.  621. 

D.  Entering  the  Bladder. — The  time  chosen  for  introducing  the 
staff  varies  with  different  operators.  Passing  the  staff  while  the  patient 
is  still  recumbent  is  the  easier  ;  passing  it  when  the  patient  is  in  litho- 
tomy position  is  rather  more  difficult,  but  secures  the  operator  against 
the  risk  of  the  staff  slipping  out  alter  the  patient  is  brought  down  into 
position,  a  risk  which  is  greater  with  the  straight  staff.  I  prefer  to 
bring  the  patient's  lower  limbs  over  the  edge  of  the  table,  to  pass  the 
Btraight  stall'  while  he  is  recumbent,  and  then  to  have  his  limbs  only 
brought  up  into  position. 

The  nates  just  projecting  over  the  edge  of  the  table,  the  sacrum  being 


Fig.  244. 


Lateral  lithotomy  with  a  straight  staff.     (Key.) 

flat  upon  it,  the  flexed  thighs  and  legs  being  held  well  out  of  the  way, 
the  surgeon,  seated  comfortably,  and  with  his  face  on  a  level  with  the 
perinaeum,  directs  an  assistant  so  to  hold  the  staff  as  to  bring  the  mem- 
branous urethra  close  to  the  surface  of  the  perinaeum.  If  a  curved  staff 
be  used,  this  is  easily  done  by  inclining  the  handle  strongly  towards 
the  abdomen.  By  this  manoeuvre,  in  Mr.  Cadge's  words  [he.  supra 
cit.),  the  point  of  the  staff  "  need  not,  and  should  not,  be  withdrawn 
from  the  bladder,  but  if  it  were  it  would  be  of  no  moment,  because  it 
would  re-enter  it  the  moment  the  handle  is  raised  ;  the  membranous 
urethra,  instead  of  being  almost  perpendicular  to  the  surface  of  the 
perineum,  as  it  is  when  the  staff  is  held  upright,  is  brought  almost 
parallel  with  it,  and  is  much  easier  to  find  with  the  knife  ;  there  is  no 
inducement  to  open  the  urethra  too  far  forwards,  ami  consequently  no 
risk  of  wounding  the  bulb  or  its  artery.  The  staff  gets  a  steady  rest 
against  the  front  of  the  pubes,  and  there  is  no  danger  to  the  rectum  at 


*  Sir  J.  E.  Erichsen  {Surgery,  vol.  ii.  p.  945)  adds  that  the  beak  cannot  be  made  to 
pass  round  such  a  stone  so  as  to  isolate  it.  To  several  other  allied  conditions  of  compli- 
cated stone  see  the  reference  at  p.  634. 


LATERAL    LITHOTOMY. 


017 


this  stage."  It  thus  combines  the  advantages  of  the  two  very  different 
methods  usually  given — viz.,  either  to  hold  the  staff  well  up  firmly 
under  the  puhes  and  thus  away  from  the  bowel,  but  also  away  from 
the  stone,  or  closely  down  upon  the  latter  and  in  proximity  to  the 
rectum  also. 

Having  felt  the  staff  thus  presented  towards  him,  having  examined 
into  the  depth  of  the  ischio-rectal  fossa,  the  site  of  the  tuber  and  ramus 
ischii,  the  surgeon,  pressing  up  the  junction  of  the  scrotum  and  raphe 
so  as  to  make  tense  the  parts  just  about  to  be  cut,  enters  his  knife  from 
a  quarter  of  an  inch  to  one  inch  and  a  half  from  the  anus,  just  to  the 
left  of  the  raphe',  and  very  likely  hits  the  groove  at  once.  The  knife  is 
then  drawn  outwards  and  backwards  with  a  rapid  sawing  movement  to 
a  point  midway  between  the  anus  and  tuber  ischii,  thus  making  an 
incision  of  two  or  three  inches,  according  to  the  age  of  the  patient  and 
size  of  the  stone.  Again  inserting  the  knife  into  the  upper  angle  of 
the  wound,  the  surgeon  makes  out  exactly  with  his  left  index  finger  the 
groove  in  the  staff,  and  exposes  this,  beyond  doubt,  in  the  wound.  The 
next  steps  differ  somewhat  accordingly  as  the  curved  or  straight  staff  is 
used  ;  they  will  be  given  separately. 

(a)  With  the  Curved  Staff. — When  the  knife's  point  is  felt  firmly 
lodged  in  the  groove,  its  handle  is  a  little  depressed  ;  the  blade,  at  the 
same  time,  turned  a  little  to  the  left,  is  pushed  steadily  along  the 
groove  till  a  gush  of  urine  or  a  sense  of  resistance  ceasing,  or  both 
together  usually,  announce  that  the  neck  of  the  bladder  has  been 
sufficiently  divided  with  the  knife.  The  finger  is  now  wormed  into  the 
bladder  over  the  concavity  of  the  staff. 

(b)  With  the  Straight  Staff.— When  the  point  of  the  knife  is  felt  to 
be  safely  lodged  in  the  groove,  the  surgeon  takes  the  handle  of  the 
straight  staff  from  his  assistant,  brings  it  down,  and  still  keeping  his 
knife  in  the  groove,  lateralises  the  staff  slightly  to  the  left.  The  handle 
of  the  knife  being  now  depressed  so  as  to  form  a  sufficient  angle  with 
it,  and  make  an  adequate  wound,  the  surgeon  runs  it  along  the  groove 
steadily,  till  he  knows  by  the  above-given  evidence  that  the  neck  of  the 
bladder  has  been  sufficiently  cut. 

The  left  index  finger  is  next  wormed  over  the  edge  of  the  staff,  the 
straight  staff  being  held  by  the  surgeon  himself  in  his  right  hand,  the 
curved  one  being  held  by  an  assistant,  till  he  feels  that  he  has  entered 
the  bladder  and  placed  the  finger  tip,  if  possible,  in  contact  with  the 
stone.  Entrance  into  the  bladder  is  known  by  feeling  the  finger  sur- 
rounded with  a  smooth  cavity  lined  with  mucous  membrane,  while 
the  finger  itself  is  girt  by  a  fibrous  ring.  The  stone  being  felt,  or  the 
bladder  cavity  distinctly  gained,  the  staff  is  withdrawn,  and  the 
surgeon,  while  taking  his  lithotomy  forceps,  dilates  the  opening  into 
the  bladder  with  his  finger,  which,  at  the  same  time,  pulls  down  and 
steadies  the  neck. 

Failure  to  enter  the  Bladder. — This  most  vexatious  and  embarrassing 
difficulty  is  most  likely  to  be  met  with  under  two  widely  different 
conditions  :  (1)  most  frequently  in  little  children  ;  (2)  in  old  patients 
with  a  very  fat,  deep  perinasum  and  enlarged  prostate.  The  first  must 
be  considered  separately. 

(1)  In  Little  Children. — The  causes  here  are  the  small  size,  delicacy, 
and  mobility  of  the  neck  of  the  bladder  and  urethra,  and  the  fact  that 


618         OPERATIONS  ON  THE  ABDOMEN. 

the  bladder  lies  high  up   nl>ove  the  pelvis.     Mr.    Cadge   quotes   the 
following  from  Sir  \Y.  FergUSSOD  : 

"The  point  of  the  finger  was,  as  usual,  placed  on  the  staff  and  poshed  gently  towards 
the  bladder.  The  finger  went  on,  bul  I  was  aware  that  it  had  not  got  i>et  ween  the  urethra 
and  the  staff.  With  an  insinuating  movement  (much  to  be  appreciated  by  the  lith  itomist 
who,  as  I  do,  professedly  makes  a  small  incision  in  this  locality),  1  endeavoured  to  get  its 
point,  as  usual,  into  the  urethra  and  neck  of  the  bladder.  But  here  I  felt  convinced  that 
I  had  failed,  and  was  aware  that  the  finger  was  getting  deeper  as  regards  the  depth  of  the 
perineum,  but  that  I  was  not  materially  nearer  the  bladder.  I  could  feel  a  considerable 
space  at  the  point  of  the  finger,  and  was  convinced  that  the  upper  part  of  the  membranous 
urethra,  as  well  as  the  sides,  had  given  way  to  the  pressure,  and  thai  now,  as  the  finger 
was  getting  deeper  into  the  wound,  I  was  only  pushing  the  prostate  and  neck  of  the  bladder 
inwards  and  upwards.  These  parts  seemed  to  recede  before  the  smallest  imaginable  force, 
whilst  I  felt  that  1  could,  in  a  manner,  make  any  amount  of  space  around  the  bare  part  of 
the  staff.  I  had  no  difficulty  in  distinguishing  between  the  surface  of  this  space  and  that 
of  the  mucous  membrane  of  the  bladder.  Moreover,  1  knew  that  I  had  never  crossed  thai 
narrow  neck  which  is  always  felt  as  the  finger  passes  into  the  bladder  when  a  limited 
incision  is  made.  An  impression  came  over  me  that  I  was  about  to  fail  in  getting  into  the 
bladder,  and  I  had  an  idea  that,  unless  I  could  open  the  urethra  in  front  of  the  prostate 
more  freely,  I  should  probably  never  reach  the  stone.  This  I  effected  with  great  caution, 
and  then  I  could  appreciate  the  passage  of  the  finger  as  usual  through  the  neck  of  the 
bladder.  The  stone  was  easily  touched  and  removed,  but  I  was  forcibly  impressed  with 
the  idea  that  I  had  nearly  failed  in  the  performance  of  the  operation."  The  child  here 
was  four  years  old. 

Mr.  Cadge  thus  met  the  same  difficulty  in  an  infant  of  one  year  and 
a  half : 

"I  felt  the  impossibility,  even  with  a  fair  incision,  of  distending  the  wound  with  my 
finger  ;  it  was  like  trying  to  get  into  the  orifice  of  the  urethra.  I  therefore  desisted  before 
doing  any  harm,  and,  taking  a  pair  of  common  dressing-forceps,  I  passed  them  easily  along  the 
staff  into  the  bladder  ;  by  opening  the  blades  gently  but.  firmly,  room  was  gained,  and  the 
finger  entered  and  made  room  for  small  lithotomy  forceps.  But  I  have  repeatedly,  after 
passing  the  dressing-forceps,  withdrawn  the  staff  and  removed  the  stone  with  them,  and 
without  introducing  the  finger  at  all." 

Difficulties  and  Mistakes  during  this  Stage  of  entering  the 
Bladder. — This  is  so  important  a  part  of  the  operation  that  the 
following  may  be  enumerated  here : 

(i)  Finding  the  staff.  This  is  not  likely  to  present  difficulties  in  the 
case  of  a  curved  staff  if  it  be  held  as  advised  at  p.  616.  Hitting  a 
straight  staff  in  a  fat  child  is  not  always  easy,  owing  to  the  small  size 
which  is  needful.  Attention  must  be  paid  to  entering  the  knife  at  the 
root  of  the  scrotum  only  just  to  the  left  of  the  raphe,  when  the  finger- 
nail will  detect  the  staff  at  once.  (2)  Not  exposing  the  stall'.  Every- 
thing which  lies  over  the  staff  in  the  upper  angle  of  the  wound  must  be 
clean-cut.  The  tissues  here,  including  the  membranous  urethra,  are  lax 
and  delicate,  and,  unless  the  knife  is  clearly  in  contact  with  metal,  the 
groove  will  not  be  followed.  (3)  Losing  the  groove.  This  most  serious 
accident  may  be  due  to  not  getting  the  knife  cleanly  into  the  groove, 
not  keeping  it  sufficiently  firmly  in  contact  with  it,  and,  thirdly,  by 
forgetting  to  depress  slightly  the  handle  of  the  knife.  (4)  Cutting  the 
prostate  too  freely  as  the  knife  is  brought  out.  This  can  easily  be 
avoided  by  keeping  the  knife  sufficiently  near  to  the  staff.  (5)  Cutting 
into  the  rectum.  This  may  be  due  to  neglect  of  the  following  pre- 
cautions :  (i.)  keeping  the  staff  up  away  from  the  bowel ;  (ii.)  guarding 


LATERAL   LITHOTOMY.  6ig 

the  bowel  with  the  left  forefinger  in  the  wound;  (iii.)  when  llio  knife  is 
lateralised,  cutting  away  from  the  gut.     Mr.  Cadge  (loc.  supra  cit.) 

points  out  that  the  usual  place  of  puncture  is  the  dilated  part  just 
above  tlie  internal  sphincter,  and  that  this  communication  may  be  made 
secondarily  by  sloughing  alter  extraction  of  a  large  stone,  or  after  the 
use  of  n  plug  for  arresting  haemorrhage.  His  experience  is  that 
"nature  seldom  fails  to  bring  about  a  cure,  or  so  to  contract  the 
wound  as  to  leave  but  trilling  inconvenience."  (  6)  Wounding  the 
posterior  wall  of  bladder. 

Sir  S.  Wells,  at  the  discussion  of  Sir  H.  Thompson's  paper  (Med.- 
Chir.  Soc,  April  2,  1878),  mentioned  a  case  in  which  Mr.  Tyrrell 
wounded  the  back  of  the  bladder,  and  hence  always  advocated  a  short 
knife.  That  this  accident  happened  even  in  the  hands  of  Aston  Key 
himself  I  know  through  the  father  of  an  old  Guy's  man  who  was 
present  at  the  time. 

E.  Finding  and  Extracting  the  Stone. — The  surgeon's  left 
index  finger,  having  passed  into  the  bladder  along  the  concavity  of  the 
staff,*  finds  the  stone,  hooks  this  down  as  near  to  the  neck  as  possible, 
and  at  the  same  time  steadies  the  neck  while  it  dilates  the  incision  in 
it  and  in  the  prostate.  This  combination  of  movements  requires  most 
careful  attention  to  each  of  its  details  separately.  The  most  important 
of  these  is  the  dilatation  of  the  neck  and  prostate.  If  the  stone  is 
found  to  be  a  large  one,  the  deep  part  of  the  wound  must  be  sufficiently 
free.  It  is  well  known  how  much  has  been  written  on  this  matter. 
The  surgeon  should  begin  by  dilating  the  neck  of  the  bladder  carefully 
and  equally  in  every  direction,  using  a  considerable  amount  of  force  in 
an  adult,  but  not  throwing  this  on  any  limited  portion  of  the  wound. 
It  may  be  accepted  as  a  certain  fact  that  the  wound  in  the  prostate  may 
extend  through  the  whole  of  this  body,  without  risk  of  cellulitis,  if  only 
the  recto-vesical  sheath  is  not  torn  through.  As  long  as  the  finger  is 
girt  by  a  fibrous  ring  this  mischief  has  not  been  done.  Whether  an 
extensive  wound  in  the  prostate  had  better  be  made  by  dilatation  and 
laceration  or  by  free  incision  will  probably  never  be  settled.  The  wise 
surgeon  will  avail  himself  of  a  safe  use  of  both — that  is  to  say,  after 
dilating  with  forcible  but  equal  pressure  all  around  the  original  wound 
in  the  neck,  he  will  introduce  a  blunt-pointed  narrow-bladed  bistoury 
flat  against  the  pulp  of  his  finger,  and  nick  the  remaining  constriction 
at  one  or  two  places,  then  dilating  again. 

Next,  as  to  the  size  of  the  stone,  the  age  of  the  patient  must  here 
be  considered.  After  middle  life  the  cellular  tissue  around  the  neck 
of  the  bladder  is  not  only  loose,  but  abounds  in  enlarged  veins.  Hence 
the  risk  of  causing  not  only  cellulitis,  but  septic  phlebitis,  by  dilating 
an  inadequate  opening  by  the  tearing,  bruising  exit  of  the  stone  instead 
of  by  the  finger  and  knife  combined. 

The  deep  opening  having  been  thus  made  sufficiently  free,  the 
surgeon,  having  selected  his  forceps,  introduces  them  along  the  finger 
(thus  further  dilating  the  wound),  the  latter  being  withdrawn  as  the 
forceps  enter.  These,  held  at  first  in  one  hand  (the  thumb  in  the  ring), 
are  fully  introduced  closed,  then  opened  widely  transversely,  and,  by  a 
quarter-turn  of  the  handles,  the  lower  blade  is  made  to  scoop  or  sweep 

*  This  is  only  withdrawn  when  the  stone  is  felt,  not  before. 


620  OPERATIONS   ON    THE    ABDOMEN. 

along  the  floor  of  the  bladder,  which  will  almosl  Burely  catch  the  Btone. 
If  this  step  fail,  it  is  repeated,  and  if  the  Btone  La  still  nol  caught,  the 
surgeon  feels  again  for  the  stun.-  either  with  the  closed  forceps  or  by 
again  inserting  his  finger,  which  will  bring  down  the  Btone,  push  off 
projecting  folds  of  mucous  membrane,  >\<-.  Differently  curved  forceps, 
Bupra-pubic  pressure,  and  a  finger  in  the  rectum,  may  all  help  now. 

The  Btone  being  caught,  the  finger  again  feels  it'  it  is  held  in  its 
shorter  axis;  if  so,  it  may  at  once  be  extracted,  if  moderate  in  Bize,  by 
Bteady  deliberate  traction  downwards  and  outwards.  As  long  as  the 
stone  advances  all  is  well  ;  if  not,  gentle  rotation  may  again  start  i- 
its  way.  In  less  easy  cases  Mr.  ( !adge's  wi  irds  Bhould  1><-  remembered  : 
"  Should  there  he  much  resistance  and  no  sense  of  gradual  yielding,  the 
Burgeon  will  ask  himself  whether  this  is  due  to  an  insufficient  opening, 
or  to  the  projection  of  the  ends  of  an  oval  stone  laterally  beyond  the 
bladder.  This  latter  may  be  known  by  observing  that  the  bladder  is 
brought  bodily  down,  so  that  the  prostate,  which  is  probably  larg< 
visible  near  the  external  wound;  in  this  case  the  -tone  must  be 
liberated,  the  finger  again  introduced,  and  a  fresh  hold  taken.  If  the 
obstruction  is  due  to  a  large  stone  and  too  small  a  wound,  the  latter  is 
to  be  enlarged  in  the  direction  of  the  first  incision  ;  this,  in  the  opinion 
of  the  writer,  is  preferable  to  making  the  division  of  the  neck  of  the 
bladder  on  the  opposite  side,  and  preferable,  too,  to  using  undue 
traction  and  force." 

In  some  cases  a  scoop  will  facilitate  extraction,  the  stone  being  firmly 
held  between  the  pulp  of  the  left  index  finger  and  the  concavity  of  the 
scoop.  In  children  one  finger  in  the  rectum  and  one  in  the  bladder 
will  often  serve  the  purpose. 

The  stone  being  out,  the  bladder  is  carefully  explored  with  the 
finger,  or  a  short-beaked  staff,  aided  by  pressure  above  the  pubes,  or 
from  within  the  bowel,  for  any  other  calculi  or  fragments.  Multiple 
calculi  will  have  been  indicated  by  facets  upon  the  first. 

Any  bleeding  vessels  are  now  secured,  a  tube  introduced,  dressings 
applied,  and  the  patient  removed  to  bed. 

Difficulties  during  the  Stage  of  Extraction  of  the  Stone. 

(i)  The  position  of  the  stone.  This  may  be  out  of  reach  owing  to 
its  being  at  the  posterior  part  of  a  dilated  bladder,  above  the  pubes,  or 
to  the  patient  having  a  very  fat  and  deep  perineum.  Pressure  al 
the  pubes  and  the  use  of  long  forceps  are  here  indicated.  (2)  An 
enlarged  prostate.  This  interferes  with  reaching  the  stone  both  with 
lingers  and  forceps.  Curved  forceps  passed  in  along  the  staff,  or  a 
gorget,  if  the  perineum  be  very  deep,  will  be  helpful  here.  An 
enlarged  middle  lobe  of  the  prostate,  or  a  separate  adenoma  of  this 
gland,  may  also  cause  trouble  by  getting  between  the  blades  of  the 
forceps.  Tearing  away  of  these  portions  of  the  gland  has  often 
occurred,  and  was  Bometimes  certainly  beneficial.  When  the  prostate 
is  known  to  be  considerably  enlarged,  it  is  far  better  to  adopt  the 
supra-pubic  route,  for  this  gives  better  access,  and  allows  the  Burgeon 
to  examine  the  bladder  thoroughly,  so  that  he  maynol  overlook  a  Btone 
behind  the  prostate  or  an  encysted  one  (p.  637;.  In  suitable  cases, 
with  but  little  cystitis,  the  prostate  may  be  enucleated  immediately 
after  the  removal  of  the  stones.  In  others,  with  much  cystitis,  or 
interference  with  the   renal  function,  it    is   better   to   be   content  with 


SUPB  \  PI  BIC    LITHOTOMY.  621 

lithotomy  only  at  first,  ami  to  remove  the  prostate  at  a  secondary 
operation,  when  the  cystitis  and  the  excretion  of  area  have  improved  as 
a  resTill  of  drainage,  Ae.  The  mere  removal  of  the  stum-  is  oo1 
enough,  for  the  obstruction  due  to  the  enlargement  of  the  prostate  is 
usually  the  cause  of  the  calculous  formation.  Perinese!  prostatectomy  is 
not  bo  satisfactory  as  the  supra-pubic  operation  when  ;i  stone  is  present, 
although  small  calculi  can  be  extracted  after  removing  the  prostate 
through  the  perinsBum.  (3)  Breaking  up  of  the  stone.  This  may 
occur  with  hard  calculi  from  too  much  force  being  used  with  the 
forceps,  but  it  much  more  often  happens  with  soft  phosphatic  calculi. 
In  such  cases  every  fragment  must  he  cleared  out — a  matter  of  some 
difficulty,  as  small  ones  are  readily  concealed  in  clots  or  folds  of 
mucous  membrane.  After  all  the  larger  ones  are  picked  out  a  catheter 
of  appropriate  size,  attached  to  a  Higgenson's  syringe,  is  inserted,  and 
the  bladder  thoroughly  and  forcibly  washed  out  with  diluted  Thompson's 
fluid  (one  in  six  or  eight,  p.  623),  or  mercury  perchloride  one  in  4,000. 
In  a  week  or  ten  days  the  bladder  should  again  be  carefully  sounded, 
and  examined  with  the  finger,  and  any  fragment  extracted,  this  being 
especially  needful  if  pain  has  persisted  after  the  operation.*  If  frag- 
ments still  persist  a  little  later,  an  evacuating-tube  and  washing-bottle, 
aided  if  necessary  by  a  ilat-bladed  lithotrite,  must  be  employed.  I  may 
here  express  my  belief  that  multiple  calculi  are  not  quite  as  rare  as  has 
been  supposed.  (4)  Size  and  shape  of  the  stone.  Mr.  Erichsen  writes 
on  this  subject :  "  A  calculus,  about  an  inch  and  a  half  in  its  shorter 
diameter,  will  be  hard  to  extract  through  an  incision  of  the  ordinary 
length  (not  exceeding  eight  lines)  in  the  prostate,  even  though  this 
be  considerably  dilated  by  the  pressure  of  the  fingers  ;  and  I  think 
it  may  be  safely  said  that  a  calculus  two  inches  and  upwards  in 
diameter  can  scarcely  be  removed  by  the  ordinary  lateral  operation 
with  any  degree  of  force  that  it  is  safe  to  employ."  Most  will  agree 
with  Mr.  Cadge  that  stones  weighing  upwards  of  3  oz.  will  be  dealt 
with  by  the  improved  supra-pubic  method.  Mr.  Jacobson  performed 
this  operation  twenty-six  times,  with  only  one  death,  which  occurred  in 
an  aged  very  emaciated  man  with  advanced  kidney  disease.  The  patient 
was  in  great  suffering,  and  death  would  have  been  probable  after  any 
operation.  Mr.  Jacobson  regards  lateral  lithotomy  as  a  very  safe 
operation  (vide  p.  647,  footnote),  and  still  advocates  it  for  children, 
and  writes:  "I  do  not  believe  in  the  frequency  of  after-sterilisation,  of 
which  a  few  cases  used  to  be  reported  from  time  to  time.  If  this  be  a 
causa  vera,  I  believe  the  risk  to  be  less  than  that  of  the  supra-pubic 
operation  in  ordinary  hands." 

SUPRA-PUBIC  LITHOTOMY   (Figs.   163—166). 

Indications. — The  surgeon  who  has  the  opportunity  of  becoming 
an  adept  in  the  use  of  the  lithotrite,  both  through  the  meatus  and 
through   a  perinaeal    wound  (p.    645),    will    seldom    have  occasion   to 

*  Recurrence  of  stone  within  two  years  almost  always  means  that  a  fragment  has  been 
left  after  the  operation.  No  greater  disappointment  than  this,  both  to  the  surgeon  and 
patient,  can  happen.  No  one,  probably,  has  cut  fifty  patients  without  having  to  admit 
and  lament  its  occurrence,  but  it  is  especially  liable  to  occur  to  the  inexperienced  (Cadge). 


622  OPERATIONS  ON  THE  AUDOMKN. 

perform  supra-pubic  lithotomy.  Where,  however,  there  has  been  no 
such  opportunity,  this  operation  will  be  required  for  the  following 
conditions.     These  I  quote  from  the  concluding  portion  of  a   paper 

which  I  read  before  the  Royal  Medico- C hi rurgical  Society  (Trans., 
vol.  lxix.  p.  377). 

(1)  "That  supra-pubic  lithotomy,  as  recently  modified,  has  a  future 
of  renewed  usefulness  before  it,  and  that  while,  as  an  operation,  it  can 
never  contrast  with  the  rapid  brilliancy  of  the  lateral  operation,  it  will 
be  found  of  great  value  by  those  who  only  have  to  deal  with  stone 
occasionally,  and  by  those  who  find  themselves  face  to  face  with  calculi 
of  considerable  size  in  adults.  (2)  That,  to  give  other  and  more  indivi- 
dual instances,  the  operation  will  be  found  useful  (a)  in  many  cases  of 
hard  stones  of  an  inch  and  a  half  in  diameter ;  (b)  in  multiple  hard 
stones;  (c)  in  some  cases  of  foreign  body  in  the  bladder  with  abundant 
calculous  deposit  (Sir  H.  Thompson)  ;  (</)  in  cases  of  encysted  stone.* 
(e)  In  the  rarer  cases  of  a  state  of  urethra  which  will  not  admit  the  use 

of  a  lithotrite  or  a  grooved  staff "     To  these  should  be  added, 

(/)  in  cases  where  the  stone  is  associated  with  enlarged  prostate 
(p.  635).  The  supra-pubic  opening  will  here  be  convenient  for  remov- 
ing the  prostate  as  well  as  the  stone,  and  also  for  thoroughly  examining 
the  interior  of  the  bladder  and  removing  all  the  calculi  with  certainty. 
The  calculus  is  generally  secondary  to  the  prostatic  enlargement,  so 
that  it  is  necessary  to  remove  the  prostate  to  give  complete  and 
permanent  relief.  The  prostate  may  be  enucleated  either  at  the  same 
sitting  or  later  if  there  is  much  cystitis,  or  the  renal  excretion  is 
seriously  lessened.  Free  drainage  and  the  removal  of  the  stone  may 
be  followed  by  great  improvement,  and  a  secondary  prostatectomy  then 
undertaken  successfully,  (g)  In  cases  of  sacculation  of  the  bladder,  or 
where  a  stone  has  been  seen  through  the  cystoscope  to  be  impacted  at 
the  ureteral  orifice  with  a  projection  into  the  bladder. 

The  greater  trouble  and  the  longer  time  which  this  operation  entails, 
both  during  its  performance  and  afterwards,  will  not  be  grudged  in 
these  days,  when  it  is  so  much  the  rule  to  pay  attention  to  the  details 
of  surgery.  Only  time  and  a  larger  collection  of  cases  will  show  how 
far,  with  much  simpler  structures  to  cut,  with  these  brought  safely 
into  reach,  and  with  modern  antiseptic  details  at  hand  in  the  after- 
treatment,  this  lithotomy  is  safer  than  the  far  more  brilliant  lateral 
one. 

Preparations. — Cystitis  must  be  treated  as  far  as  possible  by  rest 
and  by  irrigation  of  the  bladder  for  some  days  before  the  operation, 
and  by  the  administration  of  such  urinary  antiseptics  as  urotropine, 
helmitol,  boracic  aid,  benzoate  of  ammonium,  &c.  Urinary  excretion 
may  be  promoted  by  copious  libations  and  by  diuretics.  The  bowels 
should  he  kept  well  open,  and  the  rectum  thoroughly  washed  out  on 
the  morning  of  the  day  of  the  operation.  The  pubis  should  be  shaved 
and  the  abdomen  cleansed  and  compressed  overnight.  Distension  of 
the  rectum  with  a  rectal  bag  is  not  recommended,  for  its  utility  is 
doubtful,  except  in  certain  special  cases  in  which  it  is  desirable  to  raise 

*  Much  useful  information  may  be  gathered  from  a  papet  by  Mr.  Bruce  Clarke  (Brit, 
Med.  Jour/i.,  May  13,  1899),  in  which  an  account  is  given  of  27  cases  of  encysted  vesical 
calculus. 


SUPRA  I'l  BIC    LITHOTOMY. 


623 


the  base  of  the  bladder  and  bring  it  as  much  within  reach  as  possible, 
e.g.,  in  operations  for  tuberculous  disease,  and  for  the  removal  of 
tumours  from  the  base  of  the  bladder.  For  the  effect  of  rectal  disten- 
sion is  chiefly  to  raise  the  bladder  bodily  in  a  direction  upwards  and 
forwards,  and  hence  after  incision  to  make  the  base  more  prominent 
and  easier  to  reach;  the  effect  as  regards  the  Bupra-vesical  fold  of 
peritoneum  is,  on  the  other  band,  so  small  that  it  may  be  neglected. 
Moreover,  the  procedure  is  not  without  danger. 

Details  of  the  Operation, 

A.  Distension  of  the  Bladder. — Either  water  or  air  may  be  used 
for  this  purpose  after  the  bladder  has  been  thoroughly  washed  out,  the 

Fig.  245. 


Sagittal  median  frozen  section  through  the  pelvis  of  a  young  man,  the 
bladder  being  distended.     (C.  Langer.) 

chief  advantages  claimed  for  air  being  (1)  that  its  buoyancy  tends  to 
raise  the  bladder  up  to  the  surface,  whereas  the  weight  of  water  tends 
to  drag  it  downwards  towards  the  pelvis  ;  (2)  being  compressible,  it  is 
less  liable  to  do  damage  when  the  bladder  walls  are  contracted  and 
rigid  ;  (3)  there  is  no  flooding  of  the  wound  when  the  bladder  is  incised, 
and  therefore  less  liability  of  infection  of  the  peri-vesical  cellular 
tissue. 

The  air  may  be  conveniently  introduced  by  means  of  a  bicycle  pump 
attached  to  the  catheter  by  means  of  a  length  of  rubber  tubing,  no 
measurement  of  the  quantity  used  being  necessary  when  the  plan 
advised  below  is  adopted. 

If  distension  with  water  is  preferred  to  air,  either  Thompson's  fluid 
(borax,  1  pint. ;  glycerine,  2  pints  ;  water,  2  pints)  diluted  one  in  six, 
carbolic  acid  one  in  eighty,  orperchloride  of  mercury  one  in  4,000,  may 


624 


OPKRATIONS    ON    TIIK    AP.Do.MKX. 


be  used.  This  should  be  introduced  by  means  of  an  irrigator  raised 
about  a  foot  above  the  level  of  the  patient's  abdomen.  In  this  way  a 
safety-valve  is  provided  against  any  sudden  rise  of  pressure  within  the 
bladder  if  any  straining  takes  place.  If  the  plan  advised  below  is 
adopted  it  is  not  necessary  to  measure  the  quantity  of  liquid,  hut  if  it 
is  preferred  to  introduce  tins  first  it  must  be  measured,  in  this  case 
8  to  10  oz.  for  an  adult,  and  a  smaller  amount  for  a  child  will  be  found 
to  suffice  ;  larger  quantities  should  not  be  used  for  fear  of  causing 
damage  from  over-distension.  The  safest  plan  is  to  carry  out  the 
distension  of  the  bladder  after  the  incision  has  been  carried  down  to  the 
transversalis  fascia  and  the  wound  well  retracted,  as  advised  by  Tilden 

FlO.  246. 


Sagittal  median  frozen  section  of  male  pelvis,  with  distension  of  bladder 
and  rectum.     (Garson.) 

Brown  (Ann.  of  Surg.,  vol.  xxv.  p.  141).  The  air  or  antiseptic  solution 
can  then  he  gently  and  slowly  introduced,  and  its  effect  gauged  by  the 
eye  and  the  finger  placed  on  the  bladder.  In  this  way  the  supra- 
vesical fold  of  the  peritonaeum  may  be  raised  to  the  desired  extent 
without  the  slightest  risk  of  causing  damage  from  over-distension. 

B.  The  Operation  Itself. — The  pubes  having  been  cleansed,  the 
knees  slightly  flexed,  and  the  shoulders  a  little  raised,  an  incision  is 
made  about  three  inches  long,  exactly  in  the  middle  line  and  ending 
over  the  upper  border  of  the  pubes.  The  subcutaneous  fat,  often 
plentiful  in  amount,  having  been  divided,  and  any  vessels  secured  with 
Spencer  Wells's  forceps,  the  anterior  wall  of  the  rectus  sheath  is  incised 
close  to  the  middle  line,  and  the  fibres  of  one  or  other  rectus  muscle 
are  separated   from   below  upwards    for  two   or    three    inches.       The 


SUPRA  PUBIC    UTIlnTo.MY. 


625 


transversalia  fascia  is  then  picked  up  at  the  lower  angle  of  the  wound 
iind  divided.  The  retractors  now  drawing  the  edges  of  the  wound  well 
apart,  a  layer  of  loose  tissue  and  of  fat,  often  abundant,  and  frequently 
having  large  veins  in  it,  will  next  come  into  view,  lying  over  and  con- 
cealing the  bladder.  This  must  be  torn  through  carefully  and  as 
cleanly  as  possible  at  the  lower  end  of  the  incision  near  the  pubis,  a 
blunt  dissector  being  used  for  the  purpose.  The  fat  is  then  drawn 
upwards  with  the  finger  so  that  the  peritonaeum  may  be  displaced  out 
of  harm's  way  generally  without  being  seen  at  all.  Any  veins  which 
cross  the  wound  (and  a  transverse  branch  lies  often  just  opposite  the 
site  of  puncture  into  the  bladder)  should  be  secured  with  forceps.     If 


Fio.  247. 


Smooth  retractor. 

Subperitoneal 
fat  covering 
peritonaeum. 
Bladder. 


Retaining  suture. 
—  Incision  into  bladder. 
Rectus  fibres. 


Supra-pubic  cystotomy.  The  rectus  fibres  have  been  separated  and  the  sub- 
peritoneal fat  and  peritonaeum  displaced  upwards.  Tissue  forceps  are  better  than 
sutures  for  holding  the  bladder  up  against  the  parietes. 

one  is  opened  at  this  stage,  the  field  of  the  operation  will  be  obscured 
by  most  troublesome  haemorrhage.*  This  must  be  arrested  by 
pressure-forceps,  which  act  also  as  retractors,  by  sponge-pressure,  or 
a  very  hot  saline  solution ;  prolonged  manipulation  in  arresting 
haemorrhage  here  may  be  the  cause  of  that  cellulitis  later  on  which  is 
so  much  to  be  deprecated.  The  anterior  surface  of  the  bladder  will 
now  be  recognised  by  its  pink  colour,  the  fibres  of  the  detrusor  urinae, 

*  M.  Guyon  in  his  second  case  met  with  most  profuse  haemorrhage  :  "Nous  essayames, 
mais  assez  vainement,ia  nous  opposer  a  l'envahissement  de  toute  la  plaie  par  une  nappe  de 
sang  sans  cesse  renouvelee."  After  repeated  and  fruitless  attempts  to  arrest  this  hemor- 
rhage,  the  bladder  was  opened  and  the  stone  removed.  The  haemorrhage  ceased  entirely 
on  the  removal  of  the  rectal  bag.  The  patient,  aged  69,  died  with  purulent  infiltration 
of  the  sub- peritoneal  connective  tissue.     Such  severe  hemorrhage  is  very  rare. 

S. — VOL.  II.  4° 


626         OPERATIONS  ON  THE  ABDOMEN. 

and  by  its  fluctuating  ander  the  f *i  1 1 *jt « - r .  Veins  often  are  met  with 
again  here  on  the  bladder  itself,  longitudinal,  transverse,  and  occasion- 
ally plexiform.  Great  care  must  be  taken  not  to  open  up  the  fatty 
connective  tissue  which  lies  between  the  anterior  Burface  ofthe  bladder 
and  the  pubes.  A  Bpot  on  the  anterior  Burface  ofthe  bladder  having 
been  chosen  about  three-quarters  of  an  inch*  above  the  pubes,  it  is 
punctured  (a  liook  or  retaining  sutures  (vide  Fig.  247)  being  used  if 
thought  desirable),  and  the  left  index  finger  at  once  introduced  to  feel 
for  the  stone.  The  finger  at  the  same  time  keeps  the  bladder  hooked 
up,  and  prevents  it  settling  back  into  the  pelvis  as  the  bladder  collapses. 
The  stone  is  best  removed  by  two  fingers,  or,  if  preferred,  by  forceps  or 
scoop.  The  fingers,  if  successful,  have  the  advantage  of  not  risking  any 
injury  to  the  mucous  membrane.  Removal  of  the  stone  is  not  always 
easy;  it  falls  back  into  the  fundus,  or  into  a  retro-prostatic  pouch  out 
of  reach.  An  assistant's  two  fingers  passed  into  the  rectum  may  be  of 
service  in  pushing  the  stone  forwards.  Care  must  be  taken  not  to 
bruise  or  lacerate  the  edges  of  the  vesical  incision  or  to  break  the 
stone  into  pieces  by  attempting  to  remove  it  through  an  aperture 
■which  is  too  small ;  it  is  far  preferable  to  enlarge  the  latter  by 
stretching  with  two  fingers  without  delay.  More  room  can  thus 
be  obtained  without  increasing  the  bleeding  from  the  wall  of  the 
bladder. 

Great  difficulty  may  he  met  with  in  removing  an  encysted  calculus, 
owing  to  the  fact  that  the  stone  usually  entirely  tills  the  sac,  the  neck 
of  which  is  frequently  quite  narrow.  If  the  neck  cannot  be  sufficiently 
dilated  to  deliver  the  stone,  whole,  through  this,  the  plan  recommended 
by  Hurry  Ten  wick  (Med.  Ann.,  1901)  may  be  made  use  of.  It  is 
described  as  follows  : — "  If  there  is  a  projecting  nose,  it  is  snapped  off 
and  removed — if  no  dumb-bells  exist,  then  the  tiny  aperture  must  be 
located — slightly  dilated  by  the  point  of  the  forefinger,  and  it  possible 
the  stone  must  be  freed  in  its  sac.  A  caisson  or  Bpeculum  should  then 
be  passed  on  to  the  aperture,  a  beam  of  light  thrown  along  the  channel 
to  expose  the  white  surface-  of  the  stone,  a  blunt  graving  tool  or  chisel 
being  guided  on  to  it  under  control  of  the  eye.  The  assistant  now 
passes  his  finger  into  the  rectum,  and  supports  the  stone  from  behind, 
while  the  surgeon  steadies  the  point  of  the  chisel  on  the  stone,  and  taps 
its  head  smartly  with  the  mallet.  The  stone  is  fractured,  as  it  is  chiefly 
phosphatic  material.  With  a  little  manipulation  the  stone  is  turned, 
another  section  is  made,  and  so  on,  until  the  pieces  can  be  safely  pulled 
through  the  orifice  ofthe  sac  into  the  caisson  and  out." 

"When  the  sac  is  low  down  or  lateral,  the  lower  margin  of  its  neck 
may  be  safely  incised,  without  risk  of  opening  the  peritonaeum.  A 
stone  impacted  at  the  lower  end  of  the  ureter  may  if  necessary  be 
released  by  incising  the  mucous  membrane  over  it  in  a  direction 
parallel  with  the  course  ofthe  ureter. 

77/-  question  una-  arises  of  closing  the  opening  with  sutures  or  leaving 
it  open,  in  jiart  at  bast. 

*  The  spot  chosen  must  not  be  too  low,  or  infiltration  may  take  place  into  the  cavum 
Retzii  behind  the  pubes.  It  is  also  more  difficult  to  sew  the  wound  if  it  is  placed  too  low  ; 
if  too  high,  drainage  will  be  interfered  with  and  the  peritonaeum  endangert-d.  A  trans- 
verse incision  into  the  bladder  is  a  little  more  easy  to  close,  but  it  injures  the  detrusor 
dm  re. 


SUPRA  PUBIC    LITIloToMV.  627 

The  drainage  of  the  bladder  by  a  catheter,  in   the   urethra,  or  by 
suction  and  Byphonage  (p.  603)  is  so  difficult,  the  patient's  condition  so 

very  unsatisfactory  "  for  the  first  week  or  so,  owing  to  tin-  constant 
Boakage  in  spite  of  voluminous  dressings,  that  wherever  it  is  possible 

the  bladder  opening  should  he  (dosed  by  sutures.  One  of  the  first  to 
adopt  this  plan  successfully  was  Dr.  L.  S.  Pilcher,  of  New  York  :  a 
catheter  was  used  till  the  ninth  day,  the  patient,  an  adult,  went  out  011 
the  fourth,  and  on  the  fourteenth  day  was  shown  to  the  New  York 
Medical  Society,  primary  union  having  taken  place  throughout  the 
whole  extent  of  the  wound,  without  unpleasant  symptoms  of  any  kind. 
Mr.  11.  W.  Parker  had  an  equally  successful  case  in  a  child  aged  3. 
There  have  been  a  number  of  others.  Mr.  Anderson,  of  Nottingham 
(Lancet,  vol.  i.  1890,  p.  898),  sutured  the  bladder  in  a  boy  aged  10. 
Acute  pneumonia  complicated  the  after-treatment,  and  on  the  night  of 
the  fourth  day  (the  superficial  sutures  being  removed  and  the  wound 
healed)  prolonged  coughing  tore  open  the  wound.  The  case  did  well. 
Mr.  Pollard  described  three  cases  in  which  the  bladder  was  sutured 
after  supra-pubic  lithotomy  in  children.  Urine  leaked  through  in  each 
case  on  the  third  day.  All  did  well.  In  a  very  interesting  paper  by 
Mr.  Bond,  of  Leicester  (Lancet,  vol.  ii.  1889,  p.  260),  it  will  be  seen 
that  in  three  out  of  four  cases  in  which  the  bladder  had  been  sutured, 
some  urine  escaped  once  about  twelve  hours  after  the  operation.  This 
did  not  delay  the  union.  A  continuous  Lembert  suture  of  catgut  put 
in  efficiently  will  suffice  (p.  353).  Care  must  be  taken  not  to 
perforate  the  mucosa.  The  first  suture  may  be  reinforced  by  a  second 
one  in  some  cases,  especially  if  there  has  been  any  bruising  of  the 
edges.  When  the  bladder  is  sutured  great  care  must  be  devoted  to 
securing  and  maintaining  efficient  drainage  through  the  catheter,  for  if 
the  bladder  is  allowed  to  get  distended,  pelvic  extravasation  is  almost 
certain  to  occur.  A  large  sized  and  large  e}red  soft  catheter  is  inserted 
before  the  bladder  is  closed,  and  its  eye  should  be  just  above  the  vesical 
orifice.  It  is  carefull}'  secured  so  that  it  may  not  slip  either  in  or  out, 
and  the  rubber  tubing  attached  to  it  has  its  other  end  immersed  iu 
antiseptic  lotion  in  a  vessel  attached  to  the  side  of  the  bed.  The  whole 
drainage  apparatus  must  be  airtight  to  be  efficient.  If  the  eye  of  the 
catheter  gets  blocked  with  clot,  this  must  be  displaced  at  once,  by 
running  some  boracic  lotion.  Bergmann  drains  through  a  median 
perinseal  puncture,  which  is  made  by  cutting  upon  the  points  of 
forceps,  passed  from  the  bladder  along  the  urethra.  This  method 
may  be  adopted  in  some  cases  in  order  to  avoid  supra-pubic  drainage. 

Sutures  should  not  be  employed  (1)  where  there  is  cystitis,  and  the 
urine  ammoniacal  or  the  kidneys  diseased  and  the  renal  excretion  poor, 

(2)  where  the  bladder  is  irritable,  thickened,  and  the  better  for  drainage, 

(3)  where  the  extraction  is  difficult  and  prolonged,  and  the  parts 
necessarily  bruised,  (4)  where  there  is  any  reason  to  expect  bleed- 
ing; in  such  cases  the  clots  will  cause  violent  tenesmus,  and,  probably, 

*  This  is  especiall}'  the  case  in  elderly  flabby  patients  with  damaged  kidneys,  and 
unsatisfactory  vital  power  and  will.  Such  tend  to  become  apathetic,  to  lie  helplessly-  on 
their  backs  down  in  the  bed,  thus  easily  getting  stasis  in  their  lung  bases  and  broncho- 
pneumonia, together  with  a  low  septic  condition  of  the  wound.  The  nursing  of  such  cases 
is  greatly  helped  by  suture  of  the  wound,  and  thus  keeping  the  patients  dry. 

40 — 2 


628         OPERATIONS  ON  THE  ABDOMEN. 

giving  way  of  the  sutures,  (5)  where  there  is  any  stricture  or  an  irritable 
condition  of  the  urethra  sutures  are  inadmissible. 

Where  sutures  are  not  used,  in  order  to  prevent  extravasation,  the 
cut  edges  of  the  bladder  should  he  sutured  with  fine  catgut  to  the 
fascial  and  deeper  edges  of  the  wound,  two  or  three  sutures  being 
placed  on  either  side,  and  one  helow  at  the  lower  end  of  the  incision  so 
as  to  shut  off  the  tissues  behind  the  puhes.  Another  way  is  to  partly 
close  the  vesical  wound  with  purse-string  inverting  sutures,  until  it 
grasps  the  large  rubber  tube  inserted.  A  suture  may  he  used  on  either 
side  to  keep  the  bladder  in  contact  with  the  parietes. 

Two  or  three  huried  catgut  sutures  then  draw  the  muscle  fibres  and 
aponeurosis  together  above,  while  three  or  four  more  unite  the  skin,  or 
salmon-gut  suture  alone  may  he  used,  some  of  them  heing  passed 
deeply  so  that  they  approximate  the  muscles  ;  buried  sutures  are  thus 
avoided.  Iodoform  and  collodion  should  be  brushed  over  the  united 
portion  of  the  wound,  and  the  bladder  should  be  drained  by  Mr.  Cath- 
cart's  method  (p.  603).  If  this  has  not  heen  provided,  a  large 
Thomson's  supra-pubic  tube  should  be  inserted,  and  every  attempt 
made  by  a  regular  supply  of  dry  dressings,  and,  after  the  first  twenty- 
four  hours,  turning  the  patient  on  his  sides  for  a  few  hours  alternately, 
to  prevent  any  part  becoming  sore  from  the  constant  soaking.  But  if 
the  bladder  is  not  sutured,  only  some  such  method  as  Mr.  Cathcart's 
will  keep  the  parts  dry  and  save  the  patients  from  the  great  risk  of 
extravasation.  Where  sutures  are  used  it  will  be  well  not  to  unite  the 
linea  alba  and  skin  below.  For  the  first  few  days  it  will  he  unwise  to 
trust  to  the  patient's  voluntary  power  of  expulsion,  and  if  the  catheter 
becomes  plugged,  or  if  it  is  not  passed  just  when  required,  some  urine, 
possibly  septic,  may  be  forced  out  between  the  sutures  before  the 
bladder  wound  is  finally  closed,  a  process  which  must  take  two  or  three 
days.  If  this  extravasation  take  place  deep  down  in  a  wound  like  this, 
where  the  superficial  parts  have  been  closed,  there  is  the  grayest  peril 
of  a  fatal  issue  from  septic  purulent  infiltration  of  the  connective  tissue 
of  the  cavum  Retzii,  pelvis,  and  abdominal  wall. 

To  avoid  this,  the  prevesical  space  must  be  drained  in  all  cases  by 
means  of  gauze  or  a  rubber  tube  with  a  wick  of  gauze  inside  it.  After 
3  or  4  days  the  drain  can  be  safely  removed  and  the  wound  allowed  to 
close.  Belfield  (Ann.  of  Surg.,  January,  1907,  p.  101)  drains  the 
space  in  front  of  the  bladder  through  the  perinaeum.  He  opens  the 
membranous  urethra  upon  a  grooved  staff,  and  introduces  a  gorget.  "  A 
small  trocar  and  cannula  is  passed  from  above  along  the  anterior  surface 
of  the  bladder  and  prostate  into  the  groove  of  the  gorget.  The  trocar 
being  withdrawn,  a  few  silkworm  strands  are  threaded  through  the 
cannula  and  along  the  gorget  out  through  the  periimeal  wound  (a  small 
perforated  rubber  drain  may  be  attached  and  drawn  through  by  the 
threads).  A  large  soft  catheter  with  multiple  perforations  having  been 
introduced  into  the  bladder  for  perimeal  drainage,  the  supra-pubic 
incision,  bladder  and  abdominal  wall  are  closed  completely,  except 
where  the  threads  protrude,  the  anterior  bladder  wall  being  anchored 
near  the  recti  muscles.  Urine  which  may  leak  through  the  bladder 
wound,  and  tissue  fluids,  find  ready  exit  at  the  bottom  of  this  space.  In 
nine  out  of  eleven  cases,  in  which  I  have  made  this  operation,  the 
wound  was  entirely  healed  within  two  weeks ;  in  the  remaining  two — 


SUPRA-PUBIC    LITHOTOMY. 

prostatectomies  in  which  oozing  blood  was  allowed  to  block  the  perineal 

drain — the  wound  was  reopened  for  the  insertion  of  a  Larger  drain." 
Although  this  method  is  worth  trying  I  do  not  anticipate  that  it  will 
prove  to  have  any  real  advantage  over  the  method  described  above,  and 
it  has  the  disadvantage  of  adding  a  perineal  fistula. 

A  few  words  may  lie  said  here  about  the  periton&U in .  With  sueh  dis- 
tension of  the  bladder  as  has  been  advised,  with  an  incision  not  begun 
too  high  up  and  carried  well  down  over  the  pubes,  with  a  moderate 
incision  into  the  bladder,  it  is  most  unlikely  that  anything  will  be  seen 
of  the  peritonaeum.  It  may  be  very  indistinctly  felt  at  the  upper  part 
of  the  wound,  but  this  is,  usually,  all. 

If,  after  careful  distension  of  the  bladder  the  peritonaeum  still  seems 
to  encroach  too  far  upon  the  anterior  surface  of  the  bladder,  it  may  be 
pressed  upwards  and  held  out  of  the  way  by  one  or  two  fingers  of  an 
assistant,  or,  if  needful,  gently  peeled  upwards  off  the  bladder  with  a 
steel  director.*  In  elderly  people  with  lax  tissues  and  large  stones 
requiring  free  incisions,  the  peritonaeum  covered  with  its  fatty  tissue  is 
more  likely  to  be  seen  rising  and  falling  in  the  upper  angle  of  the 
wound.  There  is  more  danger  of  opening  the  peritonaeum  when  the 
bladder  is  contracted,  and  especially  when  either  supra-pubic  puncture 
or  cystotomy  has  been  previously  performed  and  has  disturbed  the 
normal  relations  of  the  parts. 

If,  what  is  most  unlikely  with  the  recent  improvements  in  the  opera- 
tion, the  peritonaeum  should  be  punctured  before  the  bladder  is  opened, 
the  puncture  should  be  picked  up  and  tied  around  with  chromic  gut. 
If  the  opening  is  more  than  a  puncture  the  cut  edges  of  the  peritonaeum 
should  be  sutured  carefully  with  catgut,  and  the  operation  continued. 

If  the  opening  is  made  after  the  bladder  is  opened,  the  surgeon  must 
decide,  according  to  the  amount  and  character  of  the  urine  which  has 
escaped,  between  suturing  the  opening  and  enlarging  it  upwards,  so  as 
to  thoroughly  sponge  out  or  cleanse  by  irrigation  with  a  2  per  cent, 
solution  of  boracic  acid,  the  peritonaea!  cavity.  But  these  accidents  are 
most  unlikely  nowadays. 

One  of  us  operated  by  this  method  fourteen  times  some  years  ago, 
the  patients  ranging  from  3  to  62  years.  Four  only  of  the  stones  were 
large.  Two  were  just  over  2  oz.,  a  third  wTas  5  oz. ;  in  the  fourth,  a 
young  woman,  the  stone,  formed  round  a  hairpin,  weighed  6  oz.  In 
five  they  were  multiple.  In  seven  the  urine  was  alkaline  and  foul. 
Four  cases  were  fatal — the  sixth,  a  lad  of  19,  an  orphan,  in  wretched 
condition  of  body,  and  in  much  misery  from  pain.  Perhaps  it  would  have 
been  wiser  to  have  waited  longer,  in  order  to  feed  him  up  before 
operating.     His  pain,  however,  was  so  severe  that  the  operation  was 

*  In  only  three  of  my  14  cases  did  I  have  any  trouble  with  the  peritonaeum.  To 
give  one  instance,  in  an  elderly  patient  of  Dr.  Bell's,  of  Blackheath,  with  two  lithic  acid 
calculi  each  weighing  1  oz..  the  peritonaeum  almost  reached  the  level  of  the  symphysis. 
It  was.  however,  easily  detached  from  the  bladder  and  held  up  with  a  retractor.  I  closed 
the  upper  part  of  the  wound  carefully  over  it,  and  sutured  the  edses  of  the  bladder  to  the 
deep  part  of  the  wound.  A  good  recovery  followed  in  this  and  the  other  two  cases,  which 
were  similar.  At  the  Congress  of  German  Surgeons  in  1SS6.  Gussenbauer,  Sounenberg, 
and  Kramer  mentioned  cases  in  which  the  peritonaeum  was  found  adherent  to  the  sym- 
physis. In  one  case  it  was  opened  with  fatal  results  ;  in  another,  the  opening  was  sewn 
up  and  the  peritonaeum  safely  separated  from  the  pubes. 


630         OPERATIONS  ON  THE  ABDOMEN. 

performed  a  week  after  his  admission  into  the  hospital.  He  did  excel- 
lently for  forty-eight  hours,  then  symptoms  of  pelvic  cellulitis  set  in, 
proving  f';it;il  on  the  fourth  day.  The  other  case  was  one  of  multiple 
stones  in  ji  man  of  58,  much  run  down  in  strength.  Eight  calculi  were 
removed,  composed  chiefly  of  males.  The  patient  Bank  shortly  after. 
11  is  kidneys  proved  to  be  in  an  advanced  stage  of  granular  degeneration. 
Two  other  patients,  elderly  men,  died  of  kidney  failure,  one  on  the 
fourth  day,  the  other  twenty-two  days  after  the  operation. 

Southam  (Brit.  Med.  'fount.,  1904,  p.  1190)  records  a  death  rate  of 
nearly  24  per  cent,  for  46  supra-pubic  lithotomies.  This  mortality 
seems  to  be  unusally  high  ;  "  it  must  be  remembered,  however,  that  the 
cases  so  treated  were  all  unsuited  for  iithotrity,  the  latter  operation 
being  contra-indicated  in  each  instance — with  one  exception — on 
account  of  the  large  size  of  the  stone,  associated  either  with  enlarge- 
ment of  the  prostate,  and  an  unhealthy  state  of  the  bladder  and  urine, 
or  with  a  feeble  condition  of  the  patient,  in  consequence  of  which  the 
shock  of  a  prolonged  crushing  operation  would  not  have  been  well 
borne.  The  fatal  result  in  these  cases  was  due  in  several  instances, 
when  the  patients  were  advanced  in  years,  to  sudden  heart  failure, 
coming  on  at  some  interval  after  the  operation,  when  all  was  apparently 
progressing  favourably  ;  in  others,  as  proved  by  necropsy,  it  was  the 
result  of  pre-existing  secondary  renal  disease,  death  being  preceded  by 
suppression  of  urine  and  other  evidences  of  uraemia." 

"  Barling  collected  72  cases  of  supra-pubic  cystotomy  performed  in 
London  and  provincial  hospitals  between  1888  and  1892,  the  patients 
all  being  under  20  years  of  age,  and  in  15  instances  there  was  a  fatal 
result,  giving  a  mortality  of  20  per  cent." 

AVhile  on  some  points  connected  with  the  operation  my  mind  remains 
open,  I  am  strongly  of  opinion  that,  with  carefulness,  it  is  a  safer  opera- 
tion than  the  lateral  method  for  those  who  only  perform  lithotomy 
occasionally,  and  for  large  stones — e.g.,  over  I  oz.  I  am  certain  that 
no  benefit  is  to  be  gained  by  substituting  it  for  the  lateral  in  the  case  of 
children. 

MEDIAN  LITHOTOMY. 

Disadvantages. 

1.  It  gives  very  little  room,  and  is  unsuited  to  any  save  the  smallest 
stones.  2.  The  wound  being  small,  the  surgeon  cannot  bury  his 
knuckles  in  it,  or  reach  the  bladder  as  easily  as  in  the  case  of  the  larger 
lateral  wound  (Cadge).  3.  The  rectum  on  the  one  hand,  and  the 
bulb  on  the  other,  are  in  greater  danger  than  by  the  lateral  method 
(Cadge).     4.   Troublesome  bleeding  is  more  frequent  (Cadge). 

Mr.  Cadge,  having  operated  on  50  or  60  cases  by  the  median 
method,  has  given  it  up  for  the  above  reasons,  and  also  because  his 
mortality  has  been  rather  higher. 

Advantages. — Recovery  is  often  extremely  rapid  ;  the  urine  quickly 
resumes  its  natural  route  ;  and  the  wound,  instead  of  gaping  and 
healing  slowly  as  the  lateral  wound  does,  heals  almost  by  first  intention.* 

*  Dr.  W.  T.  l'.ri.-".'-.  (if  Xasliville  (Trim*.  Amrr.  Swrg.  Assoc,  vol.  v.  p.  127).  thus  sums 
up  the  advantages  of  median  lithotomy  :  (1)  It  opens  up  the  shortest  and  most  direct 
route  to  the  bladder.     (2)  It  divides  parts  of  the  least  importance,     (j)  It  is  an  almost 


MKDI.W    LITHOTOMY. 


G  u 


It  inflicts  a  minimum  of  damage  ;  for  these  reasons  Mr.  Jacobson  con 
eiders  ili«'   operation   to   be  the   most  suitable!   for  elderly   men  with 
comparatively  small  stones. 

The  above  no  not,  however,  compensate,  in  Mr.  Cadge's  opinion,  for 

the  disadvantages.  He  would  avoid  it,  especially  in  children,  in 
whom  it  is  by  some  preferred,  as  in  them  a  free  incision  is  necessary  to 
facilitate  the  passing  ofthe  finger  into  the  bladder,  while  here  the  limit 
of  space  for  the  knife  is  very  small  indeed. 

The    operation    is    suited    for   prostatic    calculi,    but,    if  these    are 
associated  with  any  larger  one  in  the  bladder,  the  surgeon  must  either 

Fig.  248. 


Median  lithotomy.  The  left  fore-finger  being  introduced  .along  the  director, 
which  was  passed  into  the  bladder  before  the  withdrawal  of  the  staff.  (After 
Heath.) 

crush  this  before  he  can  extract  it  through  his  small  incision,  or  perform 
a  supra-pubic  operation. 


bloodless  operation.  (4)  It  affords  a  passage  for  any  calculus  which  can  be  safely 
extracted  through  the  perinasum.  (5)  It  affords  the  best  passage  for  the  fragmentation 
of  unusually  large  calculi.  (6)  It  reduces  the  death-rate  to  a  minimum.  In  answer  to 
the  objection  to  the  median  operation  that  it  is  unfitted  for  the  extraction  of  large  stones, 
Dr.  Briggs  states  that  by  making  it  a  medio-bilateral  operation  (vide  i /if ni),  as  large  stone3 
can  be  removed  by  it  as  can  be  extracted  by  the  lateral  method.  Since  adopting  the 
above  modification,  Dr.  Briggs  has  had  the  following  excellent  results  :  Of  the  first  74, 
none  died.  Then  two  died,  but  one  of  these  had  a  pelvio  abscess  before  the  operation,  and 
the  other  died  at  the  end  of  three  months  with  phthisis,  and  the  wound  unhealed.  Since 
then  Dr.  Briggs  has  had  46  cases  with  one  death, 


632  OPERATIONS  ON  THE  ABDOMEN. 

Operation. — If  a  curved*  staff  be  used,  one  with  a  wide  groove  is 
chosen,  and  passed  and  held  with  its  handle  inclined  towards  the  umbili- 
cus (p.  616),  the  patient  being  in  lithotomy  position.  The  surgeon 
passes  his  left  forefinger  into  the  rectum  so  as  to  steady  with  its  tip  the 
staff  in  the  membranous  urethra  and  also  to  guard  the  rectum  from 
puncture,  while  at  the  same  time  note  is  taken  of  the  depth  of  tissues 
between  the  knife  and  the  finger.  A  straight  and  very  sharp  bistoury 
is  then  pushed,  with  its  back  downwards,  through  the  skin,  half  an  inch 
above  the  anus,  straight  on  into  the  groove  in  the  staff,  which  is  now 
held  well  hooked  up  against  the  pubes.  The  knife,  having  distinctly 
exposed  the  groove,  is  pushed  a  little  onwards  so  as  to  nick  the  apex  of 
the  prostate,  and  next,  as  it  is  withdrawn,  it  is  carried  upwards  in  the 
raphe  so  as  to  divide  the  soft  parts  for  one  inch  or  more,  according  to 
the  size  of  the  stone.  The  finger  would  now  be  passed  into  the  bladder, 
and  the  staff  withdrawn.  As,  however,  the  staff  occupies  too  much 
room  in  the  limited  wound  to  allow  of  this,  a  director  (Fig.  248)  is 
passed  in  along  the  groove,  the  staff  withdrawn,  and  then  the  finger 
introduced  along  the  director  through  the  neck  of  the  bladder.  This 
is  dilated  sufficiently  and  the  scoop  or  forceps  introduced.  If  the 
finger  cannot  be  introduced  along  the  director,  forceps  of  different 
sizes  may  be  passed  and  used  to  dilate  the  passage  sufficiently. 

Some  surgeons  prefer  to  make  the  incision  from  above  downwards, 
but  cutting  from  below  upwards  would  seem  better  to  protect  the 
bowel. 

If  a  straight  staff  be  used,  the  surgeon  introducing  his  knife  as  above, 
and  having  cut  upon  the  staff  distinctly  both  to  himself  and  the  assistant 
who  is  holding  it,  takes  it  into  his  left  hand,  and,  having  brought  it 
down  into  an  oblique  position,  runs  his  bistoury  along  the  groove  so  as 
to  nick  the  prostate  ;  the  enlargement  of  the  wound  and  the  rest  of  tlie 
operation  are  conducted  as  above. 

Where  the  stone  is  too  large  to  be  extracted  by  the  ordinary  median 
operation,  the  medio-bilateral  modification  introduced  by  Gouley,  1828, 
and  used  so  successfully  in  America  by  Dr.  liriggs,  should  be  employed. 
It  consists  in  making,  after  a  longitudinal  incision  in  the  raphe,  a 
slight  bilateral  cut  in  the  elastic  ring  at  the  neck  0  the  bladder  and  the 
prostate. 

Complications  and  Causes  of  Death  after  Lithotomy. — 1.  Shock. — 
This  is  rarely  severe,  save  in  patients  much  pulled  down,  and  after  pro- 
longed operations.  Children,  as  a  rule,  however  reduced,!  rally  well 
after  the  operation  (Sir  J.  Paget,  Clin.  Essays,  p.  404).  2.  Haemor- 
rhage.— If  milder  methods  fail  this  is  best  met  by  plugging  the  wound 
with  the  umbrella-plug,  or  by  leaving  in  situ  a  pair  of  Spencer  "Wells's 
forceps,  which  will  also  aid  the  drainage.  3.  Pelvic  cellulitis. — This, 
the  most  frequent  cause  of  death,  is  due  either  to  extravasation  of  urine, 


*  Mr.  Erichsen  recommends  a  rectangular  staff,  the  angle  of  which  rests  against  the  apex 
of  the  prostate,  and  is  thus  much  easier  to  find  in  the  perinaeum.  The  special  staff  is, 
however,  often  difficult  to  introduce,  and  a  curved  one,  held  so  as  to  project  its  curve  in 
the  perinsBum,  will  be  easily  found. 

t  Occasionally,  however,  even  nowadays,  where  the  history  is  of  long  standing  and  the 
kidneys  much  impaired,  they  are  too  far  gone  for  operation.  Sec  a  case  by  Id  r.  Hutchinson 
(('/in.  Surg.,  pi.  lxxvi.  vol.  ii.  p.  126). 


LITHOTRITY.— LITHOLAPAXY.  633 

probably  septic,  or  to  laceration  of  the  deep  parts,  or  both.  It  usually 
conies  on  within  forty-eight  hours.  4.  Peritonitis. —  Usually  combined 
with  the  above.  5.  Septic  complications. — Septicemia  may  occur 
early  with  pelvic  cellulitis.  Pyaemia,  on  the  other  hand,  may  come  on 
later.  6.  Surgical  kidney.  7.  Retention  of  urine. — Common  enough 
a  few  days  after,  from  swelling  of  the  parts.  Barely  more  serious. 
8.  Suppression  of  urine.  9.  A  sloughy,  phosphatic  state  of  the  wound. 
10.  Sloughing  of  the  rectum  (p.  620).  II.  Cystitis. — Rare.  12.  Epi- 
didymitis. 13.  Later  complications  rare,  but  troublesome.  14.  Fistula. 
15.  Incontinence.      16.  Sterility. 


LITHOTRITY— OPERATION"  WITH  SEVERAL  SITTINGS- 
RAPID  OPERATION  WITH  ONE  SITTING  AND  EVACU- 
ATION—LITHOLAPAXY— PERINEAL  LITHOTRITY. 

Choice  of  Operation— Lithotrity  or  Lithotomy. — It  is  hoped 
that  the  following  points,  while  they  do  not  in  the  least  exhaust  the 
subject,  will  be  found  of  practical  assistance  : 

1.  Amount  of  experience  of  the  surgeon. — Every  attempt  should  be 
made  to  become  familiar  with  the  use  of  the  instruments,  both  outside 
the  bod}r  and  also  by  passing  a  lithotrite  for  examination  of  a  calculus 
whenever  one  is  felt  on  sounding.  No  surgeon  who  has  not  had 
abundant  opportunities  of  practising  the  needful  manipulations  will 
do  wisely  in  attempting  to  crush  a  hard  stone  which  weighs  an  ounce. 

2.  Size,  kind,  and  number  of  stones. — As  to  size,  up  to  I  oz.  or 
ij  oz.,  it  is  probable  that,  with  the  majority  of  stones,  in  fairly  prac- 
tised hands,  lithotrity  is  immensely  superior  to  lithotomy  as  far  as 
immediate  mortality  is  concerned.  I  use  the  term  "immediate" 
advisedly,  because  of  the  more  frequent  recurrence,  with  its  results, 
after  lithotrity,  and  would  refer  my  readers  to  the  remarks  on  this 
point  at  p.  636.  Much  larger  stones  may  be  successfully  crushed  by 
an  experienced  operator  with  the  specially  strong  instruments  now 
made.  Freyer  (Lancet,  Dec.  12,  1896)  gives  a  list  containing  31  cases 
in  which  the  stone  averaged  2oz.  5drs.  in  weight,  all  of  which  were 
successfully  crushed.  The  largest  stone  which  Freyer  has  crushed 
weighed  6^  oz.,  the  operation  lasting  two  hours.  The  same  author, 
moreover,  considers  that  in  all  cases  trial  should  be  made  of  litholapaxy 
before  a  cutting  operation  is  performed. 

Mr.  H.  Milton  ("Lithotrity,  Simple  and  Complicated,"  Lancet,  April 
and  May,  1896)  records  an  epoch-marking  case  in  which  he  crushed  a 
stone  (urates  and  phosphates)  weighing  over  12  oz.  The  operation 
lasted  two  hours,  and  an  especial  lithotrite  with  a  gape  of  five  inches 
was  used.  Such  an  operation  is,  of  course,  only  possible  for  an  expert 
with  especial  experience,  such  as  Mr.  Milton's  in  Egypt.  This  surgeon 
had  before  (St.  Thos.  Hasp.  Reports,  1891)  referred  to  the  extraordinary 
tolerance  which  Orientals  show  to  all  operations  connected  with  the 
genito-urinary  apparatus. 

The  difficulty  of  a  decision  sometimes  met  with  here  is  well  expressed 
by  the  words  of  Sir  W.  Fergusson,  that  the  greater  is  the  experience 
of  the  surgeon  the  greater  will  sometimes  be  his  doubt. 

To  anyone  with  very  limited   experience  rashly  contemplating  an 


634  Ol'KKATIOXS    (i\    THK    ABDOMEN. 

attack  upon  a  hard  stone  I  would  recall  Mr.  Milton's  words  (!<><■.  infra 
cit.)  :  "  During  the  first  twenty  minutes  of  a  Long  crushing  most  men 
can  maintain  the  necessary  delicacy  of  manipulation,  combined  with 
the  exercise  of  considerable  force  ;  but  when  it  comes  to  working  at 
the  same  strain  for  a  second,  third  or  fourth,  or  even  fifth,  sixth  or 
seventh  period  condition  begins  to  tell  ....  this  force  has  to  be 
exerted  with  the  greatest  discrimination  and  the  greatest  patience." 
In  addition  to  the  above  must  be  remembered  the  frequent  introduction 
and  withdrawal  of  instruments,  litho trite  and  evacuators,  and  the  result 
upon  the  neck  of  the  bladder  and  the  deep  urethra. 

More  important  than  the  size  of  the  stone  is  its  composition,  There 
is,  of  course,  no  comparison  between  a  pure  lithic  acid  or  oxalate  of 
lime  stone  on  the  one  hand  and  an  alternating  stone  with  a  good  deal 
of  phosphate  or  urates  in  its  composition,  as  a  test  of  skill  and 
endurance  both  on  the  part  of  the  surgeon  and  his  instruments. 
Dr.  Hingston,  of  Montreal  (Intern.  Encycl.  of  Surg.,  vol.  vi.  p.  311),  in 
his  article  on  Lithotrity,  points  out  that  sometimes  the  apparent  softness 
of  a  stone  is  most  misleading. 

Having  found  an  enormous  stone  in  a  patient,  he  employed  lithotrity,  as  the  stone 
seemed  soft.  After  getting  awaj'  a  large  quantity  of  phosphatic  matter,  lie  was  driven 
to  perform  lithotomy,  and  removed,  by  the  lateral  method,  a  calculus  weighing  over  5  oz. 
consisting  mainly  of  oxalate  of  lime  and  uric  acid. 

There  are  several  other  fallacies  in  gauging  the  size  and  number  of 
calculi.  Thus  the  lithotrite  may  again  and  again  seize  a  stone  which 
only  weighs  £  oz.  in  its  long  diameter,  if  flattened,  of  two  inches. 
Testing  by  passing  a  staff  around  or  rubbing  it  over  a  calculus  is  often 
most  fallacious,  and  examining  per  rectum  may,  if  the  bladder  be 
thickened,  give  evidence  of  a  stone  apparently  much  larger  than  it 
really  is.  Mr.  Cadge  (loc.  supra  cit.)  points  out  a  fallacy  with  regard 
to  multiple  stones.  "  When  more  than  one  stone  is  present,  it  is  cus- 
tomary to  seize  one,  fix  it  in  the  instrument,  and  proceed  to  sound 
afresh;  this,  however,  may  mislead,  for  a  stone,  having  been  grasped 
by  the  tips  of  the  blades  and  moved  about  in  the  bladder,  will  some- 
times rotate  a  little  in  the  blades  of  the  lithotrite  and  communicate  a 
grating  feel  to  the  hand  which  is  very  like  touching  a  second  stone." 

3.  Condition  of  the  urethra. — Two  points  have  to  be  considered 
here — (a)  how  far  will  the  urethra  admit  instruments — i.e.,  how  far  is 
its  canal  normal  or  diminished  by  stricture;  (b)  how  far,  even  if  normal 
in  calibre,  will  the  urethra  tolerate  instruments.  With  regard  to  the 
first,  a  stricture,  if  admitting  of  dilatation,  is  not  an  obstacle  to  litho- 
trity ;  on  the  other  hand,  an  old  stricture  with  surrounding  induration 
and  fistulas,  or  a  less  severe  form  which  produces  rigors  and  fever  at 
each  attempt  of  dilatation,  are  best  submitted  to  lithotomy,  which 
gives  the  best  chance  for  the  stone,  and  at  the  same  time  offers  the 
much-needed  relief  of  rest  to  the  stricture.  Mr.  Cadge  gives  the 
following  practical  hint  in  these  cases  of  stone  combined  with  stricture: 
"  Sometimes  a  stone  is  detected  in  the  urethra  behind  the  stricture,  as 
well  as  one  or  more  in  the  bladder,  or  it  may  be  partly  in  the  bladder 
and  partly  in  the  urethra,  and  in  these  cases  median  lithotomy  will 
not  only  remove  the  stone,  but  may  go  far  to  remedy  the  stricture  by 
external  division. " 


LITHOTRITY.  -LITHOLAPAXY.  635 

With  regard  to  an  irritable  urethra — i.e.,  our  without  ;i  stricture  and 
only  admitting  instruments  with  the  aid  of  anesthetics — the  chief 
points  to  consider  are  the  size  of  the  stone  and  the  ability  of  the 
Burgeon   to  deal   with   it  by  Litholapaxy.     It*  the  calculus  cannot  he 

evacuated  at  once,  or  requires  more  than  one  Bitting,  lithotomy  should 
be  preferred,  owing  to  the  results  of  the  passage  of  Instruments  and 
prolonged  voiding  of  fragments. 

4.  Condition  of  the  prostate. — An  enlarged  prostate  is  of  great 
importance,  not  only  from  its  power  of  obstructing  the  operation, 
but  from  the  changes  which  it  brings  about  in  the  bladder.  Thus, 
it  interferes  with  the  efficient  use  of  instruments,  the  picking  up  of  a 
stone  even  with  the  blades  reversed,  and  the  finding  of  the  last 
fragment.  Again,  the  use  of  the  lithotrite  and  the  passage  of 
evacuating  tubes  readily  lead  to  haemorrhage,  and  this  again  by  clots 
prevents  the  free  and  easy  use  of  the  evacuator.  Later  on,  phosphatic 
deposit,  imperfect  evacuation,  residual  urine,  and  recurrence  of  stone 
symptoms  are  all  frequent  accompaniments  of  enlarged  prostate. 

5.  Condition  of  the  bladder. — Formerly  it  was  held  needful  to 
operate  with  several  ounces  of  fluid  in  the  bladder,  and  some  suggested 
to  draw  off  the  urine  and  inject  8  or  10  oz.  of  fluid.  This  amount  has 
now  been  reduced  to  something  more  like  4  or  6  oz.  As,  if  the  urine 
is  healthy,  no  fluid  is  more  suited  to  the  bladder,  the  surgeon  should 
content  himself  with  following  Sir  H.  Thompson,  and  "ask  the  patient  to 
retain  his  urine  for  a  little  less  than  his  accustomed  period  before  the 
sitting  ;  that  is,  if  he  is  naturally  able  to  retain  his  urine  for  about  an 
hour,  he  is  requested  to  pass  it  forty  minutes  before  the  time  of  the  visit." 

Some  other  changes*  in  the  bladder  require  mention,  (a)  Saccula- 
tion pouches  or  sacs,  whether  mere  hollows  behind  or  at  the  sides  of 
an  enlarged  prostate,  or  hernial  protrusion  of  the  mucous  membrane 
between  the  muscular  fibres,  may  be  the  starting-point  of  calculus 
by  entangling  debris  or  tiny  fragments.  In  Mr.  Cadge's  words:  "The 
imprisoned  fragment  first  fills  up  the  cyst,  then,  by  continual  accretion 
of  phosphates,  it  grows  up  into  the  bladder  like  a  mushroom,  and  is 
probably  again  and  again  nibbled  off  by  the  lithotrite,  each  time  with 
temporary  benefit,  until  the  patient  dies,  worn  out  with  chronic  cystitis 
and  pyelitis."  Mr.  Cadge  goes  on  to  say  :  "  By  turning  the  aperture 
of  the  evacuating  catheter  towards  these  pouches,  and  by  the  free  use 
of  the  aspirator  in  all  directions,  the  fragments  may  be  washed  out  of 
them  and  all  removed,  but  it  cannot  be  denied  that  it  is  always  a 
serious  matter  to  shatter  a  stone  into  innumerable  fragments  in  a 
bladder  of  this  description."  (b)  Atony,  whether  with  or  without 
an  enlarged  prostate.  The  importance  of  this  is  obvious,  as  tending  to 
recurrence  of  stone  by  some  small  fragments  not  being  expelled  in 
spite  of  the  vigorous  use  of  the  aspirator,  and  also  to  cystitis  from 
imperfect  emptying  of  the  bladder. 


*  Several  allied  conditions  exist  in  which  the  position  of  the  stone  is  complicated  with 
difficulties— e.g.,  (i)  where  the  stone  has  been  partly  in  the  bladder  and  partly  in  the 
urethra.  (2)  The  stone  has  been  lodged  entirely  or  partly  in  a  diverticulum  of  the  bladder. 
(3)  The  stone  has  been  lodged  in  a  deep  pouch  behind  the  prostate.  For  helpful  informa- 
tion on  these  and  many  other  points  I  would  advise  my  readers  to  consult  Mr.  H.  Milton's 
paper  on  "  Lithotrity  in  Cases  of  Stone,  Simple  and  Complicated,"  Lancet,  April  and  May, 
1896. 


636  OPERATIONS   ON    THE   ABDOMEN. 

6.  Condition  of  the  kidneys. — Here  I  may  again  quote  a  veteran's 
opinion,  that  of  Mr.  Cadge  :  "  What  is  to  he  said  of  stone  complicated 
with  kidney  disease,  such  as  albuminuria  and  chronic  pyelitis  and 
atrophy  ?  In  these  cases  all  operations  arc  fraught  with  danger,  hut  it 
is  probable  that  the  least  danger  will  he  met  with  from  a  carefully 
conducted  one-sitting  Hthotrity.  So,  too,  in  those  cases  of  constitutional 
disease  combined  with  stone,  such  as  diahetes,  tahes,  and  other  spine 
disease,  it  will  be  well  to  avoid  the  shock  and  haemorrhage  of  lithotomy, 
and  proceed,  if  any  surgical  proceeding  is  allowable,  by  Hthotrity." 
The  surgeon,  in  considering  an  operation  in  any  of  the  above  diseases, 
will  weigh  well  the  size  of  the  stone,  his  ability  to  cope  with  it  at 
one  sitting,  and  the  amount  of  suffering  which  it  causes  the  patient. 

7.  Age. — Here,  especially,  age  is  not  to  be  reckoned  by  years 
alone. 

Recurrence. — As  no  one,  to  my  knowledge,  has  spoken  out  on  this 
subject  with  such  helpful  candour  as  Mr.  Cadge,  with  his  experience  of 
300  cases  of  stone,  I  make  no  apology  for  quoting  once  more  from  his 
writings  (Brit.  Med.  Journ.,  July  3,  1886)  :  "Although  the  immediate 
and  direct  mortality  of  Hthotrity  is  small,  the  recurrence  of  stone 
is  lamentably  frequent.  In  my  own  list  of  133  cases,  there  were 
eighteen  in  which  recurrence,  one  or  more  times,  took  place,  being 
about  one  in  seven.  Sir  H.  Thompson,  with  a  much  larger  number 
of  cases,  gives  about  the  same  proportion.  I  am  disposed  to  infer, 
however,  that  recurrence  is  more  frequent  even  than  this,  because  it  is 
not  likely  that  all  who  get  relapse  apply  to  the  same  surgeon  again. 
Living,  as  I  do,  in  a  local  centre,  and  drawing  cases  chiefly  from  a  limited 
area,  I  am  probably  more  able  to  trace,  and  more  called  on  to  treat  those 
who  suffer  a  second  and  third  time,  than  he  who  lives  in  the  metropolis 
and  draws  his  cases  from  great  distances.  Patients  may,  and  frequently 
do,  apply  to  the  same  operator  once  or  twice  ;  but,  after  a  time,  they 
either  apply  to  their  own  surgeon,  or  they  decline  further  treatment,  and 
too  often  their  subsequent  history  is  one  of  painful  endurance  of  chronic 
bladder  disease  and  gradual  exhaustion.  If,  moreover,  there  be  added 
to  the  list  those  numerous  cases  of  phosphatic  deposit  or  concretions  so 
frequently  noticed  after  Hthotrity,  the  relapses  would,  I  believe,  reach  to 
nearly  20  per  cent.  This  seems  a  heavy  indictment  to  bring  against 
Hthotrity,  but  I  am  afraid  there  is  no  gainsaying  it;  and,  if  so,  it  would 
be  wrong  to  pass  it  over  or  make  light  of  it.  Many  of  these  relapses 
might  be  prevented  if  the  patients  would  observe  directions  and  per- 
severe with  treatment.  It  certainly  is  so  with  the  unenlightened  and 
uncomplaining  hospital  patient.  Feeling  himself  well,  or  what  he 
considers  well,  he  goes  to  his  work,  and  neglects  the  use  of  the  catheter 
and  other  means;  and,  instead  of  returning  in  a  month  or  so  to  have 
his  cure  certified,  or  a  minute  remaining  fragment  removed,  he  toils 
away  as  long  as  he  can,  and  returns,  perhaps  in  a  year  or  two,  with  a 
fresh  uric-acid  stone,  or  with  chronic  cystitis  and  a  phosphatic  one. 
The  educated,  sensitive  private  patient,  on  the  other  hand,  will  watch 
his  symptoms  narrowly,  and   return   if  the  slightest  indication  of  the 

old  mischief  should  reappear This   frequent  recurrence  must 

be  due  either  (I)  to  the  descent  of  a  fresh  stone  from  the  kidneys, 
or  (2)  to  a  fragment  of  stone  having  been  left  at  the  first  operation.  As 
to  the  descent  of  a  fresh  stone  :  there  can,  of  course,  be  no  doubt  as  to 


LITHOTRITY.— LITHOLAPAXY.  637 

the  occasional  occurrence  of  this  cause,  just  as  we  see  it  occur  after 
lithotomy.  The  bladder  being  entirely  cleared  of  stone,  there  will  be 
the  same  liability  to  the  descent  of  :i  fresh  renal  calculus  after  one 
operation  as  after  the  other.  What  then,  let  me  ;isk,  is  the  fact  as 
to  lithotomy?  I  have  already  shown  that  there  were  only  _:i  cases 
out  of  more  than  IOOO  of  lithotomy  at  the  Norwich  Hospital  in 
width  recurrence  was  clearly  traced  to  perfectly  fresh  formations, 
coming,  like  the  first,  from  the  kidney,  or  about  one  in  fifty  ;  whereas, 
in  Sir  II.  Thompson's  list  of  about  600  persons  treated  by  lithotrity,  he 
mentions  61  cases  in  which  he  operated  twice;  nine,  three  times; 
three,  four  times,  and  two,  five  times — seventy-five  in  all,  or  about 
one  in  eight.  The  inference  from  these  data  seems  to  me  to  be 
inevitable,  that  relapse  of  stone  after  lithotrity  is  chiefly  due  to  other 
causes  than  the  descent  of  a  fresh  stone.  To  my  thinking  the  majority 
of  recurrences  is  caused  by  the  great  difficulty  in  ensuring  the  complete 
removal  of  all  the  debris  ;  I  have  already  referred  to  this  in  old  persons 
with  enlarged  prostates  and  feeble  atonic  bladders,  and  it  is  this  class 
of  patients  who  are  especially  liable  to  relapse."  Mr.  Cadge  goes  onto 
show  that  the  tendency  to  phosphatic  deposit  after  lithotrity  is  not  due 
to  vesical  incompetence  and  residual  urine  alone  without  some  over- 
looked fragment,  and  that  the  improved  method  with  repeated  washings 
will  still  fail  to  discover  a  last  fragment  in  some  bladders.  At  the 
present  time  the  cystoscope  and  the  evacuating  lithotrite  should  do  much 
to  prevent  fragments  from  being  overlooked  and  left  in  the  bladder. 

More  recently  Mr.  Reginald  Harrison  has  given  {Lancet,  Nov.  12, 
1899)  an  analysis  of  no  operations  for  stone,  101  of  which  were  litho- 
lapaxies.  Recurrence,  necessitating  further  operation,  took  place 
twenty-three  times,  i.e.,  in  nearly  23  per  cent.,  a  considerably  greater 
proportion  than  Mr.  Cadge  gives.  In  all  but  one  case  the  recurrence 
was  associated  with  enlarged  prostate.  Mr.  Harrison  considers  that 
this  is  accounted  for  in  several  ways,  partly  by  the  fact  that  debris  may 
he  left  behind  in  sacs  and  pouches  at  the  time  of  operation,  and  partly 
owing  to  the  inability  to  completely  empty  the  bladder  later,  so  that 
fresh  stones  descending  from  the  kidneys  are  retained  while  other 
foreign  bodies,  such  as  shreds  and  sloughs  from  an  inflamed  bladder, 
may  form  nuclei  for  the  formation  of  fresh  stones.  With  a  view  to 
preventing  recurrence  in  these  cases,  the  author  lays  great  stress  on 
the  importance  of  thorough  washing  out  at  the  time  of  operation,  also 
once  a  week  for  three  or  four  months  after  the  operation,  and  also  of 
the  adoption  of  measures  aiming  at  the  reduction  of  the  size  of  the 
prostate.  At  the  present  day  it  is  best  to  enucleate  the  prostate 
(unless  there  is  some  grave  contra-indication)  and  thus  remove  the 
cause  of  the  stone-formation  and  recurrence. 

Operation  (Figs.  249 — 251). — The  preparatory  treatment  has  been 
much  simplified.  It  is  now  recognised  that  the  best  course  is  to  remove 
the  stone  at  once:  previous  passage  of  sounds,  and  injections  of  the 
bladder,*  are  now  but  little  used.  A  few  days'  rest,  bland,  unirri- 
tating  liquid  diet,  urotropine  if  there  is  cystitis,  mild  aperients,  and 
securing  sleep  are  the  chief  indications. 

The    instruments    required    will    be    gathered    from    the    following 

*  The  amount  of  urine  to  be  held,  in  most  cases,  has  already  been  mentioned  (p.  635). 


638 


OPERATIONS   ON   THK   A.BDOMEN. 


Fig 


account:  The  patient  having  been  anaesthetised  and  lying  on  a  firm 
couch  or  mattress  close  to  the  right  side  of  the  bed  or  table,  with  his 

pelvis  raised,  and  the  body  and  limbs  well  protected  from  chill,  the 
surgeon,  standing  on  the  right  side  with  bis  instruments  close  to  him, 
introduces  his  sterilised  lithotrite.  In  doing  this  care  must  be  taken 
not  to  get  the  blades  bitched   either  just  in  front  of  the  triangular 

ligament  or  in  the  roof  of  the 
prostatic  urethra.  This  will  be  se- 
cured by  not  depressing  the  instru- 
ment till  very  late — in  fact,  not  till 
it  is  just  about  to  enter  the  bladder. 
The  instrument,  well  warmed  and 
oiled,  is  held  at  first  horizontally 
over  the  groin  or  abdomen,  the  penis 
being  drawn  over  it,  tbe  shaft  being 
all  the  time  gradually  brought  into 
the  vertical  position  as  the  instru- 
ment finds  its  way  by  its  own  weight 
into  the  bulbous,  membranous,  and 
prostatic  urethra.  Now,  and  not 
before,  the  handle  is  somewhat  de- 
pressed, and  the  instrument  glides 
quickly  into  the  cavity  of  the  bladder. 


Lithotrity,  showing  the  position  of  the  lithotrite,  during  introduction, 
grasping  the  stone  and  crushing.     (Heath.) 

If  the  prostatic  urethra  is  enlarged  and  lengthened,  the  surgeon  may 
think  that  he  has  reached  the  bladder,  but  the  fact  that  the  gentlest 
lateral  movement  of  the  lithotrite  is  interfered  with  will  show  him 
his  mistake.  Pressure  with  the  instrument  is  alone  allowable  at  the 
meatus;  some  rotation  may  be  called  for  in  guiding  the  instrument 
through  tbe  triangular  ligament  or  past  an  enlarged  prostate.  In  this 
latter  case  also  the  handles  must  be  further  depressed,  and  a  finger  in 
the  rectum  may  give  help. 


LITHOTRITY.—LITHOLAPAXY.  639 

When  the  lithotrite  1ms  entered  the  bladder  it  should  be  allowed  to 
slide,  very  gently,  down  the  trigone,  being  now  held  very  Lightly  so  as 

at  once  to  detect  the  site  of  the  stone,  which  it  now  often  touches,  but 

mUSl   not  displace. 

If  the  stone  is  felt  on  one  side,  the  instrument  is  gently  turned  to 
the  opposite  one,  opened,  and  then  turned  towards  the  stone.  If  it  be 
not  felt,  the  handle  of  the  instrument  being  slightly  raised,  and  the 
blades  very  gently  depressed  and  then  opened,  the  stone  will  often 
drop  into  them. 

If  this  fail,  the  instrument  is  turned,  open,  first  obliquely,  then  more 
horizontally,  first  to  the  one  side,  then  to  the  other.  In  the  event  of 
the  stone  still  eluding  the  lithotrite,  which  is  most  unlikely,  it  should  be 
sought  for  with  blades  depressed.  To  effect  this,  the  blades,  closed, 
are  raised  off  the  bladder  floor  by  depression  of  the  handle,  carefully 
reversed,  and  then  depressed  again  so  as  to  sweep  lightly  over  the  floor. 
They  are  then  gently  opened  and  closed,  vertically  first  and  then 
obliquely,  so  as  to  complete  the  examination. 

During  the  above,  the  following  points  must  ever  be  borne  in  mind  : 

(a)  The  handle  and  shaft  of  the  lithotrite  are  to  be  kept  as  steady  as 
possible,  so  as  not  to  jar  the  sensitive  neck  of  the  bladder  needlessly. 
(b)  All  movements  are  to  be  executed  at  or  beyond  the  centre  of  the 
vesical  cavity,  the  proper  area  of  operating,  without  hurry,  rapid  move- 
ment* or  any  other  which  partakes  of  the  nature  of  a  jerk  or  concussion 
(Sir  H.  Thompson,  loc.  supra  cit.,  p.  296).  (c)  The  male  blade  is  never 
to  be  brought  into  contact  with  the  neck  of  the  bladder,  unless  this  is 
rendered  necessary  by  the  position  of  the  stone. 

The  stone  being  seized  by  one  of  the  above  manoeuvres,  the  button! 
moved,  and  the  screw  connected — the  screw  is  gradually  turned  at  first 
to  make  the  jaws  bite,  since  a  sharp  turn  at  this  time  may  drive  the 
stone  out  either  to  right  or  left — the  calculus  is  then  carried  to  the 
centre  of  the  cavity,  which  will  show  whether  a  fold  of  mucous 
membrane  has  been  seized  (Fig.  250).  As  the  screw  is  applied  more 
and  more  forcibly,  one  or  other  of  the  following  will  be  noticed.  If 
not  well  caught,  and  if  hard,  the  stone  will  be  pushed  out  of  the  jaws  ; 
if  hard  and  well  gripped,  it  is  felt  to  split  into  fragments;  if  soft,  and 
held,  it  crumbles  down.  If  extremely  hard,  as  a  pure  lithic  acid  or 
oxalate,  any  attempt  at  advancing  the  screw  is  met  by  this  distinctly 
recoiling  instead  of  advancing.  Each  surgeon  must  now  decide  for 
himself,  according  to  his  knowledge  of  his  instruments  and  reliance  on 
his  power  to  deal  with  large,  hard  fragments,  whether  to  continue  or  at 
once  to  perform  lithotomy.  If  he  continue,  the  resistance  will  be  felt 
to  give  way,  in  the  case  of  a  very  hard  stone,  by  a  sudden  sharp  crack ; 
in  one  less  hard,  more  gradually.  If  the  stone  does  not  crack,  Freyer 
(loc.  supra  cit.)  advises  that  the  lithotrite  be  unscrewed,  the  stone  caught 
in  another  axis,  and  the  lithotrite  again  screwed  home.  By  repeating 
this,  if  necessary,  the  stone  will  usually  at  last  give  way.     The  same 

*  "  Rapid  movements  produce  currents  which  keep  the  stone  more  or  less  in  motion, 
so  that  it  is  less  easily  seized  than  when  the  surrounding  fluid  is  in  a  state  of  rest" 
(Thompson). 

t  In  this  respect  Prof.  Bigelow's  lithotrite  seems  inferior  to  Sir  H.  Thompson's,  the 
working  of  the  button  in  the  latter  being  smoother  and  less  vibrating. 


f>4<> 


OPERATIONS   ON    THE    AJBDOMEN. 


Burgeon  also  recommends  that  in  dealing  with  stones  which  nre  more 
or  loss  round  and  so  Large  that  the  lithotrite  will  not  lock  in  any 
direction,  the  jaws  of  the  instrument  should  be  dug  into  one  side  of 
the  stone  and  screwed  up,  a  portion  of  the  crust  being  thus  broken  oft", 
liv  repeating  this  a  number  of  times,  sufficient  reduction  in  size  will 
take  place  to  allow  of  the  lithotrite  being  locked  on  the  stone.  In 
overcoming  much  resistance  the  surgeon  either  screws  up  the  male 
blade  as  hard  as  he  can  and  keeps  it  so,  or,  having  gently  unscrewed  it 
a  little,  screws  it  up  again  with  a  series  of  light  jerks  so  as  to  commu- 
nicate blows  to  the  stone.  Cracking  of  the  stone  having  taken  place, 
the  fragments  will  usually  fall  close  to  the  original  site.  Thus  the 
lithotrite  has  only  to  be  kept  as  immovable  as  possible  to  ensure,  on 

Fig.  250. 


B        L     S         EL* 

This  shows  a  risk  presenl  in  operating  in  trabeculated  bladders.  While  the 
female  blade  (L)  is  in  direct  contact  with  the  stone  (S),  the  male  (L*)  is  in 
contact  with  a  ridge  of  the  mucous  membrane  (E).     B,  Bladder.     1'.  Prostate. 

(It.  Harrison.) 

drawing  out  and  again  closing  the  male  blade,  the  seizure  of  a  frag- 
ment.* This  is  crushed,  and  the  process  repeated  again  and  again 
till  sufficient  debris  is  formed.  The  lithotrite  is  then  withdrawn 
firmly  screwed  up. 

A  straight  or  curved  evacuating  tube,  No.  16  for  a  stone  of  moderate 
size,  and  18  for  a  large  one,  is  then  introduced,  the  evacuator,  filled  with 
a  warm  solution  of  boracic  acid  or  dilute  Thompson's  fluid  (p.  623),  is 
connected,  the  meatus  being  first  incised  with  a  narrow  probe-pointed 
bistoury  downwards  by  the  side  of  the  fnenuni,  if  needful.  The  tuhe, 
if  curved,  should  be  held  downwards  at  first,  bill  nol  quite  on  the 
bladder  floor;  then  to  one  side  or  the  other;  then  upwards,  washings 
being  carried  on  at  the  time  that  these  movements  are  made.     A  straight 

*  It  is  not  always  easy  to  distinguish  between  a  piece  of  soft  stone  enveloped  in 
inspissated  mucus  and  the  lining  membrane  of  the  bladder. 


LITHOTRITY.— LITHOLAPAXY. 


6  1 1 


tube  should  lie  with  its  orifice  just  within  the  neck  of  the  bladder. 
Dr.  Keyes  (Inimi.  Encycl.  of  Surg,,  vol.  vi.  p.  244)  gives  this  pre- 
caution as  to  getting  rid  of  air  entirely:  "  The  urine,  having  trickled 
away  through  the  tube,  leaves  the  latter  full  of  air,  an  element  fatal  to 
nicety  of  washing.  This  air  may  be  disposed  of  most  simply.  Thetube 
is  withdrawn  until  its  eye  is  in  the  prostatic  sinus,  the  washing-bottle 
is  attached,  and  the  stop-cock  turned,  but  no  further  suction  made.  In 
an  instant,  the  air  contained  in  the  tube  is  heard  ascending  through  the 
stop-cock  and  mounting  into  the  top  of  the  evacuator,  where  it  does  no 

Fig.  251. 


Sir  II.  Thompson's  aspirator,  last  pattern  but  one.     (Freyer.)* 

harm,  and  whence  it  cannot  possibly  return  into  the  bladder."  While 
his  left  hand  supports  the  evacuator,  with  his  right  the  surgeon  gently 
but  quickly  squeezes  the  bag  with  sufficient  force  to  send  in  about  two 
ounces  of  fluid.     On  relaxing  the  pressure  an  outward  current  takes 


*  Of  this  instrument  Dr.  Freyer  writes  (Litholapaxy,  p.  25)  :  "  I  must  confess  a  great 
liking  for  Thompson's  instrument.  One  of  this  variety  made  for  me  by  Messrs.  Weiss 
I  have  worked  with  for  four  years,  and  though  it  has  assisted  at  130  operations,  and 
been  through  three  hot  weathers  in  the  plains  of  India,  it  is  still  as  efficient  as  much 
newer  instruments  I  possess,  a  fact  which  speaks  well  for  the  india-rubber  employed  in 
its  construction." 


S. VOL.  II. 


41 


642 


OPERATIONS  ON  THE  ABDOMEN. 


place,  bringing  with  it  crushed  fragments.  Sir  II.  Thompson  recom- 
mends that,  after  the  hug  lias  expanded  and  the  current  apparently 
ceased,  the  surgeon  should  wait  a  lew  seconds,  "as  at  that  precise  time 
it  is  quite  common  for  one  or  two  of  the  larger  fragments  to  drop  into 
the  receiver  which  would  have  been  driven  hack,  perhaps,  by  too  rapidly 
resuming  the  pressure." 

If,  after  several  washings,  the  outflow  stops,  and  the  hag  no  longer 
expands,  the  end  of  the  evacuator  is  hlocked  either  by  a  fragment  of 
stone,  or  a  small  calculus,  a  clot  of  hlood,  or  the  mucous  membrane  of 
the  bladder.     If  it  he  a  fragment,  as  is  usually  the  case,  or  a  clot, 


Fig.  252.* 


The  operator  is  here  supposed  to  be  Bitting  between  the  thighs 
of  the  patient.  The  expansion  of  the  compressed  bulb  will  aspirate 
apart  of  the  abundant  debris  suspended  in  the  fluid.  The  frag- 
ments, being  too  abundant,  have  been  dispersed.     (Bigelow.) 

dislodgment  may  he  effected  by  sending  in  quickly  a  gush  of  fluid,  or 
by  the  use  of  a  gum-elastic  stylet,  after  unscrewing  the  tube.  Impact 
of  the  bladder  generally  takes  place  when  a  curved  evacuator  is  turned 
upwards,  and  when  the  bladder  is  empty.  The  sensation  given  maybe 
a  kind  of  flap,  simulating  the  click  of  a  fragment  ;  more  often  it  is  a 
dull,  vihrating  thud,  easily  recognised.  More  fluid  must  be  at  once 
injected. 

If  a  large  fragment  is  felt  striking  against  the  tube,  or  if  the  surgeon 
is  certain  that  several  good-sized  fragments  remain,  he  removes  the 
tube  and  evacuator,  and,  while  an  assistant  withdraws  the  blood-stained 
fluid  and  fragments,  and  recharges  the  evacuator,  he  introduces  a  small 


*  The  above  evacuator  is  now  old-fashioned.    .Mr.  Guiding  Bird's  pattern,  or  the  one 
figured  at  \>.  641.  will  be  found  the  most  handy. 


LITHOTRITY.— LITHOLAPAXY.  643 

lithotrite  and  crushes  up  sufficient  debris  to   go   on   again  with    the 
washings. 

All  the  time  the  surgeon  must  keep  before  his  eyes  a  mental  picture 
of  the  interior  of  the  bladder,  perhaps  diseased,  the  ureters,  perhaps 
dilated,  Leading  up  to  kidney  pelves  enlarged,  and  remember  that  the 
effects  of  any  squeeze  of  his  hands  are  felt,  not  only  all  over  the  bladder, 
but  perhaps  in  the  ureters  and  kidneys  as  well. 

Detection  and  Seizure  of  the  Last  Fragment. — This  is,  as  is  well 
known,  a  matter  of  much  difficulty,  owing  to  the  facility  with  which 
small  fragments  get  hidden  in  some  folds  of  mucous  membrane  or 
enveloped  in  blood-clot.  As  long  as  there  is  any  "clicking"  against 
the  tube,  the  surgeon  must  persevere  in  his  attempts  at  complete  re- 
moval. If,  after  several  washings,  nothing  comes  out  into  the  receiver, 
the  surgeon  should  listen  carefully  over  the  bladder,  as  thus  advised  by 
Dr.  Keyes  :*  "  The  tube  is  turned  in  various  positions,  and  the  operator 
listens.  The  swish  of  the  water  as  it  rushes  in  and  out  is  heard  with 
startling  distinctness,  and,  if  the  management  of  the  tube  is  skilful,  any 
fragment  of  stone  lying  loose  in  the  bladder  is  sure  in  a  short  time  to 
be  driven  against  the  metallic  tube  so  as  to  announce  its  presence  by 
a  characteristic  click,  quite  distinct  from  that  emitted  by  the  flapping 
of  the  bladder  wall  against  the  eye  of  the  instrument.  Fine  sand  and 
thin  scales  of  stone  make  no  sharp  click,  and  all  such  may  be  left  to 
pass  by  Nature's  efforts,  but  any  piece  large  enough  to  require  the 
lithotrite  can  hardly  escape  detection  by  the  educated  ear." 

Time  occupied  in  Litholapaxy . — This  may  be,  on  an  average,  from 
half  an  hour  to  an  hour  and  a  half.  Prof.  Bigelow  (Amer.  Journ.  Med. 
Sci.,  January,  1878)  operated  continuously  for  upwards  of  three  hours, 
removing  744  grains,  the  patient  making  a  good  recovery.  Mr.  R. 
Harrison  (Brit.  Med.  Journ.,  Aug.  10,  1882)  removed  a  two  and  a  half 
ounce  stone  in  two  hours  and  ten  minutes  (vide  also  p.  633). 

The  Old  and  the  New  Operation  of  Lithotrity  briefly  contrasted. — 
Old  lithotrity  advocated  short  sittings,  and  brief  use  of  instruments, 
and  left  the  expulsion  of  fragments,  &c,  as  much  as  possible  to  Nature. 
It  probably  requires  less  skill,  and,  in  Mr.  Cadge's  words,  "  is  gentler, 
milder,  less  formidable  altogether;  no  anaesthetic  is  probably  required; 

no  extra  assistance A  nervous,  timid  patient  may  prefer  this  to 

the  more  heroic  and  rougher,  if  more  expeditious,  method."  It  might 
be  added  that  it  is  less  tiring  to  the  surgeon.  But  these  advantages 
are  trifling  as  compared  with  its  disadvantages,  which  are  done  away 
with  by  the  new  operation,  of  which  the  chief  are  the  prolonged  passage 
of  fragments,  often  rough  and  angular,  along  a  bruised  urethra.  Mr. 
Milton  (loc.  supra  cit.)  has  invented  an  evacuating  lithotrite — a  com- 
bination of  the  usual  crushing  and  evacuating  instruments,  which  will 
be  useful  in  the  aged,  with  a  moderate  sized  and  soft  stone  and  enlarged 
prostate,  from  the  single  introduction  required.  Moreover,  the  last 
fragments  are  sucked  towards  the  jaws  of  the  lithotrite  and  are  there- 
fore far  more  easily  seized  and  crushed  if  they  are  too  large  to  enter 
the  evacuating  tube. 

The  new  method  of  litholapaxy,  introduced  by  Prof.  Bigelow,  resulted 

*  Loc.  supra  cit..  p.  246.  The  whole  of  this  account,  with  its  vigorous  life-like  language, 
will  well  repay  perusal. 

41 — 2 


644  OPERATIONS    ON    TIIK    AI'.DOMKN. 

from,  and  was  led  up  to  by,  several  achievements  of  modern  surgery. 
"Without  anaesthetics,  without  the  knowledge  of  the  large  instruments 
admitted  by  the  urethra,  without  the  pitch  of  perfection  and  power  to 
which  modem  instruments  have  been  brought,  litholapaxy  would  still 
be  an  impossibility.  Owing  to  its  brilliant  success,  and  the  rapidity 
with  which  it  relieves  the  patient,  the  single-sitting  method  has 
practically  rendered  the  other  obsolete. 

After-treatment. — The  chief  points  here  are  :  rest  in  bed,  the  patient 
turning  on  his  side  to  pass  water,  for  the  first  few  days;  hot  fomenta- 
tions to  the  abdomen,  and  hot  bottles  at  first;  morphia  subcutaneously, 
if  indicated  ;  warm  milk,  barley-water,  mineral  waters  or  lemonade,  a 
little  whisky  or  brandy  being  given,  if  needful;  all  chills  should  be 
carefully  avoided.  Mr.  Milton  {loc.  supra  cit.)  recommends  salicylate 
of  soda  at  first  every  two  and  then  every  four  hours  if  there  is  fever, 
and  diuretin  if  there  is  diminution  of  urine.  In  each  case  the  amount 
given  is  one  gramme.  If  cystitis  is  present,  urotropine  in  doses  of  5  to 
10  grs.  thrice  daily  should  be  given. 

In  addition  to  the  above,  the  putting  the  patient  frequently  in  hot 
hip-baths  for  a  quarter  of  an  hour,  the  occasional  passage  of  a  soft 
catheter,  and  the  rendering  the  urine  alkaline,  will  give  much  relief. 
The  urine  should  always  he  strained  through  muslin  to  collect  the 
debris. 

It  is  advisable  also  to  once  more  thoroughly  wash  out  the  bladder 
with  the  evacuator  a  week  after  the  operation,  as  a  safeguard  against 
recurrence  from  small  fragments  left  behind  at  the  time  of  operation. 
Where  there  is  any  obstruction,  such  as  an  enlarged  prostate,  Mr. 
Harrison  recommends  frequent  washings  over  a  prolonged  period  {vide 
supra,  p.  637). 

Complications  during  Lithotrity  and  Litholapaxy. 

1.  Escape  of  Urine. — This  may  take  place  during  or  after  the 
passage  of  the  lithotrite.  The  penis  should  he  compressed  against  the 
lithotrite,  and  a  pause  made  while  the  patient  is  got  more  fully  under 
the  anaesthetic.  If  this  fail,  tying  a  tape  round  the  penis  and  instru- 
ment, injecting  a  little  fluid,  or  putting  off  the  operation  till  the  bladder 
is  in  a  more  fitting  slate  after  the  use  of  instruments,  injections,  and 
such  drugs  as  belladonna  and  subcutaneous  injections  of  morphia,  may 
be  made  use  of.  2.  Haemorrhage. — Sufficient  blood  to  stain  the  fluid 
in  the  evacuator  during  the  operation,  and  the  urine  for  a  day  or  two 
after  it,  is  not  uncommon,  [f  the  haemorrhage  during  the  operation  is 
severe,  the  surgeon  must  decide  whether  it  is  due  to  the  damage  to  the 
bladder  or  urethra,  to  his  having  scratched  the  latter  by  withdrawing  a 
fragment  in  the  evacuator's  eye,  to  bruising  of  an  enlarged  prostate,  or 
to  co-existent  growth.  In  this  last  case  the  supra-pubic  operation 
will  probably  have  to  be  performed  either  at  the  time  or  later;  in  the 
other  cases  the  surgeon  must  decide  on  completing  or  deferring  the 
crushing  by  the  amount  he  has  already  effected,  his  experience,  and 
the  amount  of  the  bruising  inflicted.  3.  Clogging  or  Fracture  of  the 
Lithotrite. — Clogging  or  impaction  is  liable  to  happen  with  a  non- 
fenestrated instrument  with  weak  and  narrow  blades.  With  one  pro- 
perly made,  with  as  broad  blades  as  possible,  and  the  male  one  blunt, 
roughened,  and  laterally  bevelled  off,  the  accident  is  unlikely.     When 


PERINEAL    LITHOTRITY.  645 

it  occurs,  it  must  be  met  by  percussing  the  instrument,  if  opening  and 
closing  the  blades,  and  thus  freeing  them  in  the  fluid,  is  impossible. 
If  the    impaction    persist,   the  blades    must  be   withdrawn  as  far  as 

possible  by  safely  maintained  traction.  If  no  force  that  is  wise  will 
withdraw  them,  they  should  be  cut  upon  in  the  perinseum,  thrust  out, 
unloaded,  and  withdrawn,  and  the  rest  of  the  stone  removed  as  by 
a  median  lithotomy.  If,  owing  to  any  defect  in  the  instrument,  the 
blades,  though  not  clogged,  cannot  be  screwed  up,  they  must  be  cut 
upon  as  above,  thrust  through,  and,  if  possible,  filed  off.  If  a  blade 
break  off,  it  must  either  be  caught  and  withdrawn  by  another  litho- 
trite,  or  the  patient  cut  at  once.  4.  Injury  to  the  Bladder  or 
Urethra. 

Complications  after  Litholapaxy  and  Lithotrity. — These  are  much 
the  same  as  those  already  given  at  p.  632  as  occurring  after  lithotomy. 
The  chief  differences  are  the  greater  liability  to  rigors  and  urinary  fever, 
and  the  greater  frequency  of  epididymitis.  Bruising  of  the  urethra 
has  also  to  be  remembered,  whether  by  the  instruments,  or,  after  the 
old-fashioned  lithotrity,  by  the  passage  of  fragments. 


PERINEAL  LITHOTRITY. 

This  operation — first  suggested  and  carried  out  by  Dolbcau — consists 
essentially  of  lithotrity  carried  out  through  a  small  median  or  lateral 
perineal  incision. 

Surgeon-Major  Keegan  (Brit.  Med.  Joimi.,  vol.  ii.  1897, p.  23)  observes 
"  that  experience  has  taught  that  supra-pubic  lithotomy  has  not  fulfilled 
the  early  promise  of  the  days  of  its  revival,  for  the  mortality  which  has 
followed  it  in  cases  of  very  large  calculi  occurring  among  males  at  the 
middle  period  of  life  is  very  considerable.  There  is,  therefore,  a  growing 
consensus  of  opinion  among  surgeons  practising  in  the  East,  wdiere 
cases  of  very  large  calculi  are  of  frequent  occurrence,  that  perineal 
lithotrity,  whether  median  or  lateral,  will  in  the  near  future  supersede 
supra-pubic  lithotomy  in  dealing  with  this  very  important  class  of 
cases  of  stone  in  the  bladder."  Reginald  Harrison  (Brit.  Med.  Jouni., 
Dec.  12,  1896)  also  recommends  the  operation,  having  performed  it 
fifteen  times  without  a  death  or  recurrence.  In  one  case  a  very  hard 
urate  stone,  weighing  over  three  ounces,  was  crushed  and  removed  in 
about  five  minutes,  an  enlarged  middle  lobe  of  the  prostate  being 
removed  at  the  same  time. 

Some  of  the  chief  points  claimed  in  favour  of  this  operation  are  : 
(1)  Large  stones  may  be  crushed  in  a  short  space  of  time.  (2)  An 
enlarged  prostate  may  be  dealt  with  at  the  same  time.  (3)  It  may 
be  performed  in  cases  of  stricture  or  enlarged  prostate.  (4)  It  is 
less  severe  than  the  supra-pubic  operation.  (5)  Excellent  drainage 
is  provided  in  cases  of  cystitis,  &c.  (6)  Digital  examination  can 
be  made  use  of  to  determine  whether  all  the  fragments  have  been 
removed. 

Before  it  can  be  decided,  however,  whether  this  operation  should 
entirely  supersede  the  supra-pubic  operation,  further  experience  must 
be  awaited,  particularly  with  regard  to  the  important  question  of 
recurrence. 


646  OPERATIONS    ON    THE    ABDOMEN 

Operation. — A  small  median  or  lateral  perineal  incision  is  made  on  a 
grooved  staff,  as  in  lithotomy,  sufficiently  large  for  the  introduction  of 
the  finger  into  the  bladder  for  the  purposes  of  examination.  The 
"giant"  lithotrite  specially  devised  by  Mr.  Keegan  (loc.  supra  cit.)  is 
then  introduced  into  the  bladder  and  the  stone  crushed  as  in  ordinary 
lithotrity.  The  fragments  may  be  removed  either  by  means  of  forceps 
or  an  aspirator  connected  with  a  specially  large  evacuating  cannula. 
A  tube  is  then  introduced  into  the  bladder  through  the  wound  for 
purposes  of  drainage. 

Mr.  Keegan  says  that  the  specially  strong  "giant"  lithotrite  devised 
by  him,  which  is  of  the  size  of  a  No.  20  catheter  in  the  stem  and  of  No. 
25^  at  the  angle,  "  will  readily  break  up  a  hard  calculus  weighing  six 
to  eight  ounces." 

LITHOLAPAXY  IN  MALE   CHILDREN. 

The  advisability  of  this  mode  of  treating  stone  has  been  strongly 
advocated  by  Surgeon-Major  Keegan,*  who,  after  a  wide  experience  of 
large  stones  in  India,  is  inclined  to  think  that  the  objections  usually 
made  to  litholapaxy  in  boys  are  not  valid.  Thus  :  (1)  as  to  the  small- 
ness  of  the  bladder,  the  bladder  of  a  boy  of  even  only  three  or  four  is,  as 
a  rule,  quite  roomy  enough  to  permit  of  the  efficient  working  of  a  small 
lithotrite  and  a  medium  or  full-sized  aspirator  if  gently  worked.  The 
bladders  of  boys  with  stones  are,  as  a  rule,  healthy,  and  will  stand  more 
distension  proportionately  to  their  capacity  than  the  bladders  of  old 
men.  (2)  The  extreme  sensitiveness  of  the  mucous  membrane  of  the 
bladder  and  urethra.  Mr.  Keegan  thinks  that,  with  an  anaesthetic,  this 
may  be  safely  disregarded.  (3)  The  liability  to  laceration  of  the  mucous 
membrane  of  tlie  bladder  and  urethra.  This  objection  is,  he  thinks, 
a  theoretical  one  only.  (4)  The  small  calibre  of  the  urethra.  Mr. 
Keegan  states  that  not  only  is  the  calibre  of  the  urethra  in  boys  of  six 
or  eight  not  very  small,  but  that  of  boys  of  only  three  or  four  is  some- 
times very  large.  As  in  men,  the  true  calibre  of  the  urethra  cannot  be 
told  unless  the  meatus,  which  is  sometimes  very  small,  is  incised. 
Speaking  generally,  the  urethra  of  a  boy  from  three  to  six  will  admit  a 
No.  7  or  a  No.  8  lithotrite  (Eng.  scale),  and  that  of  a  boy  of  eight  or  ten 
will  admit  a  No.  10,  a  No.  11,  and  even  sometimes  a  No.  14.  "  With 
a  No.  8  lithotrite  and  a  No.  8  evacuating  catheter  it  is,  I  find,  quite 
feasible  to  dispose  of  a  mulberry  calculus  weighing  between  two  and 
three  hundred  grains  in  an  hour's  time." 

In  a  recent  publication  (Ind.  Med.  Gaz.,  August,  1900)  Mr.  Keegan 
gives  the  results  of  a  series  of  500  litholapaxies  in  boys.  He  says  : 
"  Grouping  the  500  litholapaxies  together,  the  work  mainly  of  three 
surgeons,  I  find  that  the  average  age  of  the  boys  operated  on  was  six 
years,  the  average  weight  of  stone  removed  at  each  operation  was 
ninety-five  grains,  and  the  stay  in  hospital  after  operation  amounted 
to  four  days.  The  mortality,  as  already  stated,  was  41,  or  2*2  per 
cent."  Of  the  500  operations,  Mr.  Keegan  did  239,  and  lost  5  cases, 
the  cause  of  death  being  extensive  kidney  disease.  Mr.  Keegan  had 
constructed  by  Messrs.  Weiss  a  No.  3|-  lithotrite,  which  has  done  very 

*  Litholapaxy  in  Male  Children  and  Male  Adults  (Churchill,  1SS7;  ;  Laneet,  1SS6. 


LITHOLAPAXY    IN    MALE    CHILDREN.  647 

good  work,  and  advises  anyone  wishing  to  give  litholapaxy  in  boys 
a  fair  trial  to  provide  himself  with  a  set  of  completely  fenestrated 
lithotrites  running  from  No.  4  to  No.  10  (Eng.  scale). 

Mr.  Keegan  insists  upon  the  completely  fenestrated  lithotrite  as 
being  the  only  perfectly  safe  instrument  to  use,  as,  with  any  other, 
clogging  of  the  blades  is  a  very  likely  and  a  most  dangerous 
complication. 

In  discussing,  in  the  first  edition  of  this  book,  the  advisability  of 
surgeons  adopting,  as  a  general  rule,  this  method  of  dealing  with  stone 
in  male  children,  I  pointed  out  (1)  that  one  very  important  matter,  the 
percentage  of  recurrence  after  litholapaxy  at  this  age,  had  been  left 
undealt  with  by  Mr.  Keegan  ;  and  (2)  that  such  an  individual  experience, 
splendid  as  it  is,  can  scarcely  be  taken  to  furnish  a  rule  to  those 
who  only  meet  with  stone  at  comparatively  rare  intervals.  Mr.  Keegan 
has  since  written  on  both  these  points  {hid.  Med.  Gaz.,  February,  1890, 
p.  40).  It  will  be  seen  that,  with  regard  to  the  first  point,  the  fact 
that  recurrence  after  litholapaxy  in  boys  in  India  is  so  very  small, 
is  due  to  the  opportunities  and  experience,  absolutely  unrivalled  and 
never  to  be  known  in  this  country,  which  fall  to  the  lot  of  surgeons 
in  India  in  treating  stone  in  the  bladder.  With  regard  to  my  second 
point,  that  such  an  individual  experience,  so  different  to  anything 
that  we  meet  with  here,  should  not  mislead  those  who  only  meet 
with  stone  at  comparatively  rare  intervals  to  substitute  litholapaxy 
for  the  eminently  safe  operation*  which  lateral  lithotomy  has  been 
proved  to  be  in  boys,  Mr.  Keegan,  writing  as  follows,  confirms  my 
opinion:  "I  am  disposed  to  agree  with  Mr.  Jacobson  in  doubting  if 
in  Great  Britain  lithotomy  in  male  children  will  be  replaced  by  litho- 
lapaxy. And  why  ?  Because  to  render  himself  familiar  with  the  use 
of  the  lithotrite,  the  surgeon  must  be  afforded  frequent  opportunities 
of  dealing  with  cases  of  stone  ;  and  as  such  opportunities  occur  only 
at  rare  intervals  to  the  majority  of  hospital  surgeons  in  Great  Britain, 
they  will  therefore  very  naturally  cling  to  that  operation  which  is 
performed  b}r  aid  of  the  instrument  with  which  they  are  most  familiar, 
the  scalpel." 

Owing  to  the  increasing  rareness  of  calculus  in  children  at  the  present 
time,  and  the  fact  that,  as  a  rule,  isolated  cases — and  only  successful 
ones — are  alone  published,  it  is  very  difficult  to  speak  definitely  about 
the  results  of  litholapaxy  in  children  in  European  surgery.  I  would 
call  the  attention  of  my  readers  to  a  paper  by  Alexandrow  {Dent.  Zeit. 
f.  Chir.,  1891,  Bd.  xxxii.  Hft.  5,  S.  6).  This  surgeon  performed  litho- 
trity  thirty-two  times  in  boys  between  1  and  14  years  of  age  in  a 
children's  hospital  at  Moscow.  In  twenty-seven  the  operation  was 
successful ;  the  remainder  were  fatal,  and  in  three  death  occurred  from 
injury  to  the  urethra  during  the  operation.  Mr.  E.  Owen,  with  praise- 
worthy candour,  brought  a  case  before  the  Medical  Society  {Lancet,  vol.  i. 


*  Mr.  Bryant,  in  writing  of  the  successes  which  lateral  lithotomy  has  given  in  children 
{Surgery,  vol.  ii.  p.  106),  states  that  during  seventeen  years  ioo  patients  had  been  cut 
consecutively  at  Guy's  without  a  death.  Another  matter  deserves  mention.  Cutting  for 
stone  is  no  longer  limited,  as  of  old,  to  a  few  great  centres.  How  many  institutions  in  or 
out  of  London,  how  many  cottage  hospitals,  wiU  be  provided  with  the  set  of  special 
instruments  which  are  necessary  .' 


648  OPERATIONS    ON    THE   AfeDOMEN. 

1891,  p.  665)  in  which  fatal  rupture  of  the  bladder  had  taken  place 
during  litholapaxy  in  a  boy  aged  4.  Litholapaxy  is  risky  in  children, 
and  entails  the  presence  of  special  and  expensive  instruments,  and 
always  at  any  age,  may  risk,  must  risk,  leaving  the  last  fragment,  which 
may  lead  to  recurrence. 


TREATMENT     OP     STONE     IN      THE     BLADDER      IN     THE 

FEMALE. 

Practical  Points. — The  absence  of  any  prostate  or  of  a  fixed  smooth 
trigone-surface  is  of  importance  here,  especially  with  regard  to  lithotrity. 
The  aid  given  by  a  finger  in  the  vagina,  the  dilatability  of  the  urethra, 
the  association  of  calculi  with  foreign  bodies,  are  also  well  known.  It 
is  only  occasionally  that  enlargement  of  the  uterus  or  prolapse  of  the 
vaginal  wall  of  the  bladder  interferes  with  the  treatment  of  stone. 

Operations. 

A.  In  Adults. — We  have  here  the  following  three  methods  to 
consider : 

1.  Dilatation. — When  the  stone  is  small — i.e.,  the  size  of  a  filbert,  a 
stone  not  exceeding  three-quarters  of  an  inch  in  its  largest  diameter — 
it  may  be  safely  removed  after  rapid  dilatation  with  Kelly's  dilators, 
followed  by  a  finger  (the  little  one  first). 

It  is  not  meant  by  this  that  much  larger  stones  have  not  been  success- 
fully passed  and  removed  from  the  female  bladder.  Thus,  Dr.  Yelloly 
(Med.-Chir.  Trans.,  vol.  vi.  p.  574)  gives  a  case  in  which  a  stone, 
weighing  3  oz.  3J  drs.,  was  extracted  :  incontinence  followed.  Where 
large  calculi — e.g.,  of  6  oz. — have  come  away  spotaneously,  it  has  been 
usually  b}r  a  process  of  prolapsus  and  ulceration  combined.  We  do  not 
yet  know  what  is  the  greatest  dilatation  which  the  female  urethra  will 
safety  bear.  Perhaps  the  limit  given  above  is,  if  anything,  too  small. 
Erichsen  (Surgery,  vol.  ii.  p.  1024)  gives  "8  or  10  lines  in  diameter" 
as  the  size  of  a  stone  which  can  be  safely  extracted  by  this  means. 
Sir  H.  Thompson  (Syst.  of  Surg.,  vol.  iii.  p.  308)  says,  "dilatation 
should  never  be  employed  for  any  calculus  larger  than  a  small  nut  or  a 
large  bean  in  an  adult,  which  limits  its  application  to  very  few  cases." 
Mr.  Bryant  (Surgery,  vol.  ii.  p.  120)  states  that,  "in  children,  a  stone 
three-quarters  of  an  inch  in  diameter,  and  in  adults  one  inch,  may  be 
fearlessly  removed  from  the  bladder  by  rapid  dilatation  and  extraction, 
with  the  patient  under  the  influence  of  chloroform.  I  have  removed 
larger  calculi,  two  inches  in  diameter,  by  this  means,  without  any 
injurious  after-effect,  but  it  is  probably  not  wise  to  make  the  attempt, 
the  surgeon  possessing  in  lithotrity  an  efficient  aid  or  substitute." 
Dr.  Keyes  (Intern.  Encycl.  of  Surg.,  vol.  vi.  p.  297)  recommends  not 
dilating  the  urethra  more  than  three-quarters  of  an  inch. 

2.  Litholapaxy. — By  this  means  calculus  in  the  female  bladder  may 
be  most  frequently  and  efficiently  treated.  Thus,  hard  stones  under 
an  ounce,  and  phosphatic  ones  of  a  much  larger  size,  may  be  dealt  with 
at  one  sitting.  The  character  of  the  ring  or  sound  with  the  staff,  the 
bite  of  the  lithotrite,  the  cystoscope,  and  the  condition  of  the  urine  will 
aid  here.  A  shorter  instrument  will  be  found  much  more  convenient 
to  work  with.     Where  there  is  much  irritability  of  the  bladder,  much 


STONE   IX   THE    BLADDER    IN    THE    FEMALE.  649 

difficulty  will  be  met  with  in  keeping  fluid  in  it,  owing  to  the  absence 
of  a  prostate  and  the  shortness  and  directness  of  the  urethra.  The 
pelvis  must  be  well  elevated,  the  patient  placed  fully  under  the 
anaesthetic,  and  the  finger  of  an  assistant  should  make  pressure  on 
the  urethra.  In  other  respects  the  operation  resembles  that  already 
fully  given  for  the  male  (p.  637).  The  dilatable  urethra  admits  a  full- 
size  evacuating  tube. 

3.  Lithotomy. — This  operation  is  called  for  when  the  stones  are 
multiple,*  when  one  is  large,  especially  if  mainly  hard  as  well,  when 
there  is  a  foreign  body  as  a  nucleus,!  when  there  is  great  irritability 
with  ulceration  of  the  bladder,  or  wdien  a  growth  co-exists. 

Of  the  following  methods — (a)  vaginal,  (b)  supra-pubic,  (c)  urethral, 
and  (d)  the  lateral  method  of  Buchanan — the  first  two  only  need  be 
alluded  to. 

Vaginal  Lithotomy. — By  this  is  meant  extraction  of  a  stone  through 
an  incision  in  the  anterior  vaginal  wall,  behind  the  vesical  orifice  of  the 
urethra,  and  thus  not  interfering  with  this  canal  at  all. 

This  anterior  wall  is  about  four  inches  long  in  the  adult ;  in  relation 
with  it  anteriorly  is  the  urethra,  to  be  felt  as  a  cord  through  this  wall, 
behind  this  the  bladder,  and  farther  back  the  os  and  cervix  uteri.  No 
peritonreum  is  normally  in  relation  with  this  wall,  as  this  membrane 
leaves  the  uterus  half-way  down  to  pass  directly  on  to  the  bladder. 
No  important  vessels  or  nerves  are  met  with  in  vaginal  lithotomy ;  but 
this,  though  the  simplest  and  easiest  of  all  the  methods  of  cutting  for 
stone,  will  be  but  rarely  called  for,  as  in  all  moderate  stones  in  women, 
litholapaxy  is  usually  available,  while  in  the  case  of  larger  ones,  and 
with  all  calculi  in  female  children,  the  supra-pubic  method  is  indicated, 
save  for  tiny  stones  which  can  be  removed  after  dilatation.  The  only 
drawback  of  a  vaginal  lithotomy  in  women  is  the  risk  of  a  fistula, 
but  this  need  only  be  taken  into  account  where  phosphatic  urine  is 
present,  or  where  the  edges  of  the  wound  have  been  bruised  during 
the  extraction  of  the  stone.  In  either  case  the  calculus  will  probably 
be  a  large  one  or  multiple,  a  condition,  as  already  stated,  which  is 
better  dealt  with  otherwise.  The  following  case,  which  came  under 
my  care  in  1889,  is  a  good  instance  of  how  the  operation  may  be 
occasionally  called  for : 

"  Vaginal  Lithotomy  in  a  Patient  Six  Months  and  a  Half  Pregnant  ;  Immediate 
Suture  of  the  Wound— Recovery  ;  Normal  Delivery  at  Full  Time  "  (Lancet,  vol.  i.  1889, 
p.  628).  A.  L.,  aged  27,  was  sent  to  me  by  Dr.  Montagu  Day,  of  Harlow,  December  7, 
1888.     For  three  years  she  had  had  bladder  trouble— viz.,  hypogastric  pain,   cystitis, 

*  As  in  Dr.  Galabin's  case  (_Ob.it.  80c.  Trans..  April  7,  1880),  in  which  twelve  large 
calculi  and  about  fifty  smaller  ones  were  removed  successfully  by  vaginal  lithotomy  from 
the  bladder  of  a  woman  aged  61 

t  As  in  the  large  stone  formed  round  a  hair-pin,  and  figured  (p.  579)  by  Hart  and 
Barbour  in  their  Manual  of  Oyncecology.  Here  the  projection  of  the  hair-pin  on  either 
side  of  the  stone  would  indicate,  nowadays,  the  supra-pubic  operation.  I  have  alluded  to 
a  similar  case  in  my  practice  at  p.  629.  Some  of  my  readers  may  remember  that  a  few 
years  ago  an  inquest  was  held  in  London  on  the  body  of  a  girl  who  died  with  an  undetected 
calculus  in  the  bladder,  which  dated  to  a  hair-pin.  The  sarcastic  remarks  of  the  coroner 
led  to  some  correspondence  in  the  papers,  from  which  it  would  appear  that  these. calculi 
are  less  rare  than  has  been  believed. 


650         OPERATIONS  ON  THE  ABDOMEN. 

very  frequent  micturition  day  and  night,  with  stoppages  of  the  stream,  and  acute  suffer- 
ing after  the  bladder  was  emptied.  The  patient  was  extremely  timid  and  nervous,  owing 
to  her  four  confinements  having  been  "  tighl  "  and  lingering.  Craniotomy  had  been 
required  with  the  first,  and,  with  another,  labour  was  induced  at  seven  months. — 
December  8.  The  urethra  was  dilated,  and  the  bladder  explored.  A  calculus,  apparently 
an  inch  in  either  diameter,  was  felt  ;  t lie  bladder  was  extremely  contracted  with  its 
mucous  membrane  in  places  raw  and  bleeding,  in  others  encrusted  with  phosphates.  It 
was  decided,  fur  the  reasons  given  below  (651),  to  perform  vaginal  lithotomy. —  December  10. 
Twenty-four  hours  after  the  exploration  the  patient  had  recovered  control  over  her 
bladder.  The  vagina  was  thoroughly  syringed  out  with  hydr.  perch.  (1  to  1000).  the 
posterior  wall  was  well  drawn  down  with  a  duckbill  speculum.  A  straight  lithotomy 
staff  (No.  4)  was  then  passed,  and  the  site  of  the  stone  determined.  A  Bharp  hook  was 
next  inserted  into  the  posterior  part  of  the  urethra  so  as  to  drag  t he  anterior  wall  of  the 
vagina  upwards  and  forwards.  This,  however,  caused  such  free  oozing  that  it  had  to  be 
removed,  and  sponge-pressure  applied.  The  bleeding  was  partly  caused  by  the  vascu- 
larity of  the  parts  due  to  pregnancy,  and  partly  b}-  that  set  up  by  the  dilatation  of  the 
urethra  two  days  before.  A  sharp-pointed  bistoury,  introduced  so  as  to  avoid  the  urethra 
and  neck  of  the  bladder,  was  carried  into  the  groove  of  the  staff  through  the  anterior  wall 
of  the  vagina  and  fundus  of  the  bladder,  and  then  backwards  for  nearly  two  inches.  The 
gush  of  urine  which  at  once  followed  on  the  withdrawal  (if  the  knife  carried  the  stone 
downwards,  and  it  was  extracted  with  lithotomy  forceps  with  the  utmost  ease.  After 
the  bladder  had  been  explored  with  the  finger,  it  was  repeatedly  washed  out  from  the 
wound*  with  diluted  Thompson's  fluid.  Little  bleeding  had  followed  on  the  incision, 
and  it  was  clear  that  sutures  would  entirely  control  what  remained.  The  vagina  having 
1'ieii  well  sponged  our,  the  edges  of  the  incision,  (dean  cut  and  without  bruising'!  were 
adjusted  with  six  salmon-gut  sutures  and  four  of  horse-hair.  The  apposition  was  tested 
with  a  fine  probe,  especially  behind,  where  a  little  difficulty  was  met  with  in  inserting 
the  sutures.  Owing  to  the  patient's  straining  at  this  time,  some  urine  escaped  from 
the  urethra,  but  none  came  through  the  wound.  The  vagina  was  next  thoroughly 
syringed  with  a  solution  of  hydr.  perch.  (1  in  3000),  dried  out  with  aseptic  sponges,  and 
dusted  with  iodoform.  To  secure  more  certain  asepsis,  and  also  to  support  the  wound 
and  sutures,  the  vagina  was  lightly  plugged  with  strips  of  iodoform  gauze.  Though 
this  was  done  with  all  gentleness,  it  was  soon  after  noticed  that  blood  was  trickling 
from  the  vagina.  On  removal  of  the  strips,  two  small  lacerations  on  the  right  side  of 
the  vagina,  near  the  orifice,  the  parts  here  being  exceedingly  pulpy  and  vascular, 
oozing  freely.  This  was  arrested  by  tying  up  the  bleeding  points  with  chromic  gut. 
The  vagina  was  again  irrigated  and  insufflated,  but  no  further  trial  of  plugging  was 
made.  As  soon  as  the  patient  was  replaced  in  bed,  a  soft  catheter  wa-  inserted  to  empty 
into  a  "slipper."  The  recovery  was  rapid  and  without  drawbacks.  The  ten  sutures  were 
removed  on  the  eighth  day  with  the  aid  of  chloroform.  The  catheter  was  retained  till  the 
twelfth  day,  when  the  patient  was  allowed  to  get  on  a  sofa.  She  left  the  hospital  seven- 
teen days  after  the  operation.  Dr.  Day  wrote,  on  March  19,  that  the  patient  had  been 
safely  confined  without  any  trouble  with  the  lithotomy  incision. 

The  first  question  to  decide  here  was  whether  to  operate  at  once  or 
to  let  the  pregnancy  (already  advanced  to  six  months  and  a  halt")  he 
first  concluded.  \Vhile  the  stone  itself  was  not  large  enough  to  have 
interfered  with  labour,  both  Dr.  Day  and  I  thought  that,  if  the  bladder 
were  allowed  to  remain  in  its  present  state  for  another  two  mouths  ami 
a  half,  the  cystitis  would  be  rendered  much  more  difficult  of  treatment, 
intensified,  as  it  was  likely  to  be,  by  a  lingering  and  difficult  confine- 
ment, such  as  the  patient  was  liable  to.     It  having  been  decided  that 


*  It  would  be  wiser  to  do  this  from  the  urethra. 

t  Under  less  favourable  conditions  closing  the  wound  may  have  to  be  deferred  till  the 
parts  are  quite  healthy. 


STONE    IN    THE    BLADDEB    IN    THE    FEMALE.  651 

it  was  advisable  to  interfere  at  once,  the  choice  lay  between  (1)  dilata- 
tion of  the  urethra,  (2)  litholapaxy,  and  (3)  lithotomy.     (1)  Dilatation. — 

The  size  of  the  stone  at  once  put  this  aside.  Though  small  (240  gr.), 
it  was  a  full  inch  in  one  diameter,  and  just  over  three-quarters  of  an 
inch  in  the  other.  With  such  a  stone  (a  hard  one,  of  lithic  acid  and 
lithates),  there  was  a  very  serious  risk  of  after-incontinence  (especially 
when  the  blades  of  a  small  forceps  have  to  be  taken  into  consideration 
as  well).  (2)  Litholapaxy. — If  it  had  not  been  for  the  co-existing 
pregnancy,  the  stone  might  well  have  been  thus  dealt  with.  But  as 
great  irritability  of  the  bladder  was  present,  in  addition  to  the  preg- 
nancy, it  was  thought  that  litholapaxy  was  more  likely  to  require  a 
prolonged  anaesthetic  and  to  cause  greater  disturbance  of  some  impor- 
tant pelvic  and  abdominal  viscera  than  the  remarkably  simple  and 
rapid  vaginal  lithotomy.  It  will  be  remembered  that  the  way  in  which 
the  anaesthetic  would  be  taken,  and  its  after-results,  were  more  than 
ever  matters  of  uncertainty  in  this  case.  If  the  anaesthetic  had  been 
badly  taken,  we  had  to  face  the  risks,  on  the  one  hand,  of  premature 
labour  coming  on,  and,  on  the  other,  of  difficulty  in  completing  the 
operation,  and  thus  of  fragments  being  left  behind,  which  would 
intensify  the  already  existing  cystitis.  (3)  Lithotomy. — It  being 
decided  to  resort  to  this,  the  vaginal  method  was  chosen  from  its 
great  simplicity,  the  small  amount  of  anaesthetic  required,  and  the 
facilities  which  it  gave  for  washing  out  the  bladder  at  the  time  of  the 
operation. 

Supra-pubic  Lithotomy. — This  has  been  fully  described  at  p.  623. 
The  fluid  is  retained  in  the  bladder  by  finger-pressure  upon  the  orifice 
of  the  urethra. 

B.  In  Children. — Some  of  the  conclusions  which  Mr.  Walsham  has 
drawn  in  a  very  helpful  paper  (St.  Barthol.  Hosp.  Reports,  vol.  xi. 
p.  129)  may  be  quoted  here  : 

For  small  stones  rapid  dilatation  under  chloroform  is  better,  as 
causing  less  annoyance  and  inconvenience  to  the  patient.  That 
moderate  and  even  large-sized  stones  have  been  removed  by  dilatation, 
but  that,  as  incontinence  has  frequently  followed  from  over-distension, 
it  is  not  justifiable  to  subject  the  patient  to  this  risk.  That,  after 
limited  dilatation,  should  the  stone  appear  larger  than  was  anticipated, 
it  may  be  crushed  with  safety  ;  but,  should  crushing  be  considered 
unadvisable  or  impossible,  it  is  better  to  perform  vaginal  lithotomy 
than  subject  the  patient  to  airy  risk  of  incontinence  by  over-dilatation. 
That  it  is  not  safe  to  aid  the  dilatation  by  incising  the  urethral  walls. 
That  incision  of  the  urethra  alone,  without  dilatation,  in  whatever 
direction  practised,  is  frequently  attended  with  incontinence,  and 
should  therefore  be  abandoned.  That  moderate  and  even  large  stones 
can  be  easily  removed  from  young  children  by  vaginal  lithotomy, 
aided,  if  necessary,  by  dilatation  of  the  vagina,  incision  of  the  four- 
chette,  and  crushing  of  the  stone  by  the  wound  made  through  the 
septum,  without  any  risk  of  a  permanent  vesico-vaginal  fistula  so  long 
as  the  edges  of  the  incision  are  not  bruised  in  the  extraction. 

Mr.  Walsham  considers  each  of  the  above  and  several  other  points 
separately,  and  supports  them  with  evidence.  I  think  that  this  tends 
to  show,  in  the  case  of  vaginal  lithotomy,  that,  though  a  stone  may  be 
thus  extracted  after  dilatation  of  the  vagina,  division  of  the  fourchette, 


652  OPERATIONS    ON    THE    AJBDOMEN. 

and  destruction  of  the  hymen,  it  is  by  n<>  means  easy  in  these  cases  to 
insert  sutures  satisfactorily.  It  will  be  wiser,  I  think,  to  make  use  of 
the  supra-pubic  operation  in  female  children  for  all  save  the  very 
smallest  stones.  Litholapaxy,  although  by  no  means  easy  in  these 
small  bladders  is,  however,  held  by  Mr.  Keegan  (Ind.  Med.  Rec, 
Aug.  i,  1897)  to  be  the  correct  treatment  in  the  great  majority  of 
cases  of  vesical  calculus  in  women  and  girls. 

I  would  refer  my  readers  to  a  case  of  supra-pubic  operation  by  Mr. 
Barwell  in  a  child,  aged  9,  from  whom  a  stone  weighing  two  and  a 
quarter  ounces  was  successfully  removed.  It  is  interesting  to  note 
that  Mr.  Barwell  was  led  to  adopt  the  supra-pubic  operation  from  his 
having  had  within  seven  months  no  less  than  three  cases  of  vesico- 
vaginal fistulre  originating  in  the  extraction  of  calculi  during  infancy 
and  youth  by  different  surgeons  (Med.-Chir.  Trans.,  vol.  lxix.  p.  342). 

CYSTOTOMY. 

Indications. — The  operation  of  opening  the  bladder,  apart  from  such 
cases  as  exploring  for  growth,  foreign  body,  &c,  may  be  required  in  : 

(1)  Some  cases  of  cystitis.  "When  the  urine  is  foetid  and  slimy. 
"When  pain  in  the  bladder  and  penis  is  intense,  leading  to  loss  of 
sleep  and  appetite.  When  there  is  a  high  temperature  and  other  evidence 
of  imminent  septicaemia.  When  all  other  treatment  has  failed ;  and 
when  washing  out  is  insufficient  or  unendurable. 

The  operation  here,  for  the  sake  of  the  kidneys,  must  not  be  put 
off  too  late.  Much  benefit  may  be  obtained  by  irrigating  the  bladder 
freely,  and  afterwards  mopping  it  out  with  a  small  sponge  and  a 
solution  of  silver  nitrate,  5ss  or  5j — 5J. 

2.  Some  cases  of  tubercular  cystitis  (p.  610). 

3.  As  part  of  other  operations.  Thus,  in  plastic  operations  about 
the  urethra,  to  keep  the  parts  dry,  the  bladder  may  be  opened.  I 
have  done  this  in  a  case  of  epispadias. 

4.  As  a  palliative  measure,  for  the  relief  of  obstruction  from 
enlargement  of  the  prostate. 

Supra-pubic  cystotomy  for  drainage  of  the  bladder.  A  helpful 
account  of  this  method  is  given  by  Mr.  Bond  (Lancet,  vol.  ii.  1889, 
p.  260).  The  distended  bladder  having  been  incised  above  the  pubes 
in  the  ordinary  way,  the  urethral  orifice  is  felt  for  with  the  forefinger, 
and  a  curved '  staff  passed  until  it  bulges  in  the  perimeum  just  below 
the  bulb.  The  patient  being  placed  in  lithotomy  position,  the  point 
of  the  staff  is  cut  down  upon,  pushed  through,  and  a  rubber  tube 
attached  to  it.  This  tube,  with  one  or  two  openings  in  it,  is  drawn 
through  above  the  pubes.  In  a  few  days  it  may  be  drawn  into  the 
bladder  from  below,  and  a  little  later  withdrawn  altogether. 

Where  the  supra-pubic  and  perineal  incisions  have  been  made  use 
of  for  a  stricture  which  cannot  be  dilated  from  the  front,  the  curved 
sound  is  removed  as  soon  as  the  perimeum  has  been  opened,  and  the 
stricture  thoroughly  divided.  A  grooved  director  is  then  passed  from 
the  perinceum  into  the  bladder,  and  upon  this,  as  a  guide,  a  full-sized 
catheter  is  passed  from  the  urethra  into  the  bladder  and  tied  in.  See 
a  case  of  traumatic  stricture  thus  treated  by  Sir  Henry  Howse 
(Clin.  Soc.  Trans.,  vol.  xii.  p.  9). 


RUPTURE  OF  THE  BLADDER.  053 

The  above  are  instances  of  cases  calling  for  cystotomy.  The  Burgeon 
will  have  to  choose  between  three  operations — viz.,  median  and  supra- 
pubic cystotomy  and  external  urethrotomy.  The  median  operation  is 
almost  always  to  be  preferred  to  the  lateral,  but  it  is  probable  that 
external  urethrotomy  (Ch.  xiii.)  will  be  sufficient  in  most  cases  as  to 
drainage,  and  it  is  certain  that  this  operation  is  Less  risky  from  shock, 
cellulitis,  and  secondary  hemorrhage.  The  great  object  is  to  drain 
the  cavity  thoroughly. 

RUPTURE     OF     THE     BLADDER. 

This  used  to  be  a  most  fatal  accident,  thus  out  of  143  cases  of  intra- 
peritoneal rupture  collected  by  Ullmann  in  1886,  only  two  recovered  ; 
and  only  20  out  of  94  cases  of  extra-peritoimeal  laceration  got  well 
(von  Bergmann,  vol.  v.  p.  452). 

The  late  Sir  William  Mac  Cormac*  was  the  first  to  publish  two 
successful  operations  for  intra-peritonreal  rupture  {Lancet,  1886,  vol.  ii. 
p.  118).  He  attributed  his  success  to  the  careful  use  of  Lembert's 
sutures,  instead  of  piercing  the  whole  thickness  of  the  bladder  wall, 
including  the  mucous  membrane,  as  had  been  the  usual  practice  up  to 
that  time.  Many  successful  operations  have  been  recorded  since  then. 
Alexandert  and  Jones  I  collected  54  cases  of  intra-peritonseal  rupture," 
with  a  mortality  of  63*5  per  cent,  after  32  operations  before  1893,  and 
27*5  per  cent,  after  22  operations  performed  since  1893. 

Ashhurst  (Amer.  Journ.  Med.  Sci.,  July  1906)  has  collected  no 
cases  with  63  recoveries,  and  47  deaths,  a  death  rate  of  42*72  per  cent. 

Quick  (loc.  supra  cit.)  adds  to  Jones's  22  cases,  treated  since  1893, 
7  more  recent  ones,  and  out  of  these  29,  only  7  died,  a  mortality  of 
24*1  per  cent.  These  figures  are  probably  too  favourable,  for  successes 
are  generally  published,  whereas  the  more  instructive  failures  are  too 
often  forgotten. 

Exploratory  operations  and  suture  of  the  bladder  will  be  increasingly 
successful  in  favourable  cases — i.e.,  those  seen  early  and  those  in  which 
the  injury  is  limited  to  the  bladder. 

Two  forms  of  rupture  are  recognised — the  intra-  and  extra-peritonseal, 
but,  in  some  cases,  the  tear  extends  to  both  the  intra-  and  the  extra- 
peritoneal surfaces,  and  occasionally  two  lacerations  may  co-exist,  and 
one  of  them  is  very  likely  to  be  overlooked.  It  may  be  well  to  state 
succinctly  the  symptoms. 

Intra- peritonceal  Rupture. — (1)  History  of  a  likely  injury.  (2)  In- 
ability to  pass  water.  §  This  power  has,  however,  been  preserved  in 
both  varieties  :  naturally  it  is  seen  most  frequently  and  more  com- 
pletely in  extra-peritonseal  cases.  It  is  very  rarely  normal  in  the  intra- 
peritoneal ruptures.     Attempts   at   micturition  may   be   frequent  and 

*  Many  others  have  followed.  Mr.  Walsham  has  been  able  to  report  two  successful 
cases  {Tran.<.  Med.-Chir.  Soe.,  1886  and  1895). 

t  Ann.  of  Surg.,  1901,  vol.  xxxiv.,  p.  209. 

\  Ibid.,  1903,  vol.  xxxvii.,  p.  215. 

§  Thus  the  rent  may  be  valvular  or  blocked  by  intestine,  kc.  On  all  these  and  many 
other  points  the  reader  should  refer  to  Mr.  Rivington's  writings.  Diet,  of  Surg.,  vol.  i. 
p.  152.  and  Rupture  of  the  Urinary  Bladder,  for  exhaustive  completeness  and  helpful 
information. 


654  OPERATIONS   ON   THE    ABDOMEN. 

painful,  but  only  blood-stained  fluid  may  be  voided  in  small  quantities. 
(3)  A  little  bloody  urine  drawn  off  with  a  catheter.  (4)  Difficulty  of 
manipulating  an  instrument  in  a  contracted  bladder.  (5)  If  the 
catheter,  hitting  off  the  rent,  be  passed  beyond  the  bladder,  a  much 
larger  quantity  of  blood-stained  fluid  is  withdrawn,  partly  urine,  partly 
serum,  from  irritation  of  the  peritonaeum.  If  the  flow  through  the 
catheter  is  markedly  increased  by  inspiration  and  diminished  by 
expiration,  the  rent  is  probably  a  large  one. 

(6)  Shock.  This  maybe  absent  or  pass  unnoticed  in  patients  who 
are  intoxicated  at  the  time  of  the  accident,  and  as  the  laceration 
frequently  occurs  under  these  circumstances,  this  fact  is  important  to 
bear  in  mind. 

This  form  of  rupture  commonly  follows  a  kick  or  a  blow  upon  the 
abdomen,  when  the  bladder  is  distended,  but  it  has  also  occurred 
spontaneously  during  the  retention  of  urine  from  stricture,  enlargement 
of  the  prostate,  or  any  other  obstruction.  The  accident  has  also 
occurred  during  the  crushing  of  vesical  stones  and  in  the  course  of 
perinaeal  operations  upon  the  bladder ;  Bottini's  galvano  cautery  has 
opened  the  peritonaeum  a  good  many  times  during  the  attempt  to 
cauterise  the  enlarged  prostate  in  the  dark. 

(7)  Speedy  supervention  of  signs  of  peritonaeal  irritation,  viz. : — pain 
in  the  lower  part  of  the  abdomen,  tenderness  and  rigidity.  The  surgeon 
should  not  wait  for  the  classical  signs  of  peritonitis  to  manifest  them- 
selves. Dr.  Quick  records  a  case  in  which  no  peritonitis  had  developed 
after  io|  days.  The  patient,  who  was  intoxicated  at  the  time  of  the 
accident,  was  able  to  work  on  the  following  day,  but  he  had  to  leave  off 
on  the  second  day  on  account  of  pain  and  vomiting.  He  recovered 
after  an  operation,  performed  on  the  eleventh  day  by  Dr.  G.  F.  Thompson 
(Ann.  of  Surg.,  January,  1907,  p.  94). 

In  other  cases,  in  which  the  urine  has  been  aseptic  and  no  instruments 
have  been  passed,  the  onset  of  peritonitis  has  been  considerably 
delayed. 

(8)  Perhaps  fluctuation  and  shifting  dulness  in  the  flanks,  with 
abdominal  distension. 

Extra-peritonaeal  Rupture. — This  is  often  due  to  or  associated  with 
fracture  of  the  pelvis,  but  it  frequently  happens  when  no  such  fracture 
exists.  It  has  followed  repeated  supra-pubic  aspiration.  (1)  History 
of  a  likely  injury.  (2)  Inability  to  pass  water  {vide  supra) .  (3)  A  little 
bloody  urine  drawn  off.  (4)  The  catheter  finds  the  bladder  contracted. 
(5)  No  tapping  of  a  larger  amount  of  fluid.  (6)  Evidence  of  extravasa- 
tion rather  than  of  peritonitis.  Thus,  if  the  rent  is  in  front,  the  urine 
may  be  localised  there  with  circumscribed  dulness  ;  or  widely  diffused, 
mounting  up  towards  the  umbilicus,  between  the  abdominal  muscles 
and  the  peritonaeum  ;  or  passing  into  the  iliac  fossae,  or,  by  the  canals, 
into  the  scrotum  and  thighs.  In  one  case  that  I  saw  the  extravasation 
was  much  more  extensive  upon  the  right  side  so  that  the  situation  of 
the  rent  was  correctly  diagnosed  to  be  upon  this  side.  In  another 
patient,  the  late  Mr.  Davies-Colley  localised  the  position  of  the  extra- 
peritonaeal  rent,  which  was  due  to  a  fracture  of  the  pelvis,  by  the  inability 
of  the  boy  to  flex  and  adduct  his  right  thigh  ;  vertical  fractures 
through  the  right  rami  were  found  at  the  operation.  The  patient  soon 
becomes  very  ill,   with  a  quick  pulse  and  respiration,  probably  from 


RUPTURE   OF    THE    BLADDER.  655 

reabsorption  of  urine  from  the  connective  tissue ;  these  symptoms 
appear  while  the  extravasation  is  still  sterile,  but  sooner  or  later  infection 
is  bound  to  follow. 

It  must  be  remembered  that  the  following  may  mislead  :  There  may 
be  very  little  pain  complained  of;  no  sickness;  a  normal  temperature  ; 
the  patient  may  be  able  to  walk ;  upwards  of  half  a  pint  of  urine  may 
be  drawn  off  night  and  morning,  and  yet  the  peritoneal  sac  may  con- 
tain much  fluid.  Peritonitis  may  be  absent  post-mortem,  though 
tympanites  be  present  during  life,  and  though  fluid  be  found  in  the 
peritoneal  sac.  The  patient  may  live  as  long  as  five  days,  apparently 
improving,  and  then  die  suddenly. 

The  following  may  be  useful  in  doubtful  cases : 

Mr.  Walsham  in  his  second  case  (Trans.  Med.-Chir.  Soc,  vol.  lxxviii. 
p.  278),  to  make  certain  of  the  existence  of  a  rupture,  made  use  of  the 
injection  of  air,  the  injection  of  fluid  not  being  conclusive.  "  For  this 
purpose  the  india-rubber  apparatus  belonging  to  an  ether-freezing 
microtome  was  utilised,  the  tube  of  which  was  attached  to  the  free  end 
of  the  catheter.  The  liver  dulness  having  been  carefully  percussed 
out,  a  few  cubic  inches  of  air  were  forced  through  the  catheter  by  two 
or  three  contractions  of  the  rubber  ball.  The  effect  was  instantaneous. 
The  abdominal  cavity  became  distended,  the  liver  dulness  immediately 
effaced,  and  the  whole  abdomen  tympanitic  to  percussion.  The 
patient  fell  into  a  condition  closely  resembling  collapse  ;  he  complained 
of  great  pain,  his  respiration  was  laboured,  and  the  action  of  the  heart 
turbulent." 

This  method  was  recommended  by  two  American  surgeons,  Dr. 
Morton  and  Professor  Keen,  independently,  in  1890.  Mr.  "Walsham 
was  the  first  to  employ  it.  The  cystoscope  is  not  likely  to  be  of  much 
use  except  in  the  extra-peritonseal  injuries,  owing  to  the  difficulty  of 
keeping  fluid  within  the  bladder  in  the  intra-peritonasal  ruptures. 

Operation. — This  must  be  undertaken  without  delay.  The  patient 
being  under  an  anaesthetic,  the  abdominal  wall  cleansed  and  shaved, 
and  the  parts  relaxed,*  a  free  incision  five  or  six  inches  long  in  the 
adult,  is  made  near  the  middle  line.  The  rectus  sheath  having  been 
divided,  the  rectus  drawn  outwards  and  partly  detached  if  needful,  all 
bleeding  points  secured,  the  lower  angle  of  the  wound  and  the  parts 
behind  the  pubes  are  carefully  examined  for  ecchymosis,  extravasation, 
&c.  If  neither  of  these  nor  any  collection  of  fluid  is  found  outside  the 
peritonaeum,  this  is  opened,  when  a  large  gush  of  fluid  may  be  decisive. 
The  surgeon  now  introduces  one  finger  to  feel  for  the  rent,  and  the 
detection  of  this  may  be  facilitated  by  passing  a  short-beaked  sound. 
The  rent  will  vary  in  site  and  length,!  and  also  as  to  regularit}-, 
thickening,  &c.  If  it  be  a  long  one,  and  reach  downwards  towards  the 
recto-vesical  cul-de-sac,  the  Trendelenburg  position  should  be  adopted. 
This  gives  valuable  assistance,  for  it  grants  a  good  view  of  the  posterior 
surface   and   affords   plenty   of  room   for  the  introduction    of  sutures 

*  In  Mr.  Willett's  case  (St.  Barthol.  Hasp.  Reports,  vol.  xii.  p.  209)  much  difficulty 
was  met  with  from  the  rigidity  of  the  abdominal  walls,  and  the  great  distension  of  the 
intestines,  which  kept  crowding  out  of  the  wound,  and  were  most  difficult  to  replace. 
Feritonitis  had  set  in  here,  twenty-four  hours  having  elapsed  since  the  injury. 

t  hi  Sir  W.  Mac  Cormac's  cases  tie  rents  were  four  and  two  inches  long. 


656  OPERATIONS    ON    THE    ABDOMEN. 

without  risk  of  injuring  the  small  intestines,  which  fall  away  and  fire 
protected  with  a  sterile  pad.  Sir  \Y.  Mac  Cormac  also  found  that  the 
bladder  came  up  more  readily  after  the  parietal  peritoneum  had  heen 

transversely  divided  nil  each  Bide.  An  assistant  may  lender  service  at 
this  time  by  grasping  the  upper  end  of  the  bladder  and  drawing  it 
forwards  ami  a  little  to  one  side  while  the  intestines  are  kept  back 
with  gauze  tampons  if  the  Trendelenburg  posture  has  not  been  adopted. 
The  rent,  being  now  in  view,  is  cleansed,  and  sutures  of  fine  sterilised 
silk  inserted.  The  shortest  possible  needle  should  be  employed  here, 
owing  to  the  depth  of  the  wound  and  the  limited  space  there  is  to 
work  in.  Mr.  Walsham  in  his  second  case  found  that  a  T.  Smith's 
rectangular  palate-needle  answered  admirably  in  inserting  the  deepest 
sutures.  All  of  these  should  be  put  in  before  any  are  tied,  and  if 
the  first  are  gently  drawn  upon  it  will  facilitate  the  inseition  of  the 
others.*  Sir  W.  Mac  Cormac  used  sixteen  sutures  in  one  case  ami 
twelve  in  another,  and  his  success  is  largely  due  to  the  great  care  with 
which  they  were  inserted.  Thus,  they  were  put  in  a  quarter  of  an  inch 
apart,  after  Lembert's  method  (Fig.  99,  p.  353),  including  the  serous 
and  muscular  coats  only,  beginning  at  the  Lower  part,  the  first  and  last 
sutures  being  inserted  well  beyond  the  limits  of  the  injury  so  as  to 
prevent  leakage  from  the  extremities.  Silk  is  the  best  material  to  use 
for  catgut  may  give  way  prematurely,  and  as  the  silk  does  not  pierce 
the  mucosa  there  is  little  danger  from  its  use.  Reliable  catgut  which 
will  last  over  a  fortnight  may  be  used  if  preferred.  The  following 
precautions  are  taken  in  suturing :  Fine  curved  needles  are  used  in 
holders ;  the  serous  surfaces  are  carefully  inverted.  The  anterior  or 
superior  end  of  the  laceration  should  be  sewn  first,  and  the  ends  of 
each  suture  left  long,  so  that  gentle  traction  upon  them  may  facilitate 
the  introduction  of  the  inferior  stitches  (Jones,  loc.  cit).  The  sutures 
are  passed  through  the  serous  and  muscular  coats  only.  This  avoids 
the  risk  of  traversing  the  mucous  membrane,  which  in  animals  has 
nearly  always  proved  fatal,  because — (1)  on  tightening  the  sutures,  the 
mucous  membrane  tails  between  the  edges  of  the  wound  and  hinders 
union  ;  (2)  the  urine  may  find  a  channel  through  the  points  of  passage 
of  a  suture,  and  so  into  the  cavity  of  the  peritonaeum  ;  (3)  the  loop  of 
suture  within  the  bladder  is  a  foreign  body,  and  salts  maybe  deposited 
on  it. 

Wherever  a  gap  appears,  another  suture  should  be  inserted.  All  the 
ends  are  now  cut  short.  If  there  is  time,  a  continuous  suture  may  be 
used  to  reinforce  the  first  row,1  but  Sir  \Y.  Mac  Cormac  regards  the 
double  row  as  unnecessary.  In  one  case  I  used  interrupted  catgut  for 
the  deep  row  and  a  continuous  silk  for  fortifying  and  burying  this. 
It  is  not  wise  to  inject  coloured  Liquid  into  the  bladder  with  the  view 
of  testing  the  stitching,  for  this  is  unnecessary  if  proper  care  be  taken, 
and  the  Trendelenburg  attitude  adopted.  .Moreover  it  wastes  time, 
which  is  better  given  to  careful  suturing.     The  peritonaea!  cavity  is  now 


*  In  this  case  the  rent  was  in  the  posterior  wall  extending  from  the  summit  ak) 
middle  line  to  the  base  of  tin-  trigone. 

inly  invariably  give  way. 


PI  NCTURE    OF   THE    BLADDER.  657 

most  carefully  wiped  out  with  gauze  pushed  well  down  into  tin:  pelvis 
uinl  the  Hanks  till  they  come  oul  clean  and  dry  <<n  squeezing. 

Where  the  Burgeon  is  doubtful  about  the  state  of  the  peritonaea!  sac, 
a  fenestrated  rubber  tube  containing  a  wick  of  gauze4  should  he  hit 

in  the  pelvic  pouch.  A  drain  should  be  left  in  the  pre-vesical  spare  in 
sxtra-peritonaeal  ruptures,  especially  if  the  operation  has  been  deferred 

until  it  is  difficult  or  impossible  to  find  or  suture  the  rent  satisfactorily. 
A  catheter  should  he  tied  in,  care  being  taken  not  to  pass  too  much 
of  it  into  the  bladder,  hut  to  leave  the  eye  only  just  above  the  vesical 
orifice.  The  bladder  must  not  he  allowed  to  get  full,  either  from 
slipping  or  blocking  of  the  catheter. 

Cases  occasionally  occur  where  the  neck  and  not  the  body  of  the 
bladder  is  lacerated,  a  fracture  of  the  pelvis  perhaps  co-existing. 
Where  there  is  inability  to  pass  water  and  where  it  is  uncertain  whether 
a  catheter  enters  the  bladder,  it  will  be  best  to  explore  the  front 
and  neck  of  the  bladder  by  a  supra-pubic  incision  not  opening  the 
peritonaeum.  If  blood-stained  fluid  well  up,  and  if  the  catheter  be 
detached  lying  outside  the  bladder,  the  bladder  should  be  opened  and 
a  curved  staff  passed  through  the  urethra  and  cut  down  upon  in  the 
perinaeum.  A  drainage-tube  should  then  be  passed  according  to  the 
directions  given  at  p.  652. 

This  will  drain  the  bladder  effectually,  and  prevent  any  further  escape 
of  urine.  The  space  outside  the  bladder,  around  its  neck,  must  be 
cleaned  thoroughly  by  the  supra-pubic  incision,  tamponnaded  with 
iodoform  gauze,  and,  if  needful,  drained  from  the  perinaeum. 

In  late  cases  with  pelvic  cellulitis  free  incisions  must  be  made  and 
drainage  established. 

Causes  of  Death. — Peritonitis,  shock,  haemorrhage,  cellulitis. 

Peritonitis  is  far  the  commonest  cause  of  death,  and  it  maybe  due  to 
infection  from  previously  infected  urine,  or  from  careless  instrumentation, 
from  infection  at  the  operation  or  subsequent  leakage  due  to  inefficient 
suturing. 

PUNCTURE  OP  THE  BLADDER. 

The  following  methods  will  be  considered  here  : 

i.  The  Aspirator. 

ii.  Supra-pubic  Puncture. 

i.  The  Aspirator. — This  may  be  used  in  cases  of  great  urgency, 
when  the  surgeon  is  compelled  to  relieve  retention  without  regard  to 
the  cause,  when  he  is  without  the  means  of  carrying  out  other  and 
perhaps  better  methods  ;  it  is  especially  suited  to  those  cases  in  which 
there  is  reason  to  believe  that  urine  will  again,  in  a  few  hours,  be 
passed  by  the  urethra.  Thus  in  gonorrheal  retention,  where  a  catheter 
cannot  be  passed,  having  perhaps  heen  clumsily  used,  and  where  relief 
is  urgently  required,  where  retention  has  supervened  on  a  stricture  of 
only  two  or  three  years'  standing,  this  means  may  be  used  successfully, 
giving  time  for  warm  baths  and  opium  to  act.  In  an  old  stricture,  in 
one  of  traumatic  origin,  or  in  a  case  of  enlarged  prostate,  it  can  only 

*  Mr.  Betham  Robinson  {Lancet,  Jan.  23,  1904)  records  a  recovery  from  an  intra- 
peritoneal rupture  of  the  bladder  in  a  girl  of  only  5  years  of  age. 

S. — VOL.    II.  42 


658  OPERATIONS  ON  THE  ABDOMEN. 

be  a  temporary  measure,  and  should  only  bo  used  when  other  instruments 
are  not  available. 

Tlic  .nirst  inn  arises,  How  far  will  aspiration  heir  repetition  .'  This  is  quite  uncertain. 
On  Hie  one  hand,  in  a  case  of  prostatic  retention  nol  admitting  a  catheter,  the  patient 
being  throughout  in  a  mosl  grave  condition,  Dr.  Brown  {Brit.  Med,  Jour//.,  .May  23, 
1874)  used  the  aspirator  fifteen  times  between  January  2ml  and  12th,  "with  imme- 
diate relief  on  every  occasion,  and  without  the  smallest  inconvenience  or  injury  from 
the  punctures."  Mr.  Hague  (Limed,  1885,  vol.  ii.  p.  385)  in  a  patieni  aged  90,  with 
prostatic  retention  of  forty-eight  hours'  duration,  aspirated,  and  continued  to  do  so 
daily  for  nearly  five  weeks,  as  no  catheter  could  be  passed.  Such  numerous  aspirations 
caused  no  ill  effects. 

On  the  other  hand,  in  a  ease  of  mine  of  prostatic  retention  in  which  the  aspirator  had 
been  used  only  three  times,  on  the  death  of  the  patient  from  bronchitis  on  the  fourth  day 
the  third  and  last  puncture  was  found  to  be  leaking.  Dr.  Campbell  {Brit,  Med.  Journ., 
Feb.  21,  1886)  records  a  case  in  which  the  bladder  had  been  aspirated  twice,  and  internal 
urethrotomy  then  performed.  "  Progress  was  good  for  a  day  or  two,  when  some  inflamma- 
tion appeared  at  one  of  the  punctures,  an  abscess  farmed,  peritonitis  came  on,  and  the 
man  died."  Where  aspiration  is  to  be  used,  the  condition  of  the  bladder  walls  and  of  the 
urine  must  be  taken  into  account.* 

If  aspiration  be  made  use  of,  a  fine  needle  should  be  employed,  and 
introduced  just  above  the  pubes  while  an  assistant  steadies  the  bladder 
by  pressure  on  either  side.  The  bladder  must  not  be  allowed  to  become 
much  distended  before  the  puncture  is  repeated,  otherwise  urine  may 
be  forced  out. 

ii.  Supra-pubic  Puncture. — This  operation  has  the  advantages 
of  being  easily  performed,  of  giving  permanent  relief  if  desired,  and  of 
being  safe. 

The  two  objections  brought  against  it  are — that  (1)  it  gives  bad 
drainage,  and  (2)  it  is  liable  to  extravasation. t  Neither  of  these  is 
borne  out  by  facts.  While  the  patient  is  in  bed,  good  drainage  can 
be  provided  by  turning  him  on  one  side  and  attaching  tubing  to  the 
cannula ;  when  the  patient  is  up  (and  a  cannula  so  placed  is  no  draw- 
back to  this),  the  power  of  micturition  will  probably  have  returned. 
In  a  few  cases  of  enlarged  prostate  the  patient  will  be  compelled  to 
pass  his  urine  this  way  for  the  rest  of  his  life,  but  as  soon  as  the  parts 
are  consolidated  around  the  cannula,  or  the  catheter  which  has 
replaced  the  cannula,  micturition,  though  tedious,  will  be  effected 
satisfactorily. 

I  may  allude  to  three  cases  out  of  many  in  which  I  have  used  this 
method,  two  of  retention  with  stricture,  one  of  prostatic  retention. 
I  consider  it  the  best  all-round  method,  and  the  one  of  widest  applica- 
tion that  we  have.  Its  relief  is  immediate,  safe,  and  simple  withal. 
The  two  cases  of  stricture  were  men  under  40,  admitted  with  a  history 
of  catheterism,  bleeding  urethral,  and  recent  false  passages.     On  the 

*  Mr.  Bennett  read  a  case  before  the  Medico-Chirurgica]  Society  {Lancet,  r888,  vol.  i. 

p.  41S)  of  exlra-peritoiucal  rupture  of  the  bladder  after  aspiration  in  a  patient  long  the 
subject  of  stricture.  The  opinion  of  most  Burgeons  present  seemed  to  be  that  aspiration 
was  dangerously  liable  to  leakage,  especially  in  unhealthy  bladder-. 

\  Mr.  T.  Smith  (St.  Bartkol.  Hosp.  Reports,  vol.  xvii.  p.  291)  writes:  "  I  have  seen  no 
such  tendency  to  extravasation  ;  occasionally  there  is  some  inconvenience  from  leakage: 
this  may  lie  met  by  leaving  out  the  cannula  for  a  few  hours,  which  allows  recontraction 
to  take  place." 


PUNCTURE  OF  THE  BLADDER.  659 

fifth  and  second  days  I  was  able  to  pass  a  No.  7  silver,  and  in  the 
third    case   a    condee,    catheter.        For    some    cases   of  older   Strictures, 

especially  if  with  iistuhe  and  a  damaged  perineum,  a  Longer  rest  is 
required,  and  Mr.  Cock's  or  Mr.  Wheelhouse's  operation   is   indicated. 

Operation. — This  is  most  simple,  and  eucaine  (HI  xx — ,~,j  of  a 
5  per  cent,  solution)  can  he  injected  to  prevent  any  pain.  A  median 
puncture  having  been  made  with  the  knife  through  the  skin  just  above 
the  shaved  pubes,  the  trocar  is  inserted.  I  prefer  a  curved  trocar  and 
cannula,  the  latter  carrying  tape-holes,  but  a  straight  trocar  and 
cannula  may  be  used,  through  which  an  8  or  9  gum-elastic  catheter,  or 
better,  a  Jacques'  catheter,  is  inserted  ;  in  four  hours  the  cannula  can 
be  removed,  and  a  large  catheter,  a  10  or  12,  introduced.*  To  keep 
the  cannula  firm  at  first,  I  insert  a  suture  in  the  puncture,  cover  this 
with  iodoform  and  collodion,  and  pack  some  strips  of  dry  gauze  around. 
Colt's  supra-pubic  drainage  apparatus  may  be  used  to  keep  the  patient 
dry. 

Puncture  per  rectum  has  been  properly  abandoned,  because  it  was 
attended  with  serious  dangers,  and  Avas,  moreover,  very  unpleasant. 
The  retro- vesical  pouch  of  peritonaeum  has  been  opened,  and  the  trocar 
has  been  passed  into  the  prostatic  urethra  without  affording  relief. 
Severe  cystitis  and  ascending  nephritis  sometimes  ensued. 

*  If  an  aspirator  has  been  used,  and  it  is  desired  to  replace  it  with  a  catheter,  a  catgut 
bougie  should  be  passed  through  the  cannula,  and,  this  being  withdrawn,  a  small  gum- 
elastic  catheter,  with  an  eye  in  its  point,  is  passed  over  the  bougie.  Larger  ones  can  soon 
be  got  in,  passing  them  with  terminal  eyes  over  the  smaller  ones,  or  by  means  of  a  stylet 
(T.  Smith). 


42 — 2 


CHAPTER   XII. 
OPERATIONS    FOR    DISEASES    OF     THE     PROSTATE. 

THE  TREATMENT  OF  ADENOMATOUS  ENLARGEMENT, 
OR  SO-CALLED  SENILE  HYPERTROPHY— MALIGNANT 
DISEASE— PROSTATIC    ABSCESS— PROSTATIC  CALCULI. 

ENLARGEMENT     OP     THE    PROSTATE— ANATOMICAL     AND 
PATHOLOGICAL     CONSIDERATIONS. 

The  human  prostate  is  formed  by  the  fusion  of  bilateral  accessoiy 
sexual  glands,  which  remain  separate  in  lower  animals.  The  normal 
organ  weighs  4^  drachms  upon  an  average,  but  it  is  subject  to  con- 
siderable variation,  and  prostates  weighing  as  little  as  2  or  as  much  as 
6  drachms  may  be  quite  normal.  As  a  rule  obstruction  does  not  arise 
until  the  gland  is  much  larger  than  this,  but  occasionally  quite  small 
enlargements,  especially  of  the  hard  or  fibroid  type,  may  make  a  patient 
entirely  dependent  upon  a  catheter,  the  fibroid  contraction,  with  or 
without  local  outgrowths  into  the  urethra,  serving  to  interfere  very 
seriously  with  the  size  and  shape  of  the  passage. 

The  effect  of  any  given  enlargement  also  depends  very  largely  upon 
the  rigidity  or  laxity  of  the  fascial  sheath  of  the  prostate,  and  upon  the 
presence  of  any  local  outgrowths  into  the  urethra  or  bladder. 

Prostates  weighing  no  more  than  three-quarters  of  an  ounce  have 
caused  complete  and  permanent  obstruction,  while  in  others  the 
obstruction  has  not  become  serious  until  the  soft  gland  has  reached 
enormous  dimensions,  and  has  attained  the  weight  of  5  or  6  or  even 
more  ounces. 

It  is  important  to  remember  that  the  prostate  is  (1)  enclosed  within 
a  true  fibro-muscular  capsule,  and  (2)  surrounded  by  an  external  fibrous 
sheath  derived  from  the  pelvic  fascia  {vide  Fig.  256,  p.  671). 

In  the  normal  condition  the  capsule  is  intimately  attached  to  the  gland, 
so  that  it  is  practically  impossible  to  enucleate  the  latter  from  within  this 
covering.  In  the  enlarged  prostate,  however,  things  are  very  different, 
for  a  laminated  and  thicker  pathological  capsule  now  surrounds  the 
adenomatous  gland.  This  is  derived  from  the  fibro-muscular  tissue 
and  other  parts  of  the  prostate,  which  have  not  taken  a  share  in  the 
adenomatous  change  and  have  become  displaced  outwards  by  the 
growth,  as  pointed  out  by  Mr.  Cuthbert  Wallace  (loc.  infra  cit.). 

The  enlarged  prostate  is  enucleated  from  within  this  pathological 
capsule,  or  the  separation  takes  place  between  some  of  the  lamina?,  so 
that  thin  layers  of  fibres  are  often  seen  encircling  the  prostate,  when 


ENLARGEMENT   OF   THE    PROSTATE. 


66  r 


the  latter  is  removed  in  one  piece  (vide  Fig.  255).     Very  little  bleeding 
Deed  occur  when  the  pathological  capsule  has  formed,  and  when  the 

operator  keeps   within  the  proper  layer. 


Pig.  253. 


The  bladder  and  the  prostate.  The  attachments  between  the  fibrous  sheath 
and  the  true  capsule  are  so  intimate  that  enucleation  would  be  very  difficult  or 
impossible.     (Watson,  Ann.  of  Surg.) 

(2)  The  fibrous  sheath  is  derived  from  the  pelvic  fascia.  The  external 
layers  of  this  are  very  dense,  but  towards  its  inner  surface  it  is  less 
firm,  and  harbours  the  prostatic  plexus  of  veins.  Mr.  Freyer  main- 
tains that  the  enucleation  is  performed  between  the  sheath  and  the 
capsule. 


GGz  OPERATIONS  ON  THE  ABDOMEN. 

As  pointed  out  years  ago  by  Sir  Henry  Thompson,  there  is  no  such 
thing  as  an  anatomical  <>r  a  physiological  middle  lobe;  it  is  a  pathological 
product,  and  is  generally,  if  not  always,  a  process  derived  from  one  or 
other  or  both  of  the  lateral  lobes.  The  vesical  projection  is  usually 
most  evident  just  behind  the  vesical  orifice  of  the  urethra,  and  on  the 
middle  line,  because  of  the  directing  influence  of  the  muscular  bands 
which  extend  down  to  the  urethra  from  the  ureteral  ends,  as  pointed 
out  by  Mr.  Thompson  Walker  (Royal  Med.-Chir.  Trans.,  1904, 
p.  404). 

The  fact  that  the  so-called  median  lobe  is  merely  a  prolongation  from 
the  lateral  lobes  is  of  the  highest  significance,  for  it  is  clear  that 
removal  of  the  vesical  projection  is  not  liable  to  grant  permanent  relief, 
for  the  prostate,  which  has  produced  an  offshoot,  is  more  than  likely 
to  go  on  growing,  and  to  obstruct  the  urethra  by  lateral  compression 
sooner  or  later.  Below,  the  fascial  sheath  is  attached  around  the 
urethra  to  the  triangular  ligament,  which  offers  a  strong  and  impassable 
barrier  to  the  enlarging  gland,  which  therefore  projects  upwards  towards 
the  base  of  the  bladder,  where  the  sheath  is  incomplete.  Submucous 
processes  therefore  project  upwards,  by  the  side  of  the  vesical  orifice, 
and  between  this  and  the  circular  fibres  which  surround  it  and  form 
one  of  the  sphincters  of  the  bladder.  The  sphincter  constricts  the  base 
of  the  vesical  projection,  so  that  the  greatly  enlarged  prostate  often 
assumes  the  shape  of  an  hour-glass.  It  is  probable  that  the  fibrous 
ring  formed  by  the  attachment  of  the  lateral  and  anterior  true  ligaments 
of  the  bladder  to  the  neck  of  the  latter  also  exercises  an  influence  in 
the  same  direction  upon  the  shape  of  the  enlarged  prostate.  From 
near  the  vesical  neck  the  true  ligaments  become  reflected  downwards 
to  form  the  dense  fibrous  sheath  of  the  prostate,  and  upwards  in 
a  thinner  layer  which  becomes  lost  upon  the  bladder,  to  the  lower 
part  of  which  it  forms  a  fibrous  covering.  When  the  enlarged  prostate 
is  enucleated,  the  separation  should  always  take  place  within  the  fibrous 
sheath,  and  also  within  at  least  a  part  of  the  pathological  capsule.  In 
this  way  the  prostatic  plexus  of  veins  is  not  opened,  and  the  risks  of 
severe  haemorrhage  and  phlebitis  are  minimised.  The  pelvic  cellular 
tissues  are  not  opened,  so  that  cellulitis  of  the  delicate  and  loose 
tissues  which  surround  the  bladder  and  the  other  pelvic  viscera  should 
not  occur  if  the  operation  is  properly  conducted  well  within  the  fibrous 
sheath.  This  tissue  is,  however,  opened  in  exposing  the  bladder  in 
the  supra-pubic  operation,  and  in  the  perineal  operation  it  is  also 
traversed  between  the  bladder  and  rectum.  Fortunately  no  harm  arises 
in  the  great  majority  of  cases,  because  of  the  free  drainage  which  is 
provided  in  both  operations  ;  opportunity  for  extravasation  into  the 
loose  tissues  is  therefore  rarely  afforded. 

In  some  cases,  however,  the  true  or  the  ill-developed  pathological 
capsule  may  be  so  adherent  that  real  enucleation  is  an  impossibility 
(vide  Fig.  253). 

An  inexperienced  Burgeon  performing  the  supra-pubic  operation 
may  fail  to  find  the  proper  layer  for  separation,  and  then  he  will  either 
effect  an  incomplete  removal  of  the  prostate,  or,  on  the  other  hand,  he 
may  tear  or  cut  through  the  fibrous  sheath  and  invade  the  delicate  and 
loose  pelvic  cellular  tissues.  The  one  mistake  is  liable  to  be  followed 
by  a  stricture  or  recurrence  of  the  enlargement,  while  the  other  may 


ENLARGEMENT   OF    THE    PROSTATE. 


Fig 


n  -ult  in  severe  hemorrhage  from  the  prostatic  plexus  or  in  disastrous 
pelvic  cellulitis.  For  these  reasons  the  finger  is  infinitely  better  than 
any  instrument  for  enucleating  the  prostate  from  above  the  pubes  and 
within  the  bladder.  It  is  of  supreme  importance  to  commence  the 
enucleation  between  the  proper  layers,  and  in  order  to  do  this  the 
mucous  membrane  of  the  bladder  must  be  incised  over  the  prominence 
of  the  vesical  projection,  where  the  prostate  is  only  covered  by  mucous 
membrane.  The  incision  should  also  be  within  the  widened  circle  of 
the  Bphincter,  which  surrounds  the  base  of  the  part  which  projects  into 
the  bladder.  Generally  the  incision  can  be  most  advantageously  made 
a  little  behind  the  funnel-shaped  urethral  orifice,  and  upon  the  so-called 
median  lobe.  When  this  does  not  exist,  the  opening  may  be  made 
over  a  lateral  projection. 

Indications  for  Operation. — The  ideal  conditions  for  operation  are — 
(i)  A  prostate  moderately  but  not  hugely 
enlarged — one  that  has  loosened  within  its 
coverings  by  the  separating  action  of  the 
enlargement.  A  greatly  enlarged  gland  is 
difficult  to  remove  even  supra-pubically 
because  of  impaction  in  the  pelvis,  and  the 
difficulties  of  the  perinatal  operation  under 
these  circumstances  are  very  much  greater. 

(2)  Above  all,  the  absence  of  renal  sepsis 
and  degeneration  from  backward  pressure 
and  other  causes.  The  operation  should  be 
undertaken,  if  possible,  before  the  output  of 
urea  has  been  seriously  diminished  by  long- 
continued  obstruction  and  secondary  fibroid 
changes  in  the  kidneys,  and  especially  before 
the  development  of  cystitis,  pyelitis,  or 
ascending  nephritis. 

(3)  The  absence  of  vesical  stone  and 
sacculation  of  the  bladder  from  old-standing 
obstruction. 

(4)  The  absence  of  much  impairment  of 
the  general  health  and  of  serious  disease  of 
the  vital  organs. 

To  get  the  great  advantages  of  operating  under  these  favourable 
conditions  as  far  as  possible  it  is  best  to  operate  before  the  obstruction 
is  sufficient  to  need  the  habitual  or  even  the  occasional  use  of  a  catheter 
for  its  relief,  for,  except  under  quite  exceptional  circumstances, 
catheter  life  is  bound  to  lead  sooner  or  later  to  cystitis  and  ascending 
septic  changes,  which  may  either  terminate  the  life  of  the  patient  from 
septicaemia  within  a  few  days,  or  may  subside  for  a  time  only  to  be 
repeated  again  and  again,  until  the  chances  of  surviving  an  operation, 
and  of  a  complete  local  relief  and  recovery  of  the  general  health,  are 
very  materially  diminished.  It  is  best  of  all  to  operate  before  the 
residual  urine  becomes  more  than  about  2  or  3  oz.,  even  when  a 
catheter  has  never  been  used  before,  unless  the  residue  can  be  drawn 
off  once  daily  under  circumstances  which  are  unusually  favourable  for 
preventing  infection  of  the  bladder. 

Kesidual  urine  is  very  apt  to  become  foul  either  from  infection  by 


Prostate  weighing  only  three- 
quarters  of  an  ounce  (Freyer), 
outgrowth  into  bladder.  The 
patient  was  entirely  dependent 
upon  a  catheter. 


i,h,         OPERATIONS  ON  THE  ABDOMEN. 

:i  catheter  or  from  the  rectum.  The  degree  of  disability  in  micturition 
and  the  amount  of  residual  urine  arc  far  more  valuable  than  the 
apparent  size  of  the  prostate  as  ascertained  by  rectal  and  bimanual 
examination,  for  it  is  a  matter  of  common  knowledge  thai  the  size  of 
the  prostate  does  nol  bear  any  constant  relation  to  the  disability. 
A  cystoscopic  examination  helps  very  considerably  in  suitable  cases, 
for  a  vesical  projection  or  a  collar  may  be  seen,  and  the  condition  of 
the  bladder  ascertained  (vide  Fig.  254).  In  some  cases  a  pouch  or 
a  calculus  may  be  seen,  as  in  one  of  my  cases;  in  others  carcinoma 
of  the  bladder  is  a  surprise ;  but  it  must  not  be  forgotten  that  neither 
rectal  nor  vesical  examination,  even  through  a  supra-pubic  wound,  may 
discover  any  enlargement  which  appears  to  be  sufficient  to  produce 
an  obstruction  that  is  known  to  exist.  In  such  a  case  the  prostate  is 
unusually  firm  and  only  slightly  enlarged  as  felt  per  rectum,  but  the 
urethra  is  nevertheless  obstructed.  The  following  case  may  serve  to 
illustrate  this  point,  and  it  also  presents  several  other  interesting  and 
unusual  features : — 

The  patient,  who  was  only  48  years  of  age,  was  brought  to  see  one  of  us  (R.  F.  R.) 
by  Dr.  Evan  Evans,  now  of  Lampeter,  who  had  seen  the  patient  in  consultation  with 
his  usual  medical  attendants  at  Aberayron.  The  patient  gave  a  history  of  difficulty 
in  micturition  for  about  seven  years  off  and  on,  and  for  the  last  two  years  he  had  been 
practically  dependent  upon  a  catheter,  which  he  had  learnt  to  pass  after  several  attacks 
of  acute  retention.  He  had  suffered  much  from  acute  and  chronic  cystitis,  and  had 
sometimes  to  pass  the  catheter  every  hour  or  two.  Irrigation  with  a  solution  of  silver 
nitrate  had  given  some  relief.  The  catheter  entered  without  much  difficulty,  although 
the  patient  hated  passing  it  on  account  of  the  pain,  which  he  said  was  very  severe. 
On  two  occasions  he  had  journeyed  to  London  to  consult  well-known  surgeons,  and 
one  of  these,  with  a  great  experience  of  urinary  diseases,  suggested  a  median  perinaeal 
cystotomy  after  giving  the  doctor  a  diagnosis  of  congenital  stricture  of  the  neck  of  the 
bladder. 

When  I  saw  the  patient  in  October,  1905,  the  bladder  had  never  been  examined  by 
means  of  the  sound  or  cystoscope.  The  prostate  was  firmer  than  usual  even,  and  Blightly 
enlarged.  The  urine  was  foul,  the  total  urea  was  diminished  almost  to  half  the  normal, 
and  the  general  health  was  considerably  affected,  although  there  was  no  sign  of  cardiac 
or  pulmonary  disease  beyond  a  little  chronic  bronchitis. 

The  bladder  was  washed  out,  and  the  cystoscope  was  easily  introduced  ;  the  beak 
immediately  struck  a  stone  of  large  size  :  therefore  it  was  decided  not  to  waste  time  upon 
a  further  examination.  Supra-pubic  cystotomy  was  performed,  and  the  stone  was 
removed. 

On  sweeping  the  finger  round  the  bladder  two  pouches  were  discovered,  a  small  one 
to  the  right  and  posteriorly;  the  other,  a  much  larger  one,  with  a  small  orifice  on  the  left 
wall  of  t  lie  bladder,  extended  towards  the  left  iliac  fossa,  and  contained  a  I  at 
which  was  removed  with  great  difficulty,  for  the  small  orifice  contracted  upon  the  finger 
and  instruments.  The  stone,  which  was  a  phospbatic  one,  was  crushed  and  ultimately 
removed.  There  was  very  little  alteration  of  the  urethral  orifice  of  the  bladder.  The 
prostate  was  not  removed  because  the  operation  had  already  lasted  quite  long  enough. 
The  patient  was  exhausted  from  chronic  cystitis  and  pyelitis,  and  the  excretion  of  urea 
was  diminished.  It  was  felt  that  the  large  stone,  placed  at  the  bladder  base, mighl  have 
been  at  least  partly  responsible  for  the  obstruction.  Four  months  later  the  patient 
returned  greatly  improved  in  general  health,  and  with  his  urine  in  a  fairly  healthy  con- 
dition, and  containing  far  more,  but  not  tit*-  normal  amount  of.  urea  :  but  he  had  not 
been  able  to  pass  any  water  in  the  natural  way.  The  prostate  was  still  firm,  even  upon 
the  surface,  and  a  little  larger  than  normal. 

The  urethroscope  was  paS3ed  into  the  prostatic  urethra  with  the  hope  of  discovering  the 
cause  of  the  obstruction,  and  the  lateral  walls  were  seen  to  bulge  inwards,  so  that  the 


ENLARGEMENT    OF    THE    PROSTATE.  665 

urethra  consisted  of  a  mere  antero-posterior 'slit.  Small  whitish  elevations,  probably 
adenomatous,  were  seen  upon  the  projecting  surfaces. 

A.  few  days  Later  the  prostate  was  removed  supra-pubically,  with  unusual  difficulty, 
for  il  was  a  small  fibroid  body  which  was  practically  incapable  of  enucleation,  the  true 
capsule  being  adberenl  to  the  sheath,  probably  as  a  resuli  <>f  repeated  attacks  of  prostatis 
and  cysl  itis. 

Although  the  pal  ienl  lost  a  great  deal  of  blood,  and  afterwards  romited  persistently  for 
Eour  davs.  be  made  a  good  recovery,  and  be  is  now,  a  .year  after  I  be  operal  ion,  quite  well 
and  able  to  carry  « > r  1  bis  business.  Il«'  can  empty  the  bladder  completely  and  easily,  and 
lie  docs  not  gel  up  to  pass  his  water  daring  the  aight.  The  sexual  power  has  returned, 
hut  seminal  emissions  do  mil  occur.     The  vomiting  was  considered  to  he  anemic  in  origin. 

It  is  curious  that  the  patient's  father,  grandfather,  and  several  uncles,  have  suffered 
from  enlargement  of  the  prostate,  some  of  them  at  unusually  early  ages. 

Care  must  be  taken  not  to  mistake  the  hard,  fixed  and  nodular 
enlargement  of  the  carcinomatous  prostate  for  the  adenomatous  so- 
called  senile  hypertrophy. 

When  the  catheter  can  be  used  under  the  most  favourable  circum- 
stances complications  may  be  long  delayed,  but,  sooner  or  later,  acute 
retention  will  supervene  in  the  large  majority  of  cases,  and  this  may 
be  accompanied  by  intra-vesical  lnemorrhage,  and  followed  by  cystitis 
either  from  infection  arising  from  the  careless  use  of  instruments,  or 
from  the  rectum.  Vesical  calculi  may  slowly  develop,  and  the  kidneys 
may  become  affected. 

Complete  retention,  incapable  of  relief  by  any  catheters,  even  when 
used  by  an  experienced  surgeon,  may  develop  at  any  time. 

It  is  not  wise  to  remove  the  prostate  when  an  operation  becomes 
necessary  for  complete  retention.  It  is  far  better  to  be  content  with 
supra-pubic  drainage  until  the  acute  symptoms  have  subsided,  for  the 
congestion  of  the  prostatic  plexus  is  extreme,  and  the  urine  too  often 
foul  under  these  circumstances.  After  a  variable  interval  the  prostate 
may  be  removed  under  more  favourable  circumstances,  if  the  patient 
prefers  this  to  either  permanent  drainage,  or  the  almost  certain  return 
of  his  acute  retention  at  no  distant  date. 

Unfortunately  patients  frequently  do  not  seek  treatment,  or  do  not 
consent  to  any  operation  until  some  complication  or  other  has  made 
life  a  burden  ;  and  they  may  not  consent  to  an  operation  until  grave 
changes  have  taken  place  in  the  kidneys.  It  then  becomes  a  difficult 
question  to  decide  for  or  against  a  radical  operation.  Similar  difficul- 
ties arise  in  advising  patients  who  are  very  decrepit,  or  suffering 
from  cardiac,  pulmonary,  or  other  diseases.  Under  these  circum- 
stances, the  danger  of  the  operation  is  considerably  increased,  and  the 
advantages  derived  from  it  may  be  comparatively  short-lived,  on  account 
of  the  general  condition  of  the  patient,  and  the  shortness  of  the  natural 
expectation  of  life. 

In  the  absence  of  evidence  of  grave  interference  with  the  renal 
function,  however,  supra-pubic  prostatectomy  may  be  undertaken  by  a 
skilful  surgeon,  with  a  sufficient  experience  of  this  operation,  if  the 
general  health  is  good  enough  to  justify  the  administration  of  the 
general  anaesthetic  that  is  generally  required.  Local  or  spinal  anaesthesia 
may  be  sufficient  in  some  cases. 

In  many  cases  the  question  of  operation  will  depend  upon  (a)  the 
possibility,  or  otherwise,  of  leading  a  catheter-life  under  circumstances 
which  are  favourable  for  avoiding  septic  infection  ;  (b)  the  degree  of 


666  OPERATIONS   ON   THE    ABDOMEN. 

discomfort  and  disability  involved  by  catheter-life  in  the  given  case  ; 
(c)  the  risk  of  the  operation  for  the  patient  under  consideration,  is  it 
likely  to  be  so  great,  on  account  of  renal  changes,  general  disease,  or 

extreme  age,  as  to  make  the  operation  inadvisable,  although  it  would, 
if  successful,  give  great  relief  as  long  as  life  lasts  ? 

In  conclusion,  it  may  be  brief!}'  stated  that  the  cases  in  which,  in 
my  opinion,  the  operation  is  most  called  for,  fall  into  two  groups. 
(A)  The  more  urgent,  (i)  Where  previous  appropriate  treatment,  care- 
fully carried  out,  has  failed  ;  (2)  where  there  have  been  one  or  more 
attacks  of  retention ;  or  (3)  where  hemorrhage  has  taken  place.  In 
either  case  the  peril  of  cj'stitis,  too  often  fatal  here,  is  enormously 
increased.  (4)  Where  there  is  inability  to  micturate,  but  the  patient 
is  dependent  upon  the  use  of  a  catheter,  and  especially  when  he  cannot 
pass  this  himself,  or  get  someone  to  do  it  for  him,  with  all  the  care 
and  cleanliness  that  is  necessary  to  prevent  infection.  This  will 
depend  largely  upon  the  education  and  the  means  at  the  disposal  of 
the  patient;  in  a  hospital  patient  it  is  far  safer  to  operate  than  to 
allow  the  patient  to  attempt  to  pass  a  catheter  himself.  (5)  Where 
micturition  becomes  increasingly  painful  and  frequent ;  (6)  where  the 
passage  of  the  catheter  is  increasingly  difficult  with  the  risks  of 
lnemorrhage,  formation  of  false  passages,  &c.  ;  (7)  where  the  prostate 
is  soft  and  elastic,  not  densely  hard  and  fibrous ;  the  immediate  risk 
of  operating  for  the  latter  is  greater,  and  the  chance  of  a  perfect  result 
is  less,  but  the  prognosis  is  better  when  the  perineal  operation  is 
chosen.  Of  course,  the  greater  the  power  of  voluntary  micturition 
which  remains,  the  more  natural  the  urine  as  to  urea,  sp.  gr.,  albumen, 
and  sugar,  the  greater  the  rallying  power  of  the  patient,  and  the 
clearer  the  mind  the  better  the  prognosis.  (B)  Less  urgent  cases. 
Here  the  operation  is  prospective  and  preventive.  The  patient  is 
younger,  the  power  of  voluntary  micturition  is  still  good,  there  is  no 
cystitis,  but  palliative  treatment  fails  to  relieve  the  frequent  disturb- 
ances at  night,  and  hematuria  has  begun  to  occur  at  intervals.  Here 
the  surgeon  is  abundantly  justified  in  advising  the  operation  as  a 
preventive  of  worse  things  which  are  certain  to  come.  The  operation 
will  not  be  often  accepted  here,  but  it  is  in  such  cases  that  it  will  give  the 
best  results. 

THE    CHOICE    OF  OPERATION. 

The  choice  lies  chiefly  between  supra-pubic  and  perinseal  total 
enucleation.  Partial  supra-pubic  prostatectomy  and  all  other  partial 
removals  are  unsatisfactory  either  immediately  or  remotely  or  both. 

Combined  perineal  and  supra-pubic  operations  are  rarely  necessary, 
although  they  may  afford  a  better  control  of  and  access  to  the  gland  in 
fat  subjects,  and  in  some  other  difficult  cases.  The  mortality  is,  however, 
considerably  higher  than  when  either  the  supra-pubic  or  the  perineal 
route  is  adopted  alone. 

(1)  Duration  of  the  Operation. — The  supra-pubic  operation  can  be 
more  quickly  performed  than  any  other  except  in  the  rare  cases  of 
small  and  adherent  prostates. 

(2)  Ease. — The  supra-pubic  is  easier  than  the  perineal  operation  in 
the  great  majority  of  cases,  and  this  is  especially  true  for  very  large 
prostates  (Fig.  255),  but  it  is  not  true  for  small  glands,  which  do  not 


ENLARGEMENT    <>K    TIIK    PROSTATE 


GC>7 


enucleate  but  have  to  be  cut  away,  for  it  is  a  distinct  advantage  for  the 
Burgeon  to  see  what  lie  is  doing  in  these  cases  (Fig.  253). 

(3)  Completeness  of  the  removal  and  certainty  oj  complete  relief. — 
The  supra-pubic  route  allows  the  removal  of  the  gland  en  masse  and 
surrounded  by  its  true  capsule.  This  is  a  distinct  advantage,  for  the 
surgeon  can  he  more  certain  of  completely  removing  the  prostate, 
whereas  in  the  perinatal  operation  the  enucleation  is  always  more  or 

Fig.  255. 


Prostate  weighing  10J  ounces,  actual  size.  (Freyer.)  A.  Left  lobe.  B.  Right 
lobe.  C.  Polypoid  outgrowth  from  right  lobe.  D.  Thin  band  of  pathological 
capsule. 

less  piecemeal.  Vesical  projections  are  apt  to  be  overlooked,  and  hence 
the  relief  is  less  often  complete  after  the  perinseal  than  after  the  supra- 
pubic operation. 

(4)  Exploration  of  the  Bladder. — No  one  denies  that  a  supra-pubic 
cystotomy  allows  the  most  complete  examination  of  the  interior  of  the 
bladder,  and  the  best  guarantee  that  calculi  or  sacculi  or  both  ma}'  not 
be  overlooked. 

(5)  Incontinence  of  Urine. — This  not  uncommonly  follows  the 
perineal  operation  from  interference  with  the  compressor  urethras  or 


668         OPERATIONS  ON  THE  ABDOMEN. 

its  nerves  or  both.  Dr.  Buggies  (Ann.  of  Surg.,  1905,  vol.  xli.  p.  559) 
states  that  incontinence  occurred  in  five  out  of  39  cases  at    Rochester; 

in  three1  of  these  this  serious  affliction  was  permanent,  and  in  one  other  it 
lasted  for  two  years.  Dr.  Watson  states  that  incontinence  follows 
3'5  per  cent,  of  the  perineal  operations.  On  the  other  hand,  this 
troublesome  sequela  rarely  or  never  follows  the  supra-pubic  operation, 
for  the  operator  working  within  the  fibrous  sheath  of  pelvic  fascia  need 
never  trespass  on  the  region  of  the  sphincters  and  their  nerves. 

(6)  Rectal  Injury. — The  rectum  has  been  occasionally  injured  during 
the  perineal  operation,  and  a  troublesome  recto-urethral  fistula  has  not 
uncommonly  resulted.  Dr.  Watson  states  that  it  has  occurred  in 
2'7  per  cent,  of  the  cases.  There  is  practically  no  danger  of  this 
accident,  with  the  supra-pubic  method,  for  the  finger  of  the  surgeon  is 
kept  well  away  from  the  rectum  by  the  posterior  wall  of  the  strong 
fibrous  sheath  of  the  prostate.  With  dense  and  adherent  prostates  it 
is,  however,  possible  to  tear  through  this  sheath  and  injure  the  rectum, 
but  this  must  be  a  very  rare  accident,  whereas  Belrield  states  that 
perinaeal  or  rectal  fistula  occurred  in  8  per  cent,  of  2,000  perineal 
prostatectomies  (Ann.  of  Swrg.,  January,  1907,  p.  101). 

(7)  Drainage. — This  is  a  little  freer  with  the  perineal  operation  if 
the  removal  is  complete,  and  certainby  as  regards  the  wound  it  is  better; 
it  is  a  disadvantage,  however,  to  have  to  pass  a  tube  on  to  the  bladder 
base,  where  it  induces  more  pain,  than  the  supra-pubic  tube  properly 
inserted.  Moreover,  the  patient  cannot  sit  up  so  comfortably,  and  the 
sitting-up  posture  is  of  value  in  avoiding  pulmonary  complications. 

(8)  The  Duration  of  Ancesthesia. — A  shorter  anaesthesia  is  required 
for  the  supra-pubic  operation,  and  therefore  the  complications  arising 
from  the  anaesthetic  are  less  likely  to  follow  it.  Wiener  (Ann.  of  Sur<j., 
vol.  xli.  p.  541)  records  eleven  supra-pubic  prostatectomies  performed 
under  nitrous  oxide  anaesthesia,  and  all  the  patients  recovered. 

The  lithotomy  position  is  not  a  good  one  for  a  prolonged  anaesthetic, 
especially  in  elderly  men  with  rigid  chests.  It  is,  however,  possible  to 
perform  both  the  perinaeal  and  the  supra-pubic  operations  under  spinal 
anaesthesia  (Young,  Journ.  Amer.  Med.  Assoc.,  Feb.  4,  1905).  As  a 
rule,  however,  a  general  anaesthetic  is  to  be  preferred  and  is  to  the 
advantage  of  both  the  patient  and  the  surgeon. 

(9)  Permanent  Urinary  Fistula  should  be  very  rare  after  both  the 
perinaeal  and  the  supra-pubic  operations,  and  there  is  little  difference  in 
the  time  taken  for  the  wounds  to  close  if  the  enucleation  has  been 
complete,  although  the  perinaeal  fistula  closes  a  little  earlier  as  a  rule. 

(10)  The  Loss  of  Sexual  Power  and  Sterility. — This  is  more  common 
after  the  supra-pubic  operation  than  after  a  perinaeal  one  performed  by 
Young's  method.  It  should  be  remembered,  however,  that  the 
impotence  is  not  uncommon  before  the  operation,  and  that  the  loss  of 
sexual  power  is  immaterial  in  the  majority  of  cases,  although  it  may  be  a 
serious  matter  in  the  few  comparatively  young  men.  Further,  the  sexual 
power  is  preserved  in  some  cases  after  the  supra-pubic  operation. 

(n)  Epididymitis  is  more  common  after  the  perinseal  operation. 

(12)  Tlie  Comparative  Mortality. — It  is  difficult  to  arrive  at  any  reliable 
conclusion  upon  this  subject,  for  some  surgeons  select  their  cases; 
others,  properly  regardless  of  their  statistics,  do  not  refuse  an  opera- 
tion if  there  seems  to  be  any  chance  of  affording  relief  to  the  patient. 


PARTIAL    PROSTATECTOMY.  66g 

Mr.Freyer  records  twenty-two  deaths  in  312  supra-pubic  operations,  a 

mortality  of  about  7  per  cent.  Young  lost  lour  of  his  74  cases  of 
perinseal  prostatectomy,  a  mortality  of  5*4  per  cent.  It  can  be  safely 
stated  thai  in  skilled  hands  the  mortality  of  either  of  these  operations 
should  not  be  more  than  10  per  cent.,  and  is  likely  to  be  somewhere 
between  5  and  10  percent. 

(13)  Pelvic  cellulitis  is  a  little  more  common  after  the  supra-pubic 
operation,  because  of  the  better  drainage  of  the  cellular  tissues 
provided  by  the  dependent  perinseal  incision. 

(14)  The  supra-pubic  operation  is  not  suitable  for  the  comparatively 
rare  cases  of  contracted  bladder  with  thin  non-distensible  walls.  In 
conclusion  it  may  be  stated  that  the  supra-pubic  operation  is  the  most 
suitable  for  critical  cases,  demanding  a  short  operation  with  little 
shock  and  little  anaesthetic  ;  it  is  also  to  be  recommended  when  the 
prostate  is  greatly  enlarged,  and  when  there  are  intra-vesical  projec- 
tions. When  large  stones  or  sacculi  are  present  or  a  need  for  thorough 
examination  of  the  interior  of  the  bladder  exists,  the  supra-pubic  route 
is  the  best.  The  perinseal  operation  is  more  suitable  for  the  removal 
of  small  hard  enlargements,  and  for  comparatively  young  men,  to 
whom  the  sexual  power  is  known  to  be  of  importance.  It  is  not  easy 
to  perform  in  fat  and  bulky  patients. 

The  future  will  almost  certainly  show  the  results  of  the  supra-pubic 
method  to  be  at  least  a  little  better  than  those  of  the  perinseal  operation. 
The  one  operation  should  be  the  complement  of  the  other,  and  neither 
of  them  should  be  exclusively  adopted  for  all  sorts  and  conditions  of  a 
variable  disease. 


PARTIAL     PROSTATECTOMY. 

We  owe  our  knowledge  of  what  this  operation  can  do  to  the  late  Mr. 
McGill,  of  Leeds  {Brit.  Med.  Joum.,  Oct.  19,  1889).*  The  following 
propositions  are  taken  from  his  paper : — i.  Prostatic  enlargements 
which  give  rise  to  symptoms  are  intra-vesical,  not  rectal.  Thus 
prostates  of  immense  size  which  project  towards  the  rectum  cause  no 
urinary  trouble,  while  severe  symptoms  may  supervene  when  the  pros- 
tate on  rectal  examination  is  apparently  of  normal  dimensions. 
ii.  There  are  many  varieties  of  the  intra-vesical  growth.  We  find 
(1)  a  projecting  middle  lobe — pedunculated  or  sessile,  (2)  a  middle 
lobe  with  lateral  lobes  forming  three  distinct  projections,  (3)  the  lateral 
lobes  alone,  (4)  a  pedunculated  growth  springing  from  a  lateral  lobe, 
and  (5)  "  a  uniform  circular  projection  surrounding  the  internal  orifice 
of  the  urethra."  This  variety,  described  by  Brodie,  is  not  infrequent, 
it  surrounds  the  urethra  like  a  collar,  and  projects  for  a  variable  distance 

*  Much  information  will  be  found  in  the  following  papers  :  Watson,  Ann.  of  Surg., 
1889,  pp.  1—27  ;  Belfield,  Amer.  Joum.  Med.  Sci.,  Nov.  1S90  ;  Moullin,  Brit.  Med.  Joum., 
1892,  vol.  i.  pp.  1185,  1250,  1294  ;  White,  Ann.  of  Surg.,  1893,  p.  152  ;  Woolsey,  Joum. 
Cut.  and  Gen.  Urin.  Din.,  July  and  Aug.,  1895  ;  Watson,  Ann.  of  Surg.,  1904,  vol.  xxxix. 
p.  833  ;  Young,  ibid.,  1905,  vol.  xli.  p.  549  ;  Pilcher,  ibid.,  p.  565  ;  Wiener,  ibid.,  p.  541  ; 
Cunningham,  ibid.,  p.  590  ;  Mansell  Moullin,  Enlargement  of  the  Prostate,  1904  ;  Freyer, 
1906  ;  Cuthbert  Wallace,  Trans.  Path.  Soe.,  1905,  vol.  lvi.  Part  L,  and  Practitioner,  Sept., 
1905- 


670  OPERATIONS   ON    TIIK    ABDOMEN. 

into  the  bladder,  iii.  In  many  cases  self-catheterism  is  the  only  treat- 
ment required,  iv.  That  when  this  fails,  or  is  unavailable,  more 
radical  measures  are  necessary,  v.  That  this  treatment,  to  he  effectual, 
should  (1)  for  a  time  thoroughly  drain  the  bladder;  (2)  permanently 
remove  the  cause  of  the  obstruction,  vi.  That  the  supra-pubic  route 
is  preferable  to  the  perineal  for  prostatectomy.  Most  surgeons  will 
agree  with  this ;  the  question  is  alluded  to  at  p.  666,  and  again 
below.  This  operation  was  short-lived,  as  it  was  laid  aside  for  double 
castration,  which  at  first  seemed  to  be  much  less  severe,  but  for  a 
variety  of  reasons  orchidectomy  and  allied  procedures  have  given  way 
to  total  perineal  and  supra-pubic  prostatectomy,  which  are  now  safer 
as  well  as  more  successful  than  either  partial  prostatectomy  or  castra- 
tion. Partial  prostatectomy  had  a  mortality  of  15  to  20  per  cent.,  and 
Watson  gives  that  of  double  castration  as  about  16  per  cent. 

Secondaiy  operations  have  often  had  to  be  undertaken  after  these 
procedures.  For  these  reasons  partial  prostatectomy  will  not  be 
described  here.  For  an  account  of  Fuller's  method  of  partial  pros- 
tatectomy combined  with  perineal  drainage,  vide  p.  680. 

SUPRA-PUBIC    COMPLETE    PROSTATECTOMY— TOTAL 
ENUCLEATION    OF    THE    PROSTATE. 

Although  the  late  Mr.  McGill,*  of  Leeds,  certainly  removed  large 
portions  of  the  prostate  bit  by  bit,  and  although  the  removal  may  have 
been  complete  in  one  or  two  cases,  there  is  little  doubt  that  the  credit 
of  introducing  and  perfecting  the  operation  of  total  enucleation  of  the 
prostate  en  masse  belongs  to  Mr.  Freyer,  who  first  showed  that 
this  was  a  feasible  and  rational  surgical  procedure  (Brit.  Med.  Journ., 
July  20,  1901). 

Partial  prostatectomy,  however  extensive,  was  a  very  different  thing 
from  complete  prostatectomy  as  now  performed,  and  it  was  not 
attended  with  sufficient  success  to  justify  its  general  adoption.  It  was, 
in  fact,  almost  completely  abandoned  for  other  measures,  such  as 
castration  and  vasectomy,  which  held  their  sway  for  a  time,  but  have 
been  generally  discarded  now  (vide  p.  682). 

For  much  of  the  following  description  of  the  operation  I  am  indebted 
to  Mr.  Freyer's  instructive  work  upon  this  subject.! 

Preparation. — If  possible,  the  patient  should  be  kept  at  rest  for  three 
or  four  days  before  the  operation,  the  bowels  should  be  opened  daily, 
and  an  enema  given  early  on  the  morning  of  the  operation,  so  that  the 
rectum  may  be  quite  empty.  Any  bronchitis  that  may  be  present 
should  be  attended  to,  or  in  some  cases  which  do  not  call  urgently  for 
relief,  the  operation  should  be  delayed  until  the  pulmonary  symptoms 
have  abated. 

In  cases  of  cystitis,  the  bladder  should,  if  practicable,  be  washed  out 
once  every  day  with  a  solution  of  silver  nitrate  ,,',,,,,  followed  by 
boracic  lotion  toward  the  end  of  the  irrigation.  If  cystitis  be  absent, 
lavage  is  neither  necessary  nor  wise. 

*  Brit.  Med.  Journ.,  Oct.  19,  1889.  Dr.  Fuller  (loc,  infra  dt.)  also  removed  most  of 
the  prostate  Bupra-pubically  (vide  p.  C80). 

t  Enlargement  of  the  Prostate,  3rd  ed.,  1906. 


SUPRA-PUBIC    COM  PLETE    PIN  >STATE<  T<  >M  Y 


()j\ 


For  cystitis,  certain  drugs  may  be  given  with  the  object  of  Lessening 
the  alkalinity  of  the  urine,  and  of  making  the  interior  of  the  bladder 
less  septic. 

Urotropine  gr.  xv.  or  helmitol  gr.  x.  may  be  given  in  water  twice  a 
day,  or  boracic  acid  gr.  xx.  dissolved  in  warm  water  with  the  aid  of 
borate  of  soda  or  ammon.  benzoat.  gr.  xv.  with  tincture  of  hyoscyamus 
may  be  administered.  The  pubis  is  shaved,  and  the  parts  cleansed 
and  compressed  overnight. 

Fig.  256. 


/  Peritoneum. 


placed 


Sheath  of 
prostate 


Pathological 
capsi 


Compressor 
urethras 


Approach  in  the 
Perineal  operation 


The  anatomy  of  the  prostate.  Supra-pubic  enucleation,  and  the  line  of 
approach  in  perineal  prostatectomy.  The  direction  of  most  of  the  fibres  of  the 
pathological  capsule  is  transversely  circular.  The  relations  of  the  capsule,  sheath, 
and  prostate  are  shown.  The  vesical  mucosa  which  covers  and  is  separated  from 
the  prostate  tails  down  and  forms  a  funnel  which  joins  the  remains  of  the  lower 
part  of  the  prostatic  urethra,  after  the  gland  has  been  enucleated. 

The  patient  is  anaesthetised,  after  all  the  preparations  have  been 
completed. 

Operation. — The  bladder  is  thoroughly  washed  out  through  a  large- 
sized  catheter,  and  then  distended  with  boracic  lotion.  The  catheter 
is  plugged  and  left  in.  A  vertical  median  incision  three  inches  long  is 
made  with  its  lower  extremity  at  the  pubis.  The  rectus  sheath  is 
opened,  the  muscular  fibres  separated,  and  any  haemorrhage  arrested. 

The  prevesical  fat  is  displaced  upwards,  carrying  with  it  the  peri- 
tonaeum out  of  harm's  way,  and  leaving  the  bladder  exposed. 

A  bloodless  spot  is  selected  and  the  knife  plunged  into  the  bladder ; 
as  it  is  withdrawn  the  incision  is  enlarged  downwards,  so  that  it  is 
about  an  inch  long.      Mr.  Freyer  enlarges  the  wound  by  stretching  if 


672         OPERATIONS  ON  THE  ABDOMEN. 

this  becomes  necessary  later  on.  This  has  the  advantage  of  avoiding 
any  increase  of  hemorrhage. 

To  avoid  separation  of  the  bladder  from  the  pubis,  and  subsequent 
contamination  of  the  delicate  connective  tissue  of  the  Cave  of  RetziilS, 
some  surgeons  sew  the  edges  of  the  vesical  wound   to  the  skin. 

This  also  serves  to  fix  the  anterior  wall  of  the  bladder,  which 
facilitates  the  enucleation  of  the  prostate  to  some  extent,  for  the  latter 
is  steadied  and  brought  a  little  forward. 

That  this  procedure  is  not  essential  is  showli  by  Mr.  Freyer' s  success 
without  it.  The  vesical  orifice  and  the  whole  of  the  interior  of  the 
bladder  are  now  carefully  and  rapidly  examined,  so  that  no  calculus  or 
stone-bearing  diverticulum  may  be  overlooked.  In  one  of  my  cases,  I 
removed  a  large  oval  stone  from  behind  the  prostate,  and  another  with 
much  difficulty  from  a  narrow-necked  pouch  which  had  terminated 
from  the  left  lateral  wall  high  up  (p.  664). 

An  incision  is  now  made  over  the  greatest  prominence  of  the  prostate, 
which  is  usually  a  little  behind  the  urethral  orifice.  This  is  best  made 
with  long-shanked  scissors  curved  on  the  flat  and  blunt-pointed,  the 
left  fore-finger  being  used  as  a  guide. 

Freyer  uses  a  finger-nail  for  tearing  through  the  mucous  membrane, 
so  that  he  may  not  go  too  deeply  and  thus  miss  the  proper  layer  for 
enucleation,  for  the  prostate  is  covered  only  by  thin  mucosa  on  its 
vesical  surface.  However  safe  this  plan  may  be  for  Mr.  Freyer,  it  is 
far  more  aseptic  for  the  average  surgeon  to  cut  his  nails  very  short,  so 
that  nothing  can  collect  under  their  cut  edges  and  there  avoid  the  nail- 
brush and  the  pumice  stone.  It  is  very  important  to  find  the  proper 
layer  for  the  separation,  and  not  to  trespass  upon  the  fibrous  sheath 
with  its  venous  plexus.  But  if  the  first  incision  is  carried  too 
deeply  true  enucleation  becomes  impossible,  and  the  difficulties  and 
dangers  of  the  operation  are  greatly  increased,  haemorrhage  is 
more  profuse,  much  valuable  time  is  wasted,  and  the  removal  is 
incomplete. 

When  the  left  fore-finger  has  found  the  proper  layer  of  easy 
enucleation,  one  or  two  fingers  of  the  other  hand,  which  is  covered 
with  a  rubber  glove,  are  inserted  into  the  rectum,  to  act  as  a  useful 
guide  and  to  push  the  gland  upwards  and  forwards.  The  prostate  is 
now  fixed  between  the  rectal  and  vesical  fingers,  the  triangular  liga- 
ment and  the  pubis. 

An  assistant's  finger  in  the  rectum  is  not  so  valuable,  for  the 
operator  cannot  direct  it  so  well,  nor  can  he  get  the  same  control  over 
the  prostate.  The  combined  action  and  sense  of  touch  of  the  operator's 
own  fingers  are  far  more  useful.  The  glove  is  removed  when  the 
finger  is  withdrawn  from  the  rectum,  and  the  hand  rinsed  in  lotion. 
The  separation  is  carried  on  behind,  at  the  sides  and  in  front  of  the 
prostate,  the  finger  being  always  kept  close  to  the  prostate  and  within 
the  pathological  capsule  and  the  fibrous  and  vascular  sheath  of  pelvic 
fascia,  until  the  gland  is  free,  except  below  where  the  urethra  attaches 
it  to  the  triangular  ligament.  The  tip  of  the  finger  is  now  bent  and 
gently  separates  the  urethra  from  within  the  apex  of  the  prostate  as 
far  as  possible,  the  catheter  serving  as  a  useful  guide.  The  finger 
behind  the  urethra  hooks  the  prostate  and  urethra  upwards  and  forwards, 
with  the  result  that  the  latter  snaps  at  or  above  the  insertion  of  the 


SUPEA-PUBIC   COMPLETE    PROSTATECTOMY.  673 

ejaculatory  ducts  ;  above  this  point  the  tube  is  more  closely  attached 
to  the  prostate,  and  oomes  away  with  it.  Mr.  Freyer  states  that  the 
insertions  of  the  ejaculatory  ducts  are  often  preserved  and  remain 
attached  to  the  lower  part  of  the  prostatic  urethra,  which  is  firmly  fixed 
to  the  triangular  ligament.  At  the  end  of  the  manoeuvre  which  has 
been  just  described  the  prostate  shoots  up  into  the  bladder,  whence  it  is 
withdrawn  by  strong  and  suitable  forceps,  which  compress  the  gland 
sufficiently  to  allow  its  removal  through  the  comparatively  small  vesical 
incision. 

Before  the  finger  is  removed  from  the  rectum  the  fibrous  wall  of  the 
cavity  which  contained  prostate  are  compressed,  so  as  to  diminish  the 
size  of  the  space  that  is  left  to  heal.  The  loose  lower  parts  of  the 
vesical  wall  soon  fall  down  into  and  line  this  cavity,  and  unite  with  the 
upper  end  of  the  urethra. 

After  the  removal  of  the  prostate,  the  bladder  is  thoroughly  washed 
out  through  the  catheter,  which  is  still  in.  Plot  boracic  lotion  (no 
degrees  Fahr.)  is  used  for  this  purpose.  As  soon  as  the  clots  have  come 
away  the  irrigation  is  left  off.  In  a  few  cases  bits  of  prostatic  tissue 
and  clots  have  been  left  behind  and  have  formed  the  nuclei  of  stones. 
A  large  rubber  tube  (•$  inch  diameter)  is  inserted  so  that  it  projects  for 
only  about  one  inch  into  the  cavity  of  the  bladder,  so  as  not  to  irritate 
the' bladder  base.  The  vesical  part  of  the  tube  is  fenestrated,  and  the 
other  end  is  sewn  to  the  skin.  A  piece  of  gauze  is  passed  by  the  side  of 
the  tube  into  the  Cave  of  Retzius  at  the  lower  angle  of  the  wound  for 
draining  the  prevesical  space  in  case  any  leakage  should  occur  in  the 
first  24  hours.  If  an  unusually  large  vesical  wound  has  had  to  be  made 
it  should  be  partly  closed  with  a  continuous  inverting  catgut  suture,  so 
that  the  drainage  tube  fits  snugly  in  the  remainder,  which  is  at  the  lower 
end  near  the  pubis.  The  upper  part  of  the  parietal  wound  is  closed  by 
interrupted  salmon-gut  sutures,  which  pass  deeply  and  approximate  the 
muscles  and  fasciae,  so  that  a  ventral  hernia  may  be  prevented.  No 
buried  sutures  are  used.  Sufficient  lotion  may  be  injected  through  the 
catheter  to  prove  the  efficiency  of  the  supra-pubic  drainage,  and  the 
catheter  is  then  withdrawn.  The  wound  is  covered  with  Cyanide  gauze, 
and  a  large  quantity  of  cotton  wool,  which  ensheaths  the  back  and 
sides  as  well  as  the  front  of  the  pelvis.  A  many-tailed  bandage  is 
used  to  keep  the  dressings  in  position. 

The  after-treatment. — This  is  almost  as  important  as  the  operation, 
and  much  depends  upon  the  care  and  thought  with  which  it  is  carried 
out.  Free  drainage  is  essential  for  success,  and  any  failure  of  it  may 
induce  pain  and  haemorrhage  from  distension,  and  cystitis,  cellulitis,  or 
renal  complications  may  develop. 

Irrigation  should  be  carried  out  once  daily  through  the  supra-pubic 
drainage  tube,  a  glass  tube  attached  to  an  irrigating  can  being  passed 
through  the  rubber  tube  and  well  into  the  bladder ;  the  fluid  returns 
freely  through  the  drainage  tube. 

Very  little  hydrostatic  pressure  is  either  advisable  or  comfortable  at 
first,  the  can  or  funnel  being  only  about  six  inches  above  the  level  of 
the  abdomen  ;  distension  is  painful  and  apt  to  cause  haemorrhage. 

Warm  boracic  lotion  is  the  best  for  general  use,  but  when  cystitis 
develops  or,  rather,  pre-exists,  200U  °f  nitrate  of  silver  solution  should 
be  used,  and  followed  by  the  boracic  lotion. 

s.  -vol.  11.  43 


674  OPERATIONS  ON  THE  ABDOMEN. 

The  patient  should  he  kept  still  during  the  first  24  hours,  hut  as 
soon  as  the  shock  is  over  he  must  he  propped  well  up,  and  made  to  lie 
alternately  upon  his  sides  and  hack,  so  that  pulmonary  complications 
may  he  avoided.  The  outer  dressings  should  he  changed  whenever 
they  get  wet,  so  that  the  skin  may  not  get  sore,  or  the  patient 
uncomfortable.  Shock  should  he  treated  as  already  described,  p.  305. 
Hemorrhage  by  suhcutaneous  injection  of  aseptic  ergot  and  tree 
drainage  of  the  bladder.  Pain  should  he  relieved  by  morphia,  unless 
the  kidneys  are  very  gravely  affected.  Threatening  uraemia  should  be 
met  by  ingestion  of  abundance  of  fluid,  and  by  infusion  of  saline  solution 
if  fluid  is  not  retained  by  mouth  or  rectum.  The  bowels  are  kept  open 
daily  after  the  second  day.  The  drainage  tube  can  be  safely  removed 
on  the  fourth  day,  there  being  no  fear  of  extravasation  into  the  pelvic 
cellular  tissues.  Irrigation  is  then  carried  out  by  introducing  the 
glass  tube  through  the  sinus  as  long  as  this  is  practicable,  and  then  by 
hydrostatic  pressure  through  a  catheter  inserted  through  the  urethra  ; 
this  will  not  become  necessary  until  about  the  ninth  day.  It  is  not 
necessary  to  tie  the  catheter  in,  with  the  idea  of  preventing  a  stricture. 
Its  introduction  and  its  continued  presence  only  serve  to  irritate  the 
urethra  and  the  healing  part  without  any  compensating  advantage. 
The  urine  should  begin  to  come  away  through  the  urethra  after  about 
10  to  15  days,  and  should  be  voided  entirely  along  the  natural  passage 
after  about  three  weeks  or  a  month.  After  the  supra-pubic  drainage 
tube  has  been  left  out  Colt's  improved  apparatus  may  be  found  very 
useful  to  keep  the  patient  dry  (vide  Fig.  240,  p.  602).  Mr.  Freyer 
thus  speaks  of  the  results  of  his  312  supra-pubic  prostatectomies. 
"  The  vast  majority  of  the  patients  had  been  entirely  dependent  on 
the  catheter  for  periods  varying  up  to  24  years.  Nearly  all  of  them 
were  in  broken  health,  and  many  were  apparently  moribund,  when  the 
operation  was  undertaken. 

The  great  majority  of  them  were,  indeed,  reduced  to  such  a  wretched 
condition  that  existence  was  simply  unendurable.  Few  of  them  were 
free  from  one  or  more  grave  complications,  such  as  cystitis,  stone  in 
the  bladder,  pyelitis,  kidney  disease,  diabetes,  heart  disease,  thoracic 
aneurism,  chronic  bronchitis,  paralysis,  single,  double,  or  even  treble 
hernia,  haemorrhoids,  and  in  a  few  instances  cancer  of  some  other  organ 
than  the  prostate.  Such  then  were  the  unpromising  conditions  under 
which  the  operation  was  undertaken. 

In  connection  with  these  312  operations,  there  were  22  deaths,  the 
remaining  290  cases  being  successful,  and  when  I  speak  of  success  I 
mean  complete  success,  the  patients  regaining  the  power  of  retaining 
and  passing  urine  naturally  without  the  aid  of  a  catheter,  as  well  as 
they  ever  did.  There  are  no  half  measures  about  this  operation.  The 
patient  can  be  assured  beforehand  that  if  he  is  prepared  to  accept  the 
comparatively  small  risk  attaching  thereto,  he  can  with  absolute 
certainly  look  forward  to  a  complete  cure.  In  no  instance  has  the 
patient  failed  to  regain  the  power  of  voluntary  micturition  without  the 
aid  of  a  catheter.  There  has  been  no  instances  of  relapse  of  the 
symptoms ;  on  the  contrary,  lapse  of  time  only  seems  to  consolidate 
the  cure.  In  no  case  has  there  been  contraction  at  the  seat  of  opera- 
tion leading  to  organic  stricture  ;  nor  has  there  been  any  instance  of 
a  permanent  fistula  remaining.     In  very  few  instances  have  distinct 


PERINEAL    IMIOSTATKCTOMY. 


<>7- 


symptoms  of  septicaemia  supervened.     Considering  thai  in  nearly  the 

whole  of  the  cases  the  urine  was  septic,  and  in  many  putrid  before  the 
operation,  this  comparative  absence  of  septicaemia  is  remarkable.  To 
what  an-  we  to  attribute  this  immunity.  No  matter  how  carefully  the 
bladder  is  irrigated,  it  is  quite  impossible  to  keep  the  wound  aseptic. 
It  must  be  remembered  that  a  very  large  proportion  of  aged  men 
succumb  to  septicaemia  on  entering  on  what  is  commonly  termed 
catheter  life.  Probably  those  that  survive  become  more  or  less  immune 
by  gradual  absorption  of  toxins  from  the  septic  urine,  that  prevails 
sooner  or  later  in  all  cases  of  habitual  employment  of  the  catheter." 

The  average  age  of  the  patients  was  68  years,  and  the  average  weight 
of  the  prostates  removed  was  z\  ounces;  the  largest  was  14^-  ounces, 

PERINEAL    PROSTATECTOMY. 

The  bladder  having  been  washed  out  and  the  patient  placed  in  the 
extreme    lithotomy  position,  so  that  perinaeum  almost  faces  upwards, 


Fig.  257. 


Jnyerted 
1  incision 


Perinaeal  prostatectomy.     Inverted  Y-shaped  incision.     (After  Watson,  Ann. of 
Surg.")      An  inverted  V  or  a  semilunar  incision  is  generally  sufficient. 

an  incision  is  made  as  shown  in  Fig.  257.  The  one  shaped  like  an 
inverted  V  is  sufficient  in  most  cases,  and  the  angle  may  be  avoided, 
and  a  semilunar  wound  made  after  the  ancient  plan  adopted  b}'  Celsus 
for  lithotomy.  The  central  tendinous  point  of  meeting  of  the  perinaeal 
muscles  is  sought,  and  a  transverse  incision  made  through  it  separating 
the  accelerator  urines,  and  transverse  perinaeal  muscles  from  the  sphincter 
ani  insertion.  This  step  is  of  great  importance,  and  must  be  carefully 
observed,  otherwise  the  rectum  may  be  injured.  The  rectum  is  now 
carefully  displaced  backwards  by  blunt  dissection,  which  is  carried  deep 
enough  to  expose  freely  the  posterior  surface  of  the  fibrous  sheath  of  the 
prostate.  The  wound  is  well  opened  with  retractors.  A  grooved  staff 
is  passed  into  the  urethra,  which  is  opened  exactly  in  the  middle  line  upon 
the  staff  well  above  the  triangular  ligament  and  through  the  apex  of  the 

43—2 


C;6 


OPERATIONS    ON    THK    AI'.DOMKN. 


prostate  to  avoid  any  possible  injury  of  the  compressor  urethra?.  The 
edges  of  the  urethral  incision  are  picked  up  and  retracted  with  tissue 
forceps  or  sutures  (vide  Fig.  258). 

Young's  tractor  (or  that  of  de  Pezzer)  is  then  passed  through  this 
opening  well  into  the  bladder;  its  blades  are  opened  out.     Traction  is 

Fie.  258. 
Sutures  holding  urethra  open. 


Levator  ani. 


Bound  in 

urethra. 


Perineal  prostatectomy.  Opening  the  urethra  at  the  apex  of  the  prostate 
upon  a  grooved  sound.  The  levatores  ani  are  drawn  backwards  with  the  rectum 
by  smooth  retractors,  and  the  transverse  peri  meal  muscles  are  drawn  forwards 
with  the  accelerator  mime,  and  the  bulbof  the  corpus  cavernosum.  The  posterior 
surface  of  the  prostatic  "sheath  "  is  shown.     (After  Young,  Ann.  of  Surg.') 

then  made  with  the  blades  of  the  instrument  directed  laterally  above 
the  lateral  lobes  of  the  prostate  (vide  Fig.  259).  These  and  similar 
tractors  are  of  great  value  in  bringing  the  prostate  downwards  and 
backwards  well  into  view.     The  finger,  passed  through  the  urethra, 


Fig.  259. 


END     CLOSEO 


Young's  prostatic'tractor.     (Ann.  of\8v,rg^) 


although  sensitive,  is  not  nearly  so  serviceable  and  is  in  the  way,  as 
well  as  needed  for  other  purposes.  Supra-pubic  pressure  is  rarely 
efficient,  and  traction  through  the  rectum  is  dangerous.  Care  must 
be.  taken,  especially  towards  the  end  of  the  enucleation,  not  to 
exercise  too  much  force  with  tractors,  lest  the  blades  tear  through  the 
thin  vesical  mucosa,   and  bring  away  the   urethra  and  vesical  outlet 


PERINEAL    PROSTATECTOMY. 


r77 


(Watson,  Ice  infra  cit.).  When  the  posterior  Burface  of  the  prostatic 
sheath  is  displayed  two  lateral  incisions  are  made  through  it,  so  as  to 
expose  the  true  capsule  within  (Fig.  260). 

Young  (Journ.  Amer.Med.  Assoc,  Oct.  24,  1903)  uses  these  lateral 
incisions  in  order  to  avoid  injuring  the  ejaculatory  ducts  which  run 
between  the  two  incisions  (Nicoll  occasionally  used  similar  incisions  : 
Lancet,  April  14,  1894).  The  lateral  lohes  are  then  separately  enucle- 
ated by  blunt  dissection  with  the  finger,  it'  possible,  care  being  taken  to 


Pig.  260. 


Tractor. 


Lateral  incisions 
through  prostatic 
sheath. 


Perinatal  prostatectoni3T.  Tractor  introduced,  blades  separated,  traction  made 
exposing  posterior  surface  of  the  prostate.  Incisions  in  the  fibrous  sheath  on  each 
side  of  ejaculatory  ducts,  exposing  the  true  capsule  of  the  prostate.  (After 
Young,  Ann.  of  Sunj.) 

preserve  the  urethra,  and  the  mucous  membrane  of  the  bladder  just 
below  the  blades  of  the  tractor.  "When  freely  separated  each  lobe  is 
withdrawn,  if  necessary,  with  the  aid  of  forceps.  The  position  of  the 
tractor  is  then  changed,  so  that  one  of  its  blades  engages  and  brings 
down  the  median  lobe  into  one  of  the  lateral  incisions  in  the  fibrous 
sheath.  If  this  is  not  found  to  be  practicable  the  finger  may  be  used 
instead  of  the  tractor.  Dr.  Young  states  that  "  iu  certain  cases  in 
which  a  fibrous  median  bar  or  lobe  is  impossible  to  remove  by  the 
technique  described  above  (in  which  every  effort  has  beeu  directed  to 


678 


OPERATIONS   ON    THE    ABDOMEN. 


leave  the  ejaculatory  bridge  undisturbed),  it  may  be  necessary  to  deliber- 
ately cut  through  the  capsule  covering  the  ejaculatory  ducts,  and  thus 
expose  and  enucleate  or  excise  the  median  prostatic  enlargement."  Ifa 
Btone  is  present  in  the  bladder,  ever  a  Large  one  may  be  removed  by 
"dividing  the  lateral  wall  of  the  urethra  and  dilating  the  vesical  neck," 
and  mere  dilatation  gives  Sufficient  room  in  some  cases,  'the  Madder  is 
washed  out  and  a  large  drainage  tube  inserted,  so  that  one  end  is  just 


Fig.  2G1. 


Tractor. 


Median  lobe. 
Prostatic  sheath. 


I'erinacal  prostatectomy.     Showing  the  technique  of  delivery  of  middle  lobe  into 
cavity  of  left  lateral  lobe.     (After  Venn..'.  Ann.  of  Surg.) 

within  the  bladder  and  the  other  is  stitched  to  the  skin.  Dr.  Young 
drains  the  bladder  and  carries  out  continuous  irrigation  through  two 
catheters  tied  together,  and  introduced  through  the  perineal  incision. 
Continuous  irrigation  is  not  necessary,  hut  it  is  sufficient  to  irrigate 
once  daily.  The  wound  is  lightly  packed  with  gauze.  The  anterior 
wall  of  the  rectum  is  examined  and  protected  by  suturing  the  separated 
edges  of  the  levatores  ani  in  front  of  it  with  catgut.  Care  must  be 
taken  not  to  pack  any  gauze  against  the  rectal  wall  lest  sloughing  occur. 


COMBINED    PERINEAL    WD    SUPRA-PUBIC    OPERATIONS.     679 

The  rubber  tube  may  I"-  lefl  oul  after  five  days,  and  a  Bound  should 
thm  be  passed  through  the  meatus  into  the  bladder  to  ensure  the 
patency  of  the  urethra  just  in  front  of  the  perineal  wound (Pilcher, 
loc.  infra  tit.). 

Dr.  Young  maintains  that  it  is  quite  possible  to  remove  all  the 
prostate  in  segments  without  damaging  the  ejaculatory  ducts,  and 
many  of  his  patients  have  preserved  or  regained  their  sexual  power 
{Ann.  "i  Surg.,  vol.  xli.  p.  556).  This,  although  immaterial  in  most 
cases,  may  be  of  great  importance  in  some,  especially  in  comparatively 
young  men  of  between  40  and  60.  Epididymitis  is  said  to  be  far  less 
common  when  the  ejaculatory  ducts  are  not  divided  ;  when  their  open 
ends  are  left  in  the  deep  wound,  septic  inflammation  may  travel  along 
them  to  the  epididymus. 

Median  perinseal  enucleation  through  the  urethra. — The  urethra 
is  opened,  as  in  median  perineal  cystotomy,  and  the  prostate 
enucleated  by  means  of  the  finger  introduced  into  the  prostatic  urethra, 
the  lateral  walls  of  the  urethra  being  torn  through.  The  chief  objections 
to  this  method  are  that  the  gland  cannot  be  enucleated  as  a  whole,  and 
it  may  therefore  be  incomplete,  a  vesical  projection  being  very  apt  to 
be  missed  in  spite  of  careful  supra-pubic  pressure.  The  room  afforded 
is  so  small,  and  the  depth  at  which  the  work  must  be  done,  make  it 
difficult,  and  even  impossible,  with  large  hypertrophies.  A  perineal 
fistula  or  incontinence  may  persist.  Goodfellow  records  78  operations 
by  this  method  with  two  deaths,  and  Murphy  51  with  one  death  :  Parker- 
Sym's  33  with  two  deaths  (Pilcher,  Ann.  of  Surg.,  1905,  vol.  xlix.  p.  566). 

Dr.  Chetwood  (Ann.  of  Surg.,  1906,  vol.  xliv.  p.  563)  strongly 
advocates  perineal  prostatectomy  in  two  stages,  not  only  when  acute 
retention  exists,  but  also  in  grave  cases  of  cystitis,  renal  changes,  and 
general  debility,  especially  in  advanced  old  age.  He  first  performs  a 
median  perineal  cystotomy,  and  about  a  fortnight  later,  and  under 
more  favourable  circumstances,  he  removes  the  prostate  through  the 
median  perineal  incision  and  prostatic  urethra. 

COMBINED    PERINEAL    AND    SUPRA-PUBIC 
OPERATIONS. 

(a)  Nicoll's  Operation  (Lancet,  April  14,  1894). — In  this  method 
a  supra-pubic  cystotomy  is  performed,  the  edges  of  the  vesical  wound 
being  sewn  to  the  skin,  and  the  bladder  examined.  A  sound  or  bougie 
is  passed  into  the  urethra,  and  the  left  forefinger  into  the  rectum,  and 
a  median  perineal  incision  made  to  expose  the  prostate,  the  rectum 
being  carefully  separated  from  it.  In  some  cases  the  posterior  end  of  the 
incision  may  have  to  be  prolonged  towards  the  tuber  ischii  on  one  or 
both  sides  to  afford  more  room.  A  vertical  incision  is  made  into  the 
lower  part  of  the  prostatic  sheath  in  the  middle  line,  or  two  lateral 
incisions  in  some  cases. 

The  prostate  is  then  enucleated  by  blunt  dissection,  the  assistant 
meanwhile  affording  great  help  by  pressing  the  prostate  down  with  his 
finger  within  the  bladder.  The  urethra  is  not  opened,  nor  is  the 
vesical  cavity  invaded  from  below.  A  catheter  is  passed  through  the 
meatus  into  the  bladder ;  the  perineal  wound  is  packed  with  gauze. 
The  stitches  holding  the  bladder  to  the  skin  are  then  cut,  so  that  the 


680  OPERATIONS   ON   THE    ABDOMEN. 

wound  may  quickly  close.  Irrigation  is  carried  out  daily  through  the 
supra-pubic  wound  and  the  catheter. 

It  is  claimed  that  this  method  is  accompanied  with  less  haemorrhage 
than  the  supra-pubic  operation,  and  that  the  operator  can  see  what  he 
is  doing  and  remove  as  much  as  he  likes,  also  that  the  patient  can  sit 
up,  because  a  perineal  drainage  tube  is  not  required.  A  perinatal  fistula 
can  be  avoided. 

(b)  Fuller's  Operation. — This  consists  of  a  supra-pubic  enuclea- 
tion of  "hypertrophies"  but  not  a  total  extirpation;  the  supra-pubic 
vesical  wound  is  sutured,  and  the  bladder  drained  through  a  median 
perineal  incision.  The  bladder  having  been  opened  the  extent  of  the 
prostatic  enlargement  and  the  site  of  this  urethral  opening  determined, 
the  subsequent  steps  are  carried  out  as  described  by  Dr.  Fuller  (Joarn. 
Art.  and  Gen.  Urin.  Dis.,  June,  1895,  p.  232). 

"  A  pair  of  rough,  serrated-edged  scissors  with  a  long  handle 
grasped  in  the  right  hand  are  slipped  along  the  left  forefinger  into  the 
urethral  opening,  and  are  made  to  cut  through  the  bladder  wall  in  that 
region.  The  cut  extends  from  the  lower  margin  of  the  internal  vesical 
opening  of  the  urethra  backward  for  an  inch  or  an  inch  and  a  half. 
The  blades  of  the  scissors  being  rough  and  serrated,  make  an  incision 
which  bleeds  but  little.  Then  one  of  the  forefingers,  whichever  the 
operator  may  find  the  more  convenient,  is  slipped  through  the  vesical 
hole  made  by  the  serrated  scissors,  while  at  the  same  time  the  fist  of 
the  other  hand  makes  firm  counter-pressure  against  the  perineum. 
By  means  of  this  counter-pressure  the  prostatic  growth  is  brought 
well  within  reach  of  the  forefinger  of  the  other  hand,  which  is  employed 
all  the  time  in  enucleating  the  obstruction  en  masse,  or  piece  by  piece, 
as  the  case  may  be.  This  enucleation  should  not  be  desisted  in  until 
all  the  lateral  and  median  hypertrophies,  as  well  as  all  hypertrophies 
along  the  line  of  the  prostatic  urethra,  have  been  removed."  Dr.  Fuller 
states  that  owing  to  the  small  amount  of  bleeding  he  has  always  found 
it  feasible  to  sew  up  the  supra-pubic  incision  as  described  below,  and 
that  he  has  never  had  trouble  with  secondary  haemorrhage.  A 
perineal  section  is  next  made  and  a  large-sized  rubber  tube  passed 
through  the  perinseal  incision,  and  that  through  which  the  prostate 
was  enucleated,  into  the  bladder.  After  this  hot-water  irrigation  is 
employed  for  some  time  to  stop  oozing.  Next,  the  supra-pubic  wound 
is  closed  by  a  deep  layer  of  catgut  sutures  which  include  the  bladder 
wall,  and  by  a  more  superficial  layer  of  silk-worm  gut.  The  middle  of 
the  incision  is  not  closed,  but  a  deep  provisional  salmon-gut  suture  is 
inserted  here,  taking  up  the  walls  of  the  bladder  and  the  abdomen.  A 
drainage-tube  is  inserted,  and  when  this  is  removed  in  four  or  five  days 
the  provisional  suture  is  tightened  up.  Six  cases  of  prostatectomy, 
five  of  these  operated  on  by  this  supra-pubic  method,  are  given  by  Dr. 
Fuller  ;  all  were  successful. 

Bottini's  Operation. — The  obstruction  at  neck  of  the  bladder  is 
burnt  through  by  means  of  a  specially  designed  galvano  cautery  which  is 
introduced  through  the  urethra.  This  method  has  never  become  popular 
in  England,  but  it  has  found  more  favour  in  America  and  upon  the 
continent  owing  to  the  advocacy  of  Gouley  and  Freudenburg.  Its 
popularity  is  again  on  the  wane,  for  it  can  rarely  be  any  more  than  a 
palliative  procedure,  which  is  not  free  of  danger. 


COMBINED    PERINEAL    AND   SUPRA-PUJBIC   OPERATIONS.     681 

The  following  brief  description  is  taken  from  Mr.  Mansell  Moullin's 
Enlargement  of  the  Prostate,  1904,  p.  172  : — 

"  Bottini's  instrument  as  modified  by  Freudenburg  resembles  a  litho- 
trite  in  shape,  with  a  male  blade  made  of  platinuin-iridium,  flattened 
from  side  to  side  until  it  resembles  a  knife  edge,  and  fitting  into  a 
deep  recess  in  the  female  end.  The  handle  of  the  instrument  is  hollow 
and  arranged  so  that  a  current  of  cold  water  can  be  kept  circulating 
through  it  while  the  male  blade  is  being  raised  to  a  white  heat. 

"  No  anesthetic  is  required,  if,  that  is  to  say,  the  urethra  is  fairly 
tolerant  of  instruments.  The  bladder  may  be  distended  with  water,  but 
this  is  not  absolutely  necessary. 

"  Of  late  I  have  made  use  of  air  instead,  and  it  seems  to  me  to 
answer  the  purpose  better  of  holding  the  rest  of  the  wall  of  the  bladder  out 
of  the  way  of  the  cautery.  When  the  point  is  in  the  bladder,  it  is 
turned  downwards,  as  in  searching  for  a  stone,  and  gently  drawn  out- 
wards until  it  is  felt  that  the  beak  is  in  contact  with  the  obstruction. 

"  If  there  is  any  doubt,  the  exact  position  of  the  instrument  should  be 
ascertained  with  the  finger  in  the  rectum.  The  current  is  then  turned  on, 
and  the  curve  pressed  against  the  hypertrophied  tissue,  a  stream  of  water 
being  made  to  circulate  through  the  instrument  so  as  to  prevent  the 
shaft  becoming  too  hot.  By  gently  elevating  the  handle  the  platinum 
can  be  made  to  burn  its  way  slowly  through,  a  hissing  sound  being 
distinctly  heard.  Then  the  end  of  the  instrument  is  pushed  into  the 
bladder  and  allowed  to  cool  down.  If  the  scab  sticks  to  it,  it  must  be 
burnt  off.  I  usually  make  three  linear  incisions  in  this  way  through 
the  congested  mucous  membrane  at  the  neck  of  the  bladder,  one  in  the 
middle,  and  one  on  each  side.  The  current  required  to  work  effectually 
must  be  of  considerable  strength,  twenty  or  thirty  amperes.  .  .  . 

"  Freudenburg  collected  the  records  of  683  patients  operated  upon 
by  this  method,  and  estimates  the  mortality  at  something  over  5  per 
cent.,  or  if  deaths  not  directly  attributable  to  the  operation  are  omitted  at 
a  little  more  than  4  per  cent.  In  only  6  per  cent,  of  the  cases  was  the 
operation  pronounced  a  failure,  while  in  a  third  of  the  remainder  it 
was  stated  that  there  was  an  improvement,  and  in  two-thirds  that  there 
was  a  cure." 

The  operation  can  be  performed  more  easily  and  with  more  accuracy 
through  a  median  perinaeal  incision,  as  recommended  by  Watson,  and 
this  adds  but  little  to  the  risk. 

The  advantages  claimed  for  the  operation  are  that  it  can  be  performed 
without  an  anaesthetic  with  a  low  mortality  and  little  shock  and  without 
confining  the  patient  to  bed  for  more  than  a  few  days.  External 
wounds  and  fistulse  are  avoided.  The  chief  objections  to  it  are  the 
following : — 

(a)  The  bladder  may  be  perforated. 

(b)  Free  drainage  of  the  bladder  is  not  provided,  and  retention  may 
follow  it. 

(c)  It  has  a  considerable  mortality  from  septic  changes  chiefly 
dependent  on  the  poor  drainage  and  secondarv  sloughing. 

(d)  Primary  and  secondary  haemorrhage  has  been  troublesome. 

(e)  Epididymo-orchitis  is  very  apt  to  follow  it. 

if)  Limitations  to  its  value.  It  is  of  no  use  for  lateral  enlarge- 
ments ;   it  should  never  be  used  except  by  a   skilled  operator,  and 


682         OPERATIONS  ON  THE  ABDOMEN. 

then   only  after   cystoscopy   has   enabled   the   Burgeon   to   learn  the 

exact  conditions  present  and  alter  efficient  distension  of  the  bladder, 
so  that  its  wall  may  not  be  perforated.  In  some  cases  of  associated 
stricture  or  of  impassable  obstruction  of  the  prostatic  urethra   this 

method  cannot  he  adopted,  and  in  some  cases  it  may  he  impossible 
to  apply  the  blade  to  the  obstructing  parts  of  the  prostate,  this 
may  occur  in  cases  where  there  is  a  very  large  high-reaching  third 
lohe  (Watson). 

(//)  As  the  surgeon  is  neither  able  to  see  nor  feel,  it  is  difficult  to  tell 
when  enough  has  been  done. 

(//)  A  fistula  into  the  rectum  or  pelvic  suppuration  may  occur. 

(0  The  immediate  results  are  not  often  cures,  but  merely  palliative, 
and  the  operation  is  of  necessity  incomplete,  so  that  the  lateral  lobes 
may  go  on  enlarging  and  lead  to  a  recurrence  of  symptoms  some  years 
after  an  apparently  successful  operation.  Prostatectomy  under  these 
circumstances  is  very  difficult  owing  to  scarring  and  adhesions  (Freyer, 
loc.  supra  cit.).  For  these  reasons,  the  operation  has  a  very  limited 
use,  but  it  may  be  acceptable  to  some  patients  in  preference  to  more 
radical  measures. 


CASTRATION    FOR    ENLARGEMENT    OF    THE    PROSTATE. 

About  ten  or  more  years  ago  this  operation  was  much  resorted  to, 
chiefly  through  the  work  done  by  Prof.  J.  William  White,*  of  Philadelphia 
(Ann.  of  Surg.,  1893,  and  July,  1895). 

The  following  are  the  chief  of  Prof.  White's  conclusions  : 

(i.)  Clinical  experience  shows  that  in  a  very  large  proportion  of  cases 
(87  per  cent.)  rapid  atrophy  of  the  prostatic  enlargement  follows  the 
operation,  and  that  disappearance  or  great  lessening  of  long-standing 
cystitis  (52  per  cent.),  more  or  less  return  of  vesical  contractility  (66  per 
cent.),  amelioration  of  the  most  troublesome  symptoms  (83  per  cent.), 
and  a  return  to  local  conditions  not  far  removed  from  normal  (46  per 
cent.),  ma}r  be  expected  in  a  considerable  number  of  cases. 

(ii.)  The  mortality  is  18  per  cent.  If  patients  are  operated  upon 
under  surgically  favourable  conditions — i.e.,  before  the  actual  onset  of 
uraemia,  or  before  the  kidneys  have  become  disorganised  by  backward 
pressure  and  infection — Prof.  White  thinks  that  the  mortality  will  be 
only  7*1  per  cent.  The  following  appear  to  be  some  of  the  chief  causes 
of  a  fatal  issue  :  (1)  Sepsis.  This  is  very  likely  when  it  is  difficult  to 
prevent  occasional  dribbling  of  urine.  (2)  When  mania  or  mental 
aberration  follows.  As  this  has  followed  in  a  fair  proportion  of  cases, 
it  must  always  be  reckoned  with.  (3)  Kesults  of  kidney  failure,  a 
complication  always  present  in  these  cases,  and  especially  to  be  feared 
when  the  operation  is  called  for  in  long-standing  and  advanced  cases  of 
enlarged  prostate.  In  such  the  operation  will  he  considered  by  the 
friends  to  be  the  actual  cause  of  death  ;  in  reality  it  merely  fails  to  save 


*  Frederife  and  Ramon  had  previously  performed  the  operation  <<  nt.f.  Chir.,  Sept.  2, 
1893),  but  it  is  to  Dr.  White  that  oar  profession  is  indebted  Eor  first  collecting  and  publish- 
ing with  unmistakable  clearness  the  evidences,  clinical,  pathological,  and  experimental, 
which  justified  a  thorough  trial  of  the  operation. 


CASTRATION. 

life.*     (4)  Causes  of  death  common  to  any  operation  performed  in  the 
aged,  such  as  hemiplegia  and  cardiac  failure. 

The  three  chief'  reasons  for  the  general  loss  of  favour  of  this 
operation  in  recenl  3  ears  arc — 

(1)  Its  high  mortality.  Watson  (Ann.  of  Surg.,  1904,  vol.  xxxix. 
p.  853)  gives  the  mortality  of  210  of  these  operations  as  i(>'ji  per  cent. 
Moreover,  the  death-rate  did  not  decrease  with  experience.  When  a 
careful  selection  of  cases  is  made,  however,  the  results  are  better.  Thus 
Mr.  Mansell  Moullin  (Enlargement  of  the  Prostate,  1904)  lost  only 
two  of  his  19  cases,  a  mortality  of  only  a  little  more  than  10  per 
cent.  Atrophy  occurred  in  all  except  two  of  those  that  survived,  hut  in 
these  two  a  catheter  had  to  be  used  still. 

(2)  The  uncertainty,  incompleteness,  and  impermanence  of  the  relief 
given  by  castration,  which  therefore  compares  very  unfavourably  in 
these  respects  with  total  enucleation  of  the  prostate. 

Freyer  removed  two  prostates  some  years  after  castration  had 
been  performed.     One  of  these  weighed  85-,  and  the  other  ij  oz. 

(3)  The  decrease  of  the  mortalit}^of,  and  the  comparative  completeness 
of  the  relief  afforded  by,  supra-pubic  and  perineal  total  prostatectomy. 
The  death-rate  of  these  operations,  according  to  published  results,  is 
about  8  per  cent.  It  must  always  be  remembered  that  the  real  mortality 
of  all  operations  is  higher  than  the  published  records  indicate,  but  this 
is  equally  true  of  castration,  so  that  there  is  no  doubt  that  castration 
is  more  dangerous  and  far  less  satisfactory  than  prostatectomy. 

It  is  no  longer  true  for  the  great  majority  of  cases  that  removal  of 
both  testicles  is  simpler,  easier,  and  takes  less  time  than  supra-pubic 
prostatectomy,  and  it  is  just  those  cases  in  which  enucleation  is 
difficult,  as  in  small  fibroid  enlargements,  that  castration  will  be  of 
little  or  no  value.  As  to  drainage,  castration  does  away  with  the 
inconveniences  of  any  fistula,  and  the  noisome  leakage  which  may  be 
inseparable  from  it.  On  the  other  hand  there  is  the  repugnance  which 
so  many  men,  even  when  well  on  in  life,  feel  towards  parting  with  their 
testicles,  a  repugnance  which  we  often  met,  and  which  frequently 
baffled  us. 

It  must  not  be  forgotten  that  all  the  immediate  relief  following 
double  castration  was  due  to  reflex  diminution  of  vascular  congestion, 
and  due  to  the  enforced  rest.  Much  of  the  permanent  decrease  of 
obstruction  and  the  undoubted  decrease  in  the  size  of  the  prostate  was 
doubtless  due  to  the  same  factors.  The  adenomatous  growth  may  still 
continue.  The  following  conclusions  arrived  at  by  Mr.  Cuthbert 
Wallace  (Trans.  Path.  Soc.  of  London,  vol.  lvi.,  Part  I.,  1905)  after 
very  careful  experimental  researches,  and  a  thorough  consideration  of 
the  clinical  evidence  available,  are  of  great  importance  in  their  bearing 
upon  this  subject : 

"  Castration  in  adult  life  produces  an  atrophy  of  the  prostate.  Such 
an  atrophy  takes  an  appreciable  time  to  become  established.  Castra- 
tion, although  it  produces  an  atrophy  of  the  normal  prostate  in  the 

*  In  Mr.  H.  Fenwick's  words  (Med.  Ann.,  1S96,  p.  50S).  ••there  is  every  reason  to 
believe  that  unsuitable  and  unfavourable  eases  have  been  chosen  in  the  first  wild  rush 
which  is  so  unreasonably  made  at  every  innovation.  Uremic  and  even  dying  patients 
have  been  castrated." 


us,  OPERATIONS    ON    TIIK    AI'.DOMKN. 

course  of  time,  is  not  to  bo  depended  upon  to  produce  an  appreciable 
atrophy,  useful  for  the  treatment  of  the  enlarged  organ." 

1  quite  agree  with  Mr.  Wallace  that  the  operation  has  been  rightly 
abandoned. 

Unilateral  orchidectomy  is  unscientific,  for  the  presence  of  one  testis, 
even  if  the  excretory  duct  has  been  divided,  is  sufficient  for  the  perfect 
growth  and  nutrition  of  the  prostate  (Wallace).  Therefore  it.  is  hardly 
to  be  expected  that  this  operation  would  have  any  appreciable  influence 
upon  the  enlarged  prostate,  and  when  any  effect  has  been  noticed  it  has 
been  but  transient,  and  probably  of  a  reflex  vascular  origin. 

VASECTOMY. 

The  division  or  removal  of  portions  of  the  vasa  deferentia  was  largely  practised  a  few 
years  ago  as  an  alternative  to  castration  Eor  certain  cases  of  hypertrophy  of  thepn 
(vide  p.  682).     The  chief  arguments  that  have  been  advanced  in  Eavour  of  vasectomy  are 

— (1)  that  its  effect  on  the  prostate  is  the  same  as  that  of  castration;  (2)  that  the 
operation  is  much  less  severe  than  castration,  and  therefore  better  borne  by  the  type  of 
patients  who  need  such  measures:  (3)  that  it  meets  the  rooted  objection  to  loss  of  the 
testicles  thai  many  men  have,  even  when  advanced  in  years. 

On  the  other  hand,  although  some  brilliant  successes  have  been  recorded,  the  mortality, 
as  shown  by  Wood's  figures  (loe.  supra  tit,  p.  480),  amounts  to  6-7  per  cent.,  not  very 
much  less  than  the  present  mortality  of  castration  for  enlarged  prostate.  Again,  the 
improvement  is  usually  not  so  great  as  after  castration,  and  ii  is  QO<  nearly  so  certain  ; 
Wood's  figures  show  that  some  improvement  took  place  in  only  67  per  cent.,  as  against 
90  per  cent,  improved  after  castration.  Finally,  there  is  evidence  that  relapse  takes  place 
in  some  of  the  cases  in  which  this  operation  is  performed,  and  Freyer  (  /.  incet,  vol.  i..  1900, 
p.  155)  goes  so  far  as  to  say  that  "  in  a  very  considerable  proportion  of  the  cases  there  lias 
been  no  permanent  benefit  from  this  operation."  This  might  be  expected  from  the  very 
nature  of  the  operation,  which  cannot  possibly  have  anything  like  the  same  effect  on  the 
sexual  organs  generally  that  castration  must  have. 

Experimental  evidence  has  since  shown  that  vasectomy  does  not  lead  to  atrophy  of 
either  the  healthy  prostate  or  the  testicle  (Wallace,  loe.  tit.*).  Unless  the  sympathetic 
nerves  and  the  vessels  running  with  the  vas  were  also  severed,  no  appreciable  effects  were 
noticed.  Atrophy  of  I  he  testis  Eollows  destruction  of  these  structures.  Clinical  evidence 
has  also  accumulated,  and  amply  proved  the  wort hlessness  of  this  operal  ion.  which  has 
abandoned,  and  will  not  be  described  here.  Secondary  operations  have  been  quite 
commonly  required  after  vasectomy  (Freyer,  lor.  supra  tit.'). 

Causes  of  Death  after  Operations  for  Enlargement  of  the 
Prostate. 

(1)  Uraemia  is  by  far  the  commonest;  (2)  shock;  (3)  cardiac 
failure;  (4)  ascending  suppurative  nephritis;  (5)  pelvic  cellulitis, 
pulmonary  complication,  pneumonia,  or  bronchitis  ;  (6)  mania  and 
other  forms  of  insanity;   (7)  pulmonary  embolism. 

Palliative  Operations. — Cystotomy  may  have  to  be  performed  for 
the  relief  of  acute  retention,  intra-vesical  hemorrhage,  severe  cystitis, 
threatening  uraemia,  or  for  the  removal  of  calculi.  It  is  far  better  to 
adopt  the  supra-pubic  in  preference  to  the  perineal  route,  which  is  a 
long  and  troublesome  one  in  these  cases,  for  acute  retention.  Aspira- 
tion is  not  suitable  except  merely  to  relieve  the  patient  while  awaiting 
other  and  more  satisfactory  measures.  Although  aspiration  may  be 
followed  by  such  a  diminution  of  congestion  of  the  prostate  and 
urethra  that  a  catheter  can  be  passed  after  a  few  hours,  this  is  not  to 
be  relied  upon,  for  a  repetition  of  the  aspiration  is  very  likely  to  become 


PRIMARY    MALIGNANT    DISEASE   OF   THE    PROSTATE     685 

necessary  again  and  again,  with  the  result  that  Bome  of  the  urine, 
which  is  usually  infective,  if  not  always  foul,  leaks  into  the  pelvic 
cellular  tissues,  with  disastrous  results. 

It  is,  therefore,  far  hetter,  when  all  attempts  at  catheterisation  have 
tailed.  t.>  perform  either  supra-pubic  cystotomy  or  supra-pubic  puncture 
with  a  trocar  and  cannula.  In  either  case  drainage  must  he  established, 
and  continued  until  urine  passes  naturally,  or  a  catheter  can  he  intro- 
duced through  the  urethra.  Supra-pubic  cystotomy  provides  the  hest 
drainage,  and  therefore  the  best  safeguard  against  renal  complications 
and  pelvic  cellulitis,  hut  supra-pubic  puncture  is  the  easiest  to  perform 
in  an  emergency  without  proper  help,  and  the  fistula  closes  sooner  if 
the  natural  passage  becomes  re-established.  Care  must  he  taken,  how- 
ever, not  to  remove  the  supra-pubic  catheter  until  its  track  is  sealed 
off  from  the  cellular  tissues,  so  that  extravasation  may  not  occur.  In 
most  cases  it  is  best  to  perform  supra-pubic  cystotomy  and  to  drain 
the  bladder  until  cystitis,  congestion,  and  any  umeniic  symptoms  have 
subsided,  and  then  to  perform  supra-pubic  prostatectomy,  if  there  are 
no  contra-indications. 


PRIMARY  MALIGNANT   DISEASE   OF   THE   PROSTATE. 

This  is  a  comparatively  rare  cause  of  enlargement  of  the  prostate, 
although  it  is  not  so  uncommon  as  is  generally  believed ;  and  for  this 
reason  it  is  important  to  examine  all  prostates  which  are  removed  for 
supposed  adenomatous  enlargement.  Carcinoma  is  b}r  far  the  com- 
monest malignant  growth,  and  Holmes  Green  estimates  that  from 
5  to  10  per  cent,  of  the  senile  prostatic  enlargements  are  carcinomatous. 
It  occurs  in  men  who  are  well  advanced  in  years.  The  average  age  of 
19  cases  which  were  collected  by  Holmes  Green  was  68  }-ears  (New 
York  Med.  Journ.,  Oct.  24,  1903),  and  of  100  cases  collected  by 
Kaufmann  all  were  over  40,  and  68  per  cent,  were  between  50  and  70 
years  of  age  (Hawley,  Ann.  of  Surg.,  1904,  vol.  xxxix.  p.  893).  Sarcoma 
is  much  less  common,  and  occurs  in  younger  subjects. 

The  carcinomatous  prostate  differs  from  the  adenomatous  in  being 
nearly  always  much  harder,  and  nodular  upon  the  surface.  It  also 
gives  rise  to  much  more  pain  in  the  perinseurn,  penis,  sciatic  region, 
and  rectum.  Bleeding  is  also  more  common,  and  occurs  more  fre- 
quently apart  from  retention  and  instrumentation.  Later  on  the  iliac 
and  groin  glands  may  be  enlarged,  the  rectal  wall  invaded,  and  metas- 
tasis may  become  evident,  especially  in  the  bones.  These  may  appear 
when  the  primary  gi'owth  is  comparatively  small  and  removable,  so  that 
it  is  important  to  examine  for  them. 

Operations. — (a)  In  late  cases  either  no  operation  is  indicated,  or 
palliative  supra-pubic  cystotomy  may  become  necessary  for  retention  of 
urine,  but  as  long  as  the  obstruction  can  be  overcome  by  means  of  a 
catheter,  without  much  pain,  no  operation  should  be  undertaken. 
After  a  supra-pubic  cystotomy  Colt's  apparatus  may  be  used  to  keep 
the  patient  dry  (p.  602). 

((b)  In  early  cases.  Since  Billroth's  original  case  of  perinaeal  extir- 
pation in  1859  many  attempts  have  been  made  to  perform  radical 
operations    for   malignant    disease  of   the  prostate,  but  most  of  the 


686  OPERATIONS   OX    THE    A.BDOMEN. 

attempts  have  been  far  too  Into,  so  that  many  have  considered  that 
operative  interference  is  always  unjustifiable.  Recent  results  are 
more  favourable,  however,  [f  the  diagnosis  is  made  soon,  and  before 
the  disease  has  invaded  the  bladder  or  urethra,  and  in  the  absence  of 
any  Bigns  of  dissemination,  the  growth  may  be  explored  through  the 
perineum,  and  enucleated  from  within  the  fibrous  Bheath,  if  possible. 
If  cystoscopy, has  not  been  practicable,  it  will  be  necessary  to  per- 
form supra-pubic  cystotomy,  in  order  to  determine  the  freedom,  or 
otherwise,  of  the  bladder,  before  extirpation  is  attempted.  In  some 
cases  it  is  quite  impossible  to  pass  the  cystoscope  through  the  hard 
and  contracted  prostatic  urethra,  but  this  difficulty  usually  arises  in 
late  cases,  which  are  unsuitable  for  any  radical  operation. 

To  attempt  to  remove  an  adherent  prostatic  carcinoma  is  meddlesome 
surgery,  and  is  to  be  heartily  condemned.  The  only  hope  is  in  the 
early  stage,  when  the  diagnosis  is,  unfortunately,  difficult. 

Holmes  Green  and  others  have  removed  early  carcinomatous 
prostates  in  mistake  for  so-called  senile  hypertrophy.  In  Dr.  Green's 
case  only  one  lobe  of  the  gland  was  malignant.  The  patient  recovered, 
and  was  well  a  year  later,  except  for  a  small  feecal  fistula,  the  result  of 
injury  of  the  rectum  at  the  operation. 

Oraison  reports  "  23  cases  from  the  French  clinics  in  which  perineal 
prostatectomy  was  done.  In  10  of  these  (43  per  cent.)  cure  has 
remained  permanent  after  more  than  four  years.  In  three  only  were 
there  recurrences.  Six  others  recovered,  but  were  lost  sight  of;  the 
remaining  four  died  from  the  operation  "  (Hawley,  loc.  supra  cit.). 

Prostatic  Abscess. — This  generally  opens  spontaneously  into  the 
urethra,  or  it  may  be  perforated  by  the  catheter,  which  is  introduced 
for  the  relief  of  acute  retention  of  urine.  In  other  cases  it  opens  into 
the  rectum,  and  in  some  it  burrows  back  into  the  ischio-rectal  fossa, 
and  issues  at  the  side  of  the  anus. 

The  perineal  route  is  the  best  to  choose  for  opening  and  draining 
the  abscess,  and  should  be  adopted,  if  possible,  before  the  pus  has 
burrowed  about  or  has  given  rise  to  pyaemia.  The  abscess  drains  but 
poorly  along  the  urethra,  and  its  discharge  in  this  direction  may  be 
followed,  in  some  cases,  by  c}Tstitis,  urethritis,  or  troublesome  urinary 
fistulse. 

Dr.  Alexander  (Ann.  of  Swrg.,  1906,  vol.  xlii.  p.  883)  opens  all 
prostatic  abscess  through  the  prostatic  urethra,  into  which  he  introduces 
a  finger  through  an  opening  made  into  the  membranous  urethra  upon 
a  grooved  staff.  A  finger  of  the  other  hand  is  introduced  into  the 
rectum  as  a  guide,  and  the  finger  within  the  urethra  tears  through  the 
mucous  membrane  and  opens  the  abscess  or  dilates  a  pre-existing 
small  opening.  All  trabecule  are  broken  down,  and  a  free  opening  is 
made.  The  bladder  is  then  drained  through  a  tube  introduced  into 
the  perineal  wound.  A  few  strips  of  gauze  are  passed  alongside  the 
tube  as  far  as  the  opening  into  the  abscess  cavity,  which  is  not 
packed. 

Dr.  Lusk  (Ann.  of  Surf/.,  January,  1907,  p.  103)  objects  to  this 
method  for  cases  in  which  the  abscess  has  not  already  ruptured  into  the 
urethra,  and  prefers  to  open  the  abscess  through  the  fore  part  of  ischio- 
rectal fossa,  behind  the  base  of  the  triangular  ligament,  and  between 
the  anterior  borders  of  the  levatores  ani.     In  this  way  the  urethra  is 


PRIMARY    MALIGNANT    DISEASE    OF   THE   PROSTATE     687 

not  opened,  and  the  danger  of  cystitis  and  the  troubles  of  a  urinary 

fistula  arc  avoided. 

I  think  Dr.  Lusk's  way  is  the  best  method  for  the  cases  indicated 
by  bin),  and  it  is  an  easy  and  safe  method.  There  is  hardly  any 
danger  of  injuring  the  rectum,  which  is  separated  from  the  wound  by 
the  levator  ani  and  anal  fascia.  The  structures  in  the  perineal  triangle 
and  those  between  the  triangular  ligament  are  entirely  avoided,  while 
the  pudic  vessels  and  nerves  are  left  en  sheathed  by  the  obturator 
fascia  in  the  outer  wall  of  the  ischio-rectal  fossa.  Dr.  Alexander's 
method  is  a  rapid  and  excellent  one  for  late  cases  in  which  the  abscess 
has  opened  into  the  urethra,  or  has  burrowed  down  alongside  the 
membranous  urethra. 

Prostatic  Calculi. — These  are  usually  small,  and  are  best  removed 
through  a  median  perinatal  section  (vide  p.  630). 


CHAPTER  XIII. 
OPERATIONS  ON  THE  URETHRA  AND  PENIS. 

RUPTURED  URETHRA.  —  EXTERNAL  URETHROTOMY.  — 
INTERNAL  URETHROTOMY.  —  THE  TREATMENT  OP 
STRICTURE  RETENTION.  —  CIRCUMCISION.— AMPUTA- 
TION  OP  PENIS.— EPISPADIAS.— HYPOSPADIAS. 

RUPTURED  URETHRA. 

In  a  few  cases  the  surgeon  may  succeed  in  passing  a  catheter  into  the 
bladder.  He  is  most  likely  to  do  so  by  keeping  the  point  along  the  roof 
of  the  urethra,  for  this  is  the  part  which  most  frequently  escapes  injury. 
If  the  instrument  enter  the  bladder  in  a  case  where  there  has  been 
much  bruising*  of  the  perinseum  and  extravasation  of  blood,  a  median 
incision  should  still  be  made  to  allow  of  relief  of  tension  and  escape  of 
breaking  down  clots,  and  so  give  good  drainage.  If  this  is  not  done, 
the  probability  is  great  that  a  little  later,  owing  to  damage  of  soft  parts, 
tension  of  blood  clot,  and  a  little  escape  of  urine  by  the  side  of  the 
catheter,  this  step  will  be  required  at  a  time  when,  from  the  presence 
of  septic  fever,  and  the  condition  of  the  extravasated  blood  and  urine, 
the  occasion  is  less  favourable.!  Again,  though  a  catheter  can  be 
passed  at  the  time,  it  by  no  means  follows  that  when,  owing  to  it 
being  plugged,  or  from  some  other  reason,  it  requires  removal  in  a  few 
days,  a  fresh  one  can  be  inserted.  An  incision  will  then  have  to  be 
made,  and,  as  already  stated,  under  conditions  less  favourable.  J 

When,  as  is  usually  the  case,  a  catheter  cannot  be  passed  into  the 
bladder,  the  patient  is  placed  in  lithotomy  position,  and  the  parts 
haying  been  shaved  and  cleansed,  a  grooved  staff  of  as  full  size  as  the 
parts  will  admit  is  passed  as  far  as  it  will  go — i.e.,  to  the  site  of  the 
rupture;  it  is  then  made  to  project  in  the  perinaeum,  and  the  surgeon, 
entering  a  straight  sharp-pointed  bistoury  in  the  middle  line  at  a  point 
an  inch  to  an  inch  and  a  half  in  front  of  the  anus,  pushes  it  on  till  it 


*  Complete  rupture  of  the  urethra  may  co-exist  with  a  mere  contusion  of  the 
perinaeum,  especially  if  much  tenderness  is  present. 

|  Kaufmann  (Von  Bergmann's  System  of  Practical  Surgery  .  out  of  .(.j  rases,  found 
that  the  catheter  had  to  be  removed  in  22.  for  extravasation  had  occurred  in  3.  PerinaeaJ 
abscess  had  developed  in  9.  and  extensive  sloughing  in  10;  five  of  the  patients  died  from 
these  ' iplications. 

%  Mr.  Bntherford  [Glasgow  Hosp.  I>>'/>.)  advises  Bupra-pubic  puncture  in  addition  to 
any  other  procedure,  and  describes  three  cases  in  which  he  adopted  this  plan  with 
advantage. 


RUPTURED    URETHRA.  68g 

strikes  the  groove,  and  th.n  cuts  along  this,  both  upwards  aiid  down- 
wards, so  as  to  expose  freely  the  Bpol  at  which  the  urethra  is  ruptured. 
As  the  knife  is  brought  out,  the  skin  wound  is  enlarged  till  this  is 
about  an  inch  and  a  half  long,  the  lower  end  being  hall' an  inch  in  front 
of  the  anus.  I  prefer  to  cut  down  upon  the  stall'  with  an  ordinary 
scalpel,  although  the  method  already  given  is  quicker. 

With  the  linger  clots  are  now  turned  out,  and,  retractors  being 
inserted  deeply,  the  wound  is  sponged  out  thoroughly.  A  good  deal 
of  bleeding  may  now  take  place  from  some  wounded  vessel,  hitherto 
closed  by  extravasated  blood,  or  from  the  cms  penis,  detached  on  one 
side  by  the  violence  which  ruptured  the  urethra,  especially  if  there  be 
a  fractured  pelvis.  This  lnumorrhage  will  yield  to  firm  pressure  or  to 
forci-pressure.  The  anterior  end  of  the  urethra  is  next  readily  found 
by  the  end  of  the  staff,  which  projects  through  it.  The  finding  of  the 
deeper  or  vesical  end,  often  difficult,  will  be  facilitated  by  careful 
sponging,  a  mirror  and  reflected  light,  pressure  above  the  pubes,  and 
the  use  of  fine  probes  or  straight  gum-elastic  catheters.  This  end 
often  projects  as  a  small  clot  or  bleeding  point ;  at  other  times  it 
resembles  a  partly  twisted  artery.* 

If  it  be  found,  a  catheter  of  as  large  size  as  possible  should  always 
be  introduced,  if  practicable,  from  the  meatus,  and  then  through  the 
vesical  end  of  the  urethra  into  the  bladder,  guided  by  a  finger  in  the 
wound,  a  Brodie's  probe,  or  a  Teale's  gorget  (Fig.  264).  If  this  be 
found  impracticable,  a  catheter  should  be  passed  into  the  bladder  from 
the  wound.  One  of  these  methods  should  always  be  made  use  of,  if 
possible,  as  it  enables  the  patient  to  be  kept  dry  by  tubing  attached 
to  the  catheter. 

But  if  no  catheter  can  be  got  into  the  bladder,  either  along  the  penis 
or  from  the  wound,  the  surgeon  need  not. worry  himself  as  long  as 
a  free  exit  has  been  given  for  the  urine  and  extravasated  blood.  In 
these  cases  it  is  not  unusual  for  the  bladder  to  become  somewhat 
distended  during  the  first  two  or  three  days,  owing  to  the  urine  not 
escaping  with  sufficient  freedom,  or  to  the  closure  of  the  vesical  end  of 
the  urethra  from  swelling  after  the  injury  and  the  manipulations  to  find 
it,  or  from  the  patient,  if  a  child,  shrinking  from  passing  his  water. 
This  difficulty  will  usually  be  met  by  hot  flannels  frequently  applied  to 
the  abdomen,  and  a  few  doses  of  laudanum,  but  if  it  be  evident  that 
the  urine  does  not  escape  with  sufficient  freedom,  the  surgeon  must 
again  examine  the  wound  with  the  aid  of  an  anaesthetic,  clean  out  any 
fresh  clots,  and  again  try  to  find  the  vesical  end  of  the  urethra,  aided 
now,  perhaps,  by  a  better  light. 

If  this  fail,  supra-pubic  tapping  or  aspiration,  or  if  the  patient's 
condition  be  good,  making  a  small  supra-pubic  opening  into  the  bladder 
and  thence  passing  a  short  curved  staff  into  the  perinseum,  and  so  finding 
the  vesical  end  of  the  urethra  (p.  652),  must  be  resorted  to. 

Urethritis  and  cystitis  are  not  uncommon  in  children.  They  are 
best  met  by,  as  soon  as  possible,  leaving  out  the  catheter  for  a  while. 

With  regard  to  the  question  of  trying  to  suture  the  urethra,  it  is 
always  advisable,  if  possible,  to  draw  the  ends  of  the  urethra  together 

*  The  farther  back  the  tear,  the  greater,  of  course,  the  difficulty  iu  riudiug  the 
urethra. 

s. — vol.  11.  44 


690  OPERATIONS   ON    THE   A.BDOMEN. 

on  the  catheter  with  a  fine  curved  needle  on  a  bolder,  and  catgut 
sutures.  Bui  this  will  often  be  found  a  matter  of  great  difficulty,  and 
even  impossible.  When  effected,  it  does  not  diminish  the  need  of 
subsequent  regular  use  of  catheters,  and  the  perineal  wound  must  be 

drained  for  R  few  days  in  any  case,  however  well  the  surgeon  may  have 
been  able  to  sew  the  urethra. 


EXTERNAL  URETHROTOMY  (Figs.  262  to  266). 

This  operation  includes  the  different  forms  of  perineal  section  with 
or  without  a  guide — viz.,  Syme's,  AVheelhouse's,  and  Cock's  operations. 

By  some,  external  urethrotomy  is  reserved  for  those  cases,  such 
as  Syme's,  in  which  a  staff  can  be  passed  through  the  stricture,  and 
"  per  in  seal  section  "  for  those  in  which  no  such  help  is  available — e.g., 
Mr.  Cock's  operation.  As,  however,  these  terms  are  readily  confused 
by  students,  and  as  in  Wheelhouse's  operation  a  stall'  is  used, 
though  it  cannot  be  passed  through  the  stricture,  I  think  it 
preferable  to  employ  the  term  external  urethrotomy,  specifying  which 
operation  is  meant  by  using  the  author's  name — viz.,  Syme's  external 
urethrotomy,  &c. 

Indications  for  External  Urethrotomy. — This  operation  is  recom- 
mended for  (1)  cases  of  impermeable  stricture,  for  which  both  dilatation 
and  internal  urethrotomy  are  inapplicable. 

(2)  Cases  of  stricture  which  do  not  yield  to  dilatation,  or  rather 
continue  to  present  symptoms  after  being  dilated,  in  other  words, 
contractile,  irritable,  and  resilient  strictures,  in  which  dilatation  is 
accompanied  with  much  pain,  or  in  which  it  is  found  that  a  No.  7  can 
perhaps  be  passed  one  day  and  only  a  No.  3  a  day  or  two  later.  These 
are  usually  cases  of  false  passages  at  the  side  of  the  real  stricture,  the 
instrument  having  been  forced  through  the  urethral  wall  just  in  front 
of  the  constriction  and  then  back  again  into  the  dilated  urethra 
behind. 

(3)  Traumatic  constrictions  are  also  sometimes  very  intractable 
with  dilatation,  and  elongated  multiple  strictures  are  very  troublesome, 
and  are  often  best  treated  by  external  urethrotomy. 

(4)  Cases  in  which  rigors  and  constitutional  disturbances  follow  any 
attempt  at  dilatation. 

(5)  When  fistula?  or  cystitis  complicate  the  stricture,  it  is  best  to  use 
this  operation. 

AVheelhouse's  operation  is  far  more  often  employed  than  that  of 
Syme,  for  the  former  is  more  generally  applicable  to  all  kinds  of 
strictures,  whereas  Syme's  operation  needs  a  permeable  urethra  lor  its 
performance.  Cock's  operation  is  the  most  suitable  for  bad  cases  with 
acute  retention,  extravasation,  or  multiple  fistuhe  and  diseased  kidneys. 

Syme's  External  Urethrotomy. — Here  the  stricture  is  divided  on 
a  fine  staff  (vide  infra)  passed  through  it. 

Operation. — The  patient,  having  been  prepared  by  mild  aperients  and 
bland  liquid  diet  for  the  operation,  is  brought  under  an  anfiBsthetic, 
and  while  his  legs  hang  over  the  end  of  the  table  the  surgeon  introduces 
a  Syme's  staff.  This  has  a  narrow  terminal  portion  which  passes 
through  the  stricture,  a  shoulder  which  rests  upon  the  face  of  the 
stricture,   and  a  wider,    stouter  part  above  the  shoulder  to  make  the 


KXTKUNAL    I   i;KTIIi;oT().\IV. 


691 


instrument  easier  to  find  in  the  perineum.     The  patient  being  placed, 

in  a  good  light,  in  lithotomy  position,  and  the  parts  cleansed  and 
shaved,  the  surgeon  makes  an  incision  exactly  in  the  median  line  down 
upon  the  stall',  exposing  the  wider  portion  above  the  shoulder.  When 
the  surgeon  is  certain  that  this  is  laid  hare,  he  runs  the  knife  forwards 
along  the  groove,  so  as  to  divide  the  stricture  completely.  The  stall'  is 
now  withdrawn,  and  the  rest  of  the  treatment  must  vary  somewhat.  l( 
the  condition  of  the  patient  admits  of  it,  a  full-sized  gum-elastic  catheter 
should  he  passed  from  the  meatus  into  the  bladder,  guided  by  a  linger 
in  the  wound  or  in  the  rectum,  or  by  a  grooved  director  passed  from  the 
perineum.  If  the  irritability  of  the  parts  does  not  admit  of  this,  a 
gum-elastic  catheter  must  be  inserted  from  the  perimeum, 
cut  short,  and  kept  in  situ  with  tapes,  the  urine  running  Fig.  262. 
off,  by  tubing  attached,  into  a  basin  containing  carbolic 
acid  lotion  ;  or  Prof.  Syme's  curved  perineal  catheter 
may  be  employed. 

As  soon  as  a  catheter  can  be  passed  from  the  meatus, 
it  should  be  kept  in  for  two  or  three  days,  and  changed, 
if  needful,  with  an  anaesthetic  at  first.  As  soon  as  pos- 
sible it  should  be  passed  twice  a  day,  and  the  patient 
should  be  clearly  told  of  the  absolute  necessity  which 
exists  of  keeping  up  the  good  effects  of  the  operation  by 
the  passage  of  an  instrument  at  regular  intervals,  and  of 
occasionally  reporting  himself  to  his  surgeon. 

Wheelhouse's  External  Urethrotomy.  —  Here  the 
stricture  is  first  found  by  a  staff  passed  down  to  it,  and 
then  divided  on  a  fine  probe-pointed  director  passed 
through  it. 

Mr.  Wheelhouse  (Brit.  Med.  Journ.,  June  24,  1876) 
recommends  his  method  as  having  "the  advantage  of 
greatly  increased  precision.  It  renders  an  operation,  con- 
fessedly hitherto  one  of  the  most  difficult  in  surgery,  a 
comparatively  easy  one,  and  one  which,  in  my  hands  and 
in  those  of  my  colleagues,  has  given  results  infinitely 
more  favourable,  with  an  immediate  and  ultimate  effect 
upon  our  cases,  than  we  had  ever  seen  before  its  intro-  (Wheelhouse.) 
duction." 

Operation. — "  The  patient  is  placed  in  lithotomy  position,  with  the 
pelvis  a  little  elevated,  so  as  to  permit  the  light  to  fall  well  upon  it, 
and  into  the  ground  to  be  made.  The  staff*  (Fig.  262)  is  to  be  intro- 
duced with  the  groove  looking  toward  the  surface  and  brought  gently 
into  contact  with  the  stricture.  It  should  not  be  pressed  much  against 
the  stricture,  for  fear  of  tearing  the  tissues  of  the  urethra  and  causing 
it  to  leave  the  canal,  which  would  mar  the  whole  after-proceedings, 
which  depend  upon  the  urethra  being  opened  a  quarter  of  an  inch  in 
front  of  the  stricture.  "Whilst  an  assistant  holds  the  staff  in  this  position, 
an  incision  is  made  into  the  perinaaum,  extending  from  opposite  the 
point  of  reflection  of  the  superficial  fascia  to  the  outer  edge  of  the 


*  This  is  fully  grooved  through  the  greater  part,  but  not  through  the  whole  of  its 
extent,  the  last  half-inch  uf  the  groove  being  "  stopped  "  and  terminating  in  a  round 
button-like  end. 


44" 


692 


OPERATIONS   ON    THE    A.BDOMEN. 


sphincter  ani.  The  tissues  of  the  perineum  are  to  be  steadily  divided 
until  the  urethra  is  reached.  This  is  now  to  be  opened,  in  the  groove 
of  the  staff,  not  upon  its  point,  so  as  certainly  to  secure  ii  quarter  of  an 
inch  of  healthy  tube  immediately  in  front  of  the  stricture.  As  soon  as 
the   urethra   is  opened,  and    the  groove  in  the  stall"  fully  exposed,  the 

I'H;,  263. 


End  of 
Wheelhouse  staff 


Retractor  holding 
Mju  urethra  open 


Wheelhouse's  operation.     The  urethra  has  been  opened  in  front  of  the  stricture. 
(After  Wheelhouse.) 


Fig.  264. 


edges  of  the  healthy  urethra  are  to  be  seized  on  each  side  with  straight- 
bladed  nibbed  forceps  and  held  apart.  The  staff  is  then  to  be  gently 
withdrawn  until  the  button-point  appears  in  the  wound.     It  is  then  to 

be  tinned  round,  so  that  the  groove 
may  look  to  the  pubes,  and  the  button 
may  be  hooked  on  to  the  upper  angle 
of  the  opened  urethra,  which  is  then 
held  stretched  open  at  three  points 
thus  (Fig.  263),  and  the  operator  looks 
into  it  immediately  in  front  of  the 
stricture.  While  thus  held  open,  a 
probe-pointed  director*  is  inserted 
into  the  urethra,  and  the  operator,  if 
he  cannot  see  the  opening  of  the  stric- 
ture, which  is  often  possible,  generally 
Teale'B  probe-gorget.  succeeds  in  very  quickly  finding  it  and 

pusses  the  point  onwards  through  the 
stricture  towards  the  bladder.  The  stricture  is  sometimes  hidden 
amongst  a  crop  of  granulations    or  warty   growths,   in   the  midst  of 


*  Or  a  common  hlunt-i.ointeil  probe  may  be  need.    Occasionally  a  bougie  (No.  2  or  3) 

is  useful. 


EXTERNAL    CJRETHROTOMY. 


f>93 


which  the  probe-point  easily  finds  the  true  passage.  The  director 
having  been  passed  into  the  bladder  (its  entrance  into  which  is  clearly 
demonstrated  by  the  freedom  of  its  movements),  its  groove  is  turned 
downwards,  the  whole  length  of  the  stricture  is  carefully  and  delibe- 
rately divided  on  its  under-surface,  and  the  passage  is  thus  cleared. 
The  director  is  still  held  in  the  same  position,  and  a  Btraight  probe- 
pointed  bistoury  is  run  along  the  groove  to  ensure  complete  division  of 
all  bands  or  other  obstructions.  These  having  been  thoroughly  cleared, 
the  old  difficulty  of  directing  the  point  of  a  catheter  through  the  divided 
stricture  and  onwards  into  the  bladder  is  to  be  overcome.  To  effect 
this,  the  point  of  a  probe-gorget  (Fig.  264)  is  introduced  into  the  groove 

Fig.  265. 


Wheelhouse 


Wheelhouse's  operation.     The  probe-gorget  is  used  to  guide  the  catheter  into 
the  bladder.     (After  Wheelhouse.) 

in  the  director,  and,  guided  by  it,  is  passed  onwards  into  the  bladder 
dilating  the  divided  stricture,  and  forming  a  metallic  floor,  along  which 
the  point  of  the  catheter  cannot  fail  to  pass  securely  into  the  bladder. 
The  entry  of  the  gorget  into  the  latter  viscus  is  signalised  by  an  imme- 
diate gush  of  urine  along  it.  A  silver  catheter*  (Xo.  10  or  n)  is  now 
passed  from  the  meatus  down  into  the  wound,  is  made  to  pass  once 
or  twice  through  the  divided  urethra,  where  it  can  be  seen  in  the  wound, 
to  render  certain  the  fact  that  no  obstructing  bands  have  been  left 
undivided,  and  is  then,  guided  by  the  probe-gorget,  passed  easily  and 
certainly  along  the  posterior  part  of  the  urethra  into  the  bladder 
(Fig.  265).     The  gorget  is  now  withdrawn,  the  catheter  fastened  in 


A  soft  catheter  is  better  and  safer  to  tie  in. 


694  OPERATIONS   ON   THE    ABDOMEN. 

the  urethra  and  allowed  to  remain  for  three  or  four  days,  an  elastic 
tube  conveying  the  urine  away.  After  three  or  four  days  the  catheter 
is  removed,  and  is  then  passed  daily,  or  every  second  or  third  day, 
according  to  circumstances,  until  the  wound  in  the  perineum  is  healed  ; 

and  after  the  parts  have  become  consolidated  it  requires,  of  course,  to 
be  passed  still  from  time  to  time,  to  prevent  recontraction."* 

This  will  be  found  a  most  effectual  operation,  but  in  many  cases  the 
hitting  off  of  the  mouth  of  the  stricture  is  a  less  simple  matter  than 
would  be  gathered  from  Mr.  Wheelhouse's  account.  This  is  especially 
the  case  when  the  parts  are  engorged  and  softened,  as  the  free  oozing 
which  is  met  with  under  these  conditions  may  be  most  difficult  to  arrest 
even  with  firmly  applied  sponges  on  holders,  the  slightest  trickling  of 
blood  being  sufficient  to  obscure  the  orifice  of  the  stricture.  A  false 
passage  at  the  site  of  the  stricture  may  complicate  matters  very  much, 
and  a  stricture  in  the  penile  portion  of  the  urethra  may  prevent  the 
passage  of  the  staff  altogether.  A  good  light,  gentleness,  and  patience 
are  at  all  times  requisite. 

Occasionally  a  firm  nodular  or  traumatic  stricture  may  be  excised 
after  Konig's  method,  the  urethral  ends  being  sutured  as  for  ruptured 
urethra.  In  other  cases  a  good  deal  of  periurethral  scar  tissue  may 
be  dissected  away  with  the  object  of  lessening  the  chance  of  recurrence 
of  the  stricture.  Grafting  operations  for  the  reconstruction  of  the 
urethra  after  more  extensive  resections  or  traumatic  destruction  have 
not  been  attended  with  encouraging  success. 

Cock's  Operation.  —  An  external  urethrotomy,  which  opens  the 
urethra  behind  the  stricture,  and  without  a  guide  (Fig.  266).  The 
following,  in  the  words  of  its  deviser,  are  the  advantages  of  this 
operation,  so  well  known  to  Guy's  men  (Guy's  Hosj).  Reports,  1866, 
vol.  xii.  p.  267)  :  "  The  bladder  is  reached  without  any  unnecessary 
mutilation  of  the  perinseum.  The  communication  is  effected  in  nearty 
a  straight  line  from  the  exterior  to  the  cavity  of  the  viscus,  so  that  the 
cannula,  which  is  inserted  and  retained,  can  be  removed  whenever 
necessary,  and  can  be  easily  replaced.  The  functions  of  the  entire 
urethra  are  suspended,  and  may  be  kept  in  abeyance  for  an  unlimited 
period.  The  urine  no  longer  finds  its  way  abnormally  through  the 
stricture  and  sinuses  of  the  perinseum.  The  tissues  are  no  longer 
subjected  to  constant  irritation  from  infiltration.  The  constitutional 
symptoms  are  relieved,  and  time  and  opportunity  are  given  for  the 
removal  by  absorption  of  those  adventitious  products  which  obstructed 
the  urethra,  indurated  the  perinseum,  and  rendered  the  introduction  of 
an  instrument  impossible.  The  pressure  on  the  kidneys  is  removed, 
and,  if  expedient,  the  bladder  may  be  readily  washed  out,  until  its 
lining  membrane  assumes  a  healthy  character.  The  strictured  and 
damaged  portion  of  the  urethra  being  no  longer  subjected  to  the 
constant  pressure  of  urine  from  behind,  may  probably  so  far  recover 
itself  as  to  allow  of  restoration  by  the  ordinary  means  of  dilatation  ;  or, 
should  the  canal  have  become  permanently  obliterated,  the  patient  still 

*  The  wound  Bhonld  be  syringed  occasionally  daring  the  operation  with  a  dilute 
solution  of  mercury  perchloride,  and  a  little  iodoform  dusted  in  at  the  close.  If  any 
bleeding  is  going  on,  the  wound  Bhonld  be  plugged  around  the  catheter  with  strips  of 
iodoform  gauze. 


cock's  EXTERNAL  URETHROTOMY. 


695 


retains  the  means  of  emptying  his  bladder  through  the  artificial  opening 
without  difficulty  or  distress,  and  at  very  moderate  inconvenience 

hinis.  If." 

The  following  are  the  cases  to  which  the  operation  is  well  suited: 

where  the  stricture  has  existed  for  a  number  of  years;  where  the 
urethra  has  become  permanently  obstructed  or  destroyed  by  the 
constant  pressure  of  urine  from  behind,  and  by  reiterated  attempts, 
generally  fruitless,  to  introduce  an  instrument;  where  extravasation 
into  the  perinreum  has  again  and  again  taken  place,  causing  repeated 
abscesses  and  their  consequences,  the  formation  of  urinary  sinuses  and 
fistula?,  until  the  normal  textures  of  the  perimcum  become  obliterated, 

Fig.  266. 


Prostate. 
Stricture. 


Cock's  knife 
entering  dila- 
ted urethra. 


Left  index  finger  on  the  rectum. 


Cock's  operation. 


and  are  replaced  by  an  indurated,  gristly  structure  ;  where  the  bladder 
has  become  thickened  and  contracted  by  the  constant  action  of  its 
muscular  coat  until  little  or  no  cavity  is  left ;  and  where  the  urine  is 
constantly  distilling  by  drops  either  through  the  urethra  or  through 
one  or  several  fistulous  openings,  which  dot  the  surface  of  the  perinaeum, 
penetrate  through  the  indurated  scrotum,  and  even  find  their  way  to 
the  nates  below,  and  the  region  of  the  pubes  above.  If  unrelieved, 
these  cases  invariably  terminate  fatally.  Fortunately  they  are  un- 
common at  the  present  day.  Cases  of  stricture  with  acute  retention 
and  extravasation  of  urine  are  very  quickly  and  easily  relieved  by  the 
operation,  for  the  urethra  is  distended  behind  the  stricture. 

The  keystone  of  the  whole  proceeding  is  the  fact  that,  "however 
complicated  may  be  the  derangement  of  the  perinaeum,  and  however 
extensive  the  obstruction  of  the  urethra,  one  portion  of  the  canal 
behind  the  stricture  is  always  healthy,  often  dilated,  and  accessible 
to  the  knife  of  the  surgeon.  I  mean  that  portion  of  the  urethra  which 
emerges  from  the  apex  of  the  prostate — a  part  which  is  never  the 


696  OPERATIONS  ON  THE  ABDOMEN. 

subject   of  stricture,   and    whose   exact    anatomical  position  may  be 

brought  under  the  recognition  of  the  finger  of  the  operator." 

Operation. — The  patient  is  to  be  placed  in  the  usual  position  for 
lithotomy;  and  it  is  of  the  utmost  importance  that  the  body  and  pelvis 
should  be  straight,  s<>  that  the  median  line  may  be  accurately  preserved. 
The  left  forefinger  of  the  operator  is  then  introduced  into  the  rectum, 
the  bearings  of  the  prostate  are  next  examined  and  ascertained,  and  the 
tip  of  the  linger  is  lodged  at  the  apex  of  the  gland.  The  knife* 
is  then  plunged  steadily,  but  boldly,  into  the  median  line  of  the 
perineeum,  and  carried  on  in  a  direction  towards  the  tip  of  the 
left  forefinger,  which  lies  in  the  rectum.  At  the  same  time,  by  an 
upward  and  downward  movement,  the  vertical  incision  may  be  carried 
in  the  median  line  to  any  extent  that  is  considered  desirable.  The 
lower  extremity  of  the  wound  should  come  to  within  half  an  inch  of 
the  anus. 

"The  knife  should  never  be  withdrawn  in  its  progress  towards  the 
apex  of  the  prostate,  but  its  onward  course  must  be  steadily  maintained, 
until  its  point  can  be  felt  in  close  proximity  to  the  tip  of  the  left  fore- 
finger. "When  the  operator  has  fully  assured  himself  as  to  the  relative 
position  of  his  finger,  the  apex  of  the  prostate,  and  the  point  of  his 
knife,  the  latter  is  to  be  advanced  with  a  section  somewhat  obliquely 
either  to  the  right  or  the  left,  and  it  can  hardly  fail  to  pierce  the 
urethra  where  the  latter  is  distended  and  enlarged  between  the 
prostate  and  the  stricture.  If,  in  this  step  of  the  operation,  the  anterior 
extremity  of  the  prostate  should  be  somewhat  incised,  it  is  a  matter  of 
no  consequence. 

"  In  this  operation  it  is  of  the  utmost  importance  that  the  knife  be 
not  removed  from  the  wound,  and  that  no  deviation  be  made  from  its 
original  direction  until  the  object  is  accomplished.  If  the  knife  be 
prematurely  removed,  it  will  probably,  when  reinserted,  make  a  fresh 
incision  and  complicate  the  desired  result.  It  will  be  seen  that  the 
wound,  when  completed,  represents  a  triangle,  the  base  being  the 
external  vertical  incision  through  the  perinasum,  while  the  apex,  and 
consequently  the  point  of  the  knife,  impinges  on  the  prostate.  This 
shape  of  the  wound  facilitates  the  next  step  of  the  operation. 

"  The  knife  is  now  withdrawn,  but  the  left  forefinger  is  still  retained 
in  the  rectum.  The  probe-pointed  director  is  carried  through  the 
wound,  and,  guided  by  the  left  forefinger,  enters  the  urethra,  and  is 
passed  into  the  bladder.  A  No.  12  gum-elastic  catheter,  straightened 
on  its  stylet,  is  slid  along  the  director,  the  stylet  then  removed,  the 
catheter  cut  short,  and  secured  in  position  with  tapes." 

While  most  fully  alive  to  the  excellence  of  this  operation  both  as 
to  speediness  of  relief  and  the  perfect  rest  it  gives  to  damaged  parte, 
I  should  like  to  point  out  to  those  who  are  only  likely  to  perform  it 
occasionally  (a)  that  it  is  not  such  an  easy  operation  as  it  appears; 
{b)  that  it  is  a  severer  operation  than  the  size  of  the  wound  would 
suggest.  Haemorrhage  is  not  very  uncommon  from  the  engorged 
condition  of  the  parts,  and  a  low  form  of  septic  phlebitis  is  not  very 
infrequent  after  the  operation.  For  these  reasons  I  would  restrict  it 
to  the  cases  mentioned  at  p.  695. 


*  Cock's  knife  is  doubli 


cock's  EXTERNAL  URETHROTOMY.         697 

Complications  and  Causes  of  Failure  after  External  Urethrotomy. 
— 1.  Haemorrhage  (footnote,  p.  O94).  2.  Rigors.  These  should  be 
met  by  warmth  ;  leaving  out  the  catheter  or  substituting  ;i  softer  one; 
plenty  of  diluent  drinks;  washing  out  the  bladder  with  diluted  Thomp- 
son's fluid  (p.  623),  Dover's  powders,  or  small  injections  of  morphia, 
if  the  condition  of  the  kidney  admits  of  these.  Five  or  ten  grains  of 
quinine  may  be  given  in  milk  every  two  or  three  hours,  if  it  does  not 
excite  vomiting.  3.  Septic  trouble—  e.g.,  septic  phlebitis.  4.  Pelvic 
cellulitis.  5.  Persistence  of  a  fistulous  opening  in  the  perineum. 
6.  Recurrence  of  the  contraction. 


THE    TREATMENT    OF    STRICTURE-RETENTION. 

When  the  obstruction  is  not  quite  complete,  or  the  need  for  relief 
very  urgent,  a  few  hours'  rest  in  bed,  opium,  warm  hip  baths,  or 
fomentations  often  succeed  in  enabling  the  patient  to  pass  water  and 

Fig.  267. 


Wymlham  Powell's  urethroscope.     (Down  Brothers.) 

empty  his  bladder  either  partially  or  completely.  Then,  if  not  before, 
a  small  soft  catheter  (size  ^  to  3  silk  web,  or  soft  black)  can  generally 
be  passed  and  tied  in.  The  stricture  soon  dilates  sufficiently  to  allow 
the  urine  to  pass  by  the  side  of  the  catheter,  if  the  latter  fails  to 
drain.  Once  he  has  succeeded  in  passing  even  the  smallest  catheter  or 
bougie  the  surgeon  must  not  remove  it  in  the  hope  of  being  able  to 
introduce  a  larger  one,  for  he  may  then  find  that  he  cannot  even 
reinsert  the  original  one.  After  one  or  two  days  a  larger  instrument 
can  be  passed  if  used  immediately  after  the  withdrawal  of  the  first 
one.  Larger  instruments  can  be  tied  in  daily  until  the  dilatation  is 
completed. 

The  introduction  of  the  catheter  ma3r  be  greatly  aided  by  injecting  a 
solution  of  adrenalin  chloride  (10100)  into  the  urethra  to  diminish  the 
congestion  of  the  mucous  membrane  at  the  stricture.  Distension  of  the 
urethra  with  warm  sterile  olive  oil  is  also  useful.  The  oil  is  kept  in  during 
the  passing  of  the  catheter  by  holding  the  meatus  firmly  against  the  instru- 
ment. The  distension  serves  to  remove  folds  of  mucous  membrane,  to 
slightly  dilate  the  stricture,  and  especially  to  displace  the  orifice 
backwards,  so  that  it  lies  at  the  apex  of  the  funnel  formed  by  the  urethra 
in  front  of  it.     Without  distension  of  the  anterior  urethra  the  stricture 


698  OPERATIONS    ON    THE    AI'.DOMEN. 

often  projects  forwards  perhaps  eccentrically  into  the  lumen  like  an  intus- 
susception. So  that  a  catheter  fails  to  enter  an  opening  which  is  quite 
large  enough  when  its  position  is  corrected. 

Failing  the  introduction  of  a  fine  catheter,  filiform  bougies  may  be 
tried,  and  with  perseverance  one  of  these  can  be  passed  in  most  cases, 
with  the  aids  mentioned  above.  The  urethroscope  may  be  useful  in 
localising  the  orifice  and  also  in  conducting  and  introducing  the  bougie 
with  the  aid  of  sight.  Sometimes  a  catheter  can  be  passed  upstream  as 
the  patient  succeeds  in  voiding  a  little  urine.  Once  a  bougie  has  been 
got  through  the  stricture,  it  may  either  be  tied  in  or  used  as  a  guide  for 
a  "  tunnel  "  or  "  railway  "  catheter  to  run  along. 

A  conical  silver  catheter  can  be  screwed  on  to  a  suitable  bougie  and 
slowly  made  to  follow  the  latter  into  the  bladder  without  any  risk  of 
making  a  false  passage.  The  bougie  coils  safely  within  the  bladder. 
This  plan  is  far  better  than  to  attempt  to  forcibly  dilate  stricture  with 
a  metal  catheter  without  any  guide.  In  most  cases  such  attempts  either 
fail  altogether  or  succeed  only  by  making  a  false  passage  by  the  side  of  the 
real  canal  of  the  stricture.  By  keeping  the  point  in  the  middle  line  a 
skilful  surgeon  may  direct  his  instrument  back  again  into  the  urethra 
where  the  latter  is  fortunately  dilated  behind  the  stricture,  but 
although  a  good  anatomist  may  succeed  in  entering  the  bladder  and 
in  affording  immediate  relief  in  this  way,  the  method  is  too  dangerous 
to  be  recommended  for  general  use,  and,  moreover,  the  ultimate  results 
are  often  poor,  for  the  false  passage  usually  recontracts,  and  obstruc- 
tion returns  sooner  or  later.  Such  false  passages  are  sometimes  mis- 
named resilient  strictures. 

In  most  cases  where  the  patient  is  still  comparatively  young,  where  the 
stricture  is  not  of  long  duration,  where  there  are  no  urinary  fistula)  or  a 
damaged  perinseum,  the  retention  can  be  relieved  and  the  cure  of  the  stric- 
ture started  in  one  of  the  ways  mentioned  above,  but  in  others  all  such 
attempts  may  fail,  especially  owing  to  the  existence  of  recently  made 
false  passages  and  haemorrhage  from  injudicious  instrumentation. 

It  will  have  been  gathered  from  the  remarks  at  p.  657  that  supra- 
pubic aspiration  ma}'  be  used  in  very  urgent  cases,  and  may  be  repeated 
safely  once  if  necessary.  For  the  large  majority  of  cases  of  acute  and 
complete  retention  due  to  impermeable  stricture,  especially  when  the 
patient  is  under  45,  and  a  few  days'  rest  will  ensure  the  passage  of  a 
catheter,  I  believe  that  supra-pubic  tapping  of  the  bladder  will  be  the 
safest  and  simplest  operation  (p.  658).  This  will  be  followed  in  four 
or  five  days  by  the  passage  of  a  catheter,  aided  by  an  anaesthetic  perhaps. 
Wheelhouse's  operation  is  veiy  highly  spoken  of  by  the  Leeds 
surgeons.  A  good  light  and  especial  instruments  are  essential.  The 
cases  to  which  Mr.  Cock's  excellent  operation  should  be  limited  have 
been  already  pointed  out  (p.  695). 

INTERNAL    URETHROTOMY. 

Indications. — Before  specifying  these,  I  would  say  that  with  regard  to 
the  question  between  external  and  internal  urethrotomy,  or  the  need 
of  either,  it  is  chiefly  a  matter  of  personal  experience.  In  other  words, 
surgeons  who  practise  usually  some  such  operation  as  that  of  Prof. 
Syme — or  use  Mr.  Wheelhouse's  method — when  careful  dilatation,  aided 


INTERNAL    URETHROTOMY.  699 

by  an  anaesthetic,  fails,  will  probably  have  as  good  results  as  those  who 
resort  to  internal  urethrotomy.  As  it  is  a  clean  division  of  the  entire 
stricture  which  is  required,  this  can  be  effected  nmst  readily,  and  with 
less  practice,  and  with  simpler  instruments,  by  external  urethrotomy; 
but  internal  urethrotomy  lias  the  great  advantage  of  avoiding  a  urinary 
fistula  except  as  a  very  rare  complication.  But  it  must  be  remembered 
that,  after  all,  it  is  not  so  much  the  division  of  the  stricture,  whether 
from  without  or  within,  which  will  be  curative,  as  the  amount  of 
perseverance  which  the  patient  shows  afterwards.  Again,  at  the  com- 
mencement of  internal  urethrotomy  each  stricture  must  be  dilated 
sufficiently  to  admit,  in  the  case  of  an  instrument  cutting  from  without 
inwards,  a  split  sound  equivalent  to  No.  2  English,  while  in  instruments 
cutting  in  the  opposite  direction  the  bulb  is  as  large  as  No.  4  or  5.  This 
being  so,  the  cases  must  be  very  few  in  which  the  surgeon  does  not  find 
it  possible,  and  in  which  the  patient  does  not  prefer,  to  complete  the  case 
by  dilatation. 

Amongst  these  few  cases  are — 1.  Strictures  localised  and  annular, 
which  (a)  contract  rapidly  after  dilatation,  or  (/?)  in  which  rigors 
persistently  follow  attempts  at  dilatation.  2.  Non-dilatable  strictures 
— e.g.,  some  traumatic  ones.  3.  Penile  strictures.  These  are  very 
elastic,  and  shrink  quickly  after  dilatation,  and  incision  of  these  strictures 
seldom  causes  serious  constitutional  disturbance.  4.  In  some  cases 
where  time  is  an  object.  Thus,  in  young  subjects  whose  disease  has  not 
existed  long  enough  to  alter  the  condition  of  the  kidneys,  cutting  may 
be  admissible  for  a  sticture  that  should  be  simply  dilated  in  an  older 
patient  whose  kidneys  have  undergone  degeneration  (Berkeley  Hill, 
Diet,  of  Siirg.,  vol.  ii.  p.  727).  5.  According  to  some  (Berkeley  Hill, 
loc.  supra  cit.),  urethrotomy  affords  a  longer  interval  of  freedom  from 
contraction  than  does  any  other  plan  of  widening  a  stricture.  The 
urethroscope  may  occasionally  afford  useful  information  which  may  not 
only  enable  the  surgeon  to  decide  upon  internal  urethrotomy,  but  also 
indicate  the  exact  direction  and  degree  of  the  interference  that  is 
necessary.  The  operation  can  be  carried  out  through  the  urethro- 
scope tube,  with  the  aid  of  direct  vision  in  some  cases. 

Contra-indications. 

1.  Strictures  not  localised  and  ring-like,  but  extending  over  a  con- 
siderable surface.  2.  A  "  stricture  "  in  which  the  difficulty  is  mainly 
due  to  congestion,*  though  this  is  scarcely  a  stricture  at  all.  3.  A 
stricture  accompanied  by  urethritis. 

I  have  endeavoured  to  point  out  fairly  the  indications  for  internal 
urethrotomy.  I  suspect  that  this  is  one  of  those  operations  of  which  an 
increasingly  frequent  use  is  liable  to  lead  to  something  very  like  abuse. 
But,  however  this  may  be,  I  should  like  to  point  out  first  a  fallacy,  as  it 
seems  to  me.  Thus,  Sir  H.  Thompson  (Dis.  of  Urin.  Organs,  p.  40) 
speaks  of  a  urethrotome  as  "  nothing  more  than  a  little  knife  with 
a  long  blade  .  .  .  used  precisely  as  we  use  a  scalpel  anywhere  else. 
Just  as  we  should  use  a  small  knife  in  tenotomy  without  the  sense  of 

*  As  bearing  upon  the  allied  condition  of  "spasm,"  the  late  Mr.  B.  Hill  (Brit.  Mrih 
Jo>tr».,  1879,  vol.  ii.  p.  856)  stated  that  if  an  apparently  narrow  bulbo-membranous  and 
a  penile  stricture  co-exist,  on  the  latter  being  properly  divided,  the  former  will  disappear, 
having  been  due  to  reflex  muscular  contraction. 


700         OPERATIONS  ON  THE  ABDOMEN. 

vision  where  it  is  not  necessary,  but  guided  by  tlie  sense  of  touch,  so  do 
I  advise  you  to  acl  in  urethrotomy."  No  doubt  this  comparison  is 
correct  as  far  as  it  goes,  but  its  wry  simplicity  is  misleading.     There 

can  be  no  real  comparison,  I  maintain,  between  division  of  a  tendon, 
which  can  always  be  practically  made  subcutaneous,  and  that  of  a 
stricture,  perhaps  tour  inches  from  the  surface,  Burrounded  by  vascular 
tissue,  incision  of  which  may   easily   lead    to   hemorrhage  or    septic 

trouble,  an  incision  which  cannot  from  the  subsequent  flow  of  urine  be 
completed  aseptically,  and  which  implicates  other  parts  in  such  intimate 
sympathy  with  that  operated  on — e.g.,  the  kidneys. 

Again,  I  would  point  out  that  internal  urethrotomy  is  not  the  simple 
affair  that  it  is  sometimes  represented  to  be.  1  would  refer  my  readers 
to  the  experience  of  one  whose  name  is  associated  with  this  operation. 
Mr.  Berkeley  Hill  (Lancet,  April  8,  1876,  p.  524)  speaks  thus  of  a  trial 
which  he  gave  to  the  method  of  treating  early  stricture  by  Otis's 
operation  of  internal  urethrotomy  : 

"  All  the  cases  operated  on  were  those  of  long-standing  gleets,  with 
contraction  in  one  or  more  parts  of  the  spongy  urethra,  and  had  under- 
gone multifarious  treatment.  The  number  of  patients  is  sixteen, 
fifteen  of  my  own  and  one  of  Dr.  Otis's.  In  five  cases" the  gleet  stopped 
after  the  operation,  and  the  patient  was  at  the  last  report — taken  in 
none  less  than  three  weeks,  in  most  some  months,  after  the  operation — 
able  to  pass  a  bougie  of  the  estimated  size  of  the  urethra.  In  short, 
they  may  be  claimed  as  cures.  But  of  these  five  the  operation  was 
serious  to  two  :  one  had  free  bleeding  for  three  days,  the  other  three 
attacks  of  rigors.  Of  the  remaining  eleven,  among  whom  Dr.  Otis's 
own  operation  must  be  included,  the  gleet  persisted  in  all;  in  several 
the  urethra  shrank  again  to  its  size  before  the  operation,  and  in  some 
very  serious  complications  ensued.  In  four  bleeding  lasted  several 
days,  and  in  one  was  alarming.  Three  patients  had  rigors.  In  two  the 
shivering  was  unimportant,  being  that  which  follows  the  first  transit  of 
urine  along  the  incised  urethra  in  certain  individuals,  but  is  not 
repeated  or  attended  by  further  consequences  ;  in  the  third  patient 
the  rigors  preceded  abscess  in  the  buttock.  One  patient  had  orchitis. 
Thus  in  seven  the  operation  might  fairly  be  termed  a  trifle,  causing  no 
pain  nor  any  after-fever,  but  in  five  only  was  the  operation  successful." 

In  skilful  hands  at  the  present  day  the  dangers  of  the  operation  are 
very  small  when  aseptic  precautions  are  carefully  observed.  Conse- 
quently it  has  become  more  popular  of  late,  and  it  gives  good  results 
when  the  after-treatment  is  properly  carried  out. 

Complications. — (1)  Haemorrhage.  If  severe  this  may  be  met  by 
pressure  on  the  perineum,  with  a  pad  or  a  stick  in  the  bed,  bo  that  the 
patient  may  keep  up  the  compression  himself.  (2)  Perineal  abscess. 
(3)  Sloughing  and  perineal  fistula.  These  are  very  rare.  (4)  Extra- 
vasation. (5)  Septicaemia.  (6)  Epididymitis.  The  first  five  of  these 
are  usually  due  to  cutting  too  deeply,  or  to  the  patient  not  being 
sufficiently  prepared  or  unfit  for  the  operation.  The  last  is  usually 
brought  about  by  injudicious  haste  in  the  use  of  bougies. 

The  essentials  of  a  ij<><hI  urethrotome  are — (1)  a  guide  through  the 
stricture  into  the  bladder,  usually  in  the  form  of  a  filiform  guide-bougie, 
or  of  a  curved  terminal  portion  of  the  urethrotome,  sufficiently  fine  to 
pass   through    the  narrowest  stricture  ;   (2)  a  cutting  edge  which,  at 


[NTERNAL    URETHROTOMY. 


701 


first  shielded,  can  be  protruded  by  the  surgeon  us  exactly  as  he  desires; 
(3)  some  means  of  steadying  the  mobile  stricture  fibres  us  they  are 
divided. 

Two  Chief  Modes  of  Internal  "Urethrotomy. — The  stricture  may 
be  divided — («)  from  without  inwards,  i.e.,  towards  the  bladder; 
(b)  from  within  outwards,  away  from  the  bladder.  A  short  account 
of  the  chief  instruments  will  be  given,  and  the  two  methods  briefly 
contrasted. 

a.  Those  cutting  from  without  inwards. — By  this  means  narrower 
strictures  can  be  divided  than  in  the  other  method,  in  which  the 
instruments  used  are  generally  based  on  Civiale's  pattern,  in  which 
the  bulbous  end  carries  the  knife. 

Most  of  the  urethrotomes  which  cut  from  without  inwards  are 
modifications  of  Maisonneuve's  pattern.  A  tine  hollow  staff  being 
guided  through  the  stricture  by  a  filiform  bougie,  along  the  hollow 
staff  a  stylet  carrying  a  triangular  shield  or  wedge  is  run  ;  this,  pushed 
against  the  stricture,  serves  to  steady  it,  while  it  is  divided  by  a  knife 
concealed  in  the  wedge  or  shield. 

One  of  the  best  known  of  the  instruments  on  this  pattern  is  the  late 
Mr.  B.  Hill's.  It  consists  of  a  narrow  split  sound,  No.  2  English, 
which  can  be  guided  through  narrow  tortuous  strictures  by  being 
attached  to  a  filiform  bougie  previously  passed  into  the  bladder.* 
Secondly,  a  wedge  runs  along  dovetail  grooves  between  the  halves  of 
the  split  sound.  In  this  wedge  is  concealed  a  knife  that  can  be  pro- 
truded between  the  halves  of  the  split  sound  when  the  stricture- 
tissue  prevents  their  separation  sufficiently  to  allow  the  wedge  to  pass 
on.  The  wedge,  t  pushed  up  to  the  situation  of  the  stricture,  in  separat- 
ing the  split  sound  tightens  and  steadies  the  stricture  thoroughly,  while 
the  knife  divides  it  to  the  width  required  by  the  wedge  to  pass  along.! 
If  a  wedge  be  chosen  to  expand  the  urethra  to  its  full  natural  capacity 
the  cut  will  not  pass  beyond  the  stricture  into  the  vascular  erectile  tissue 
external  to  it.  The  knife  can  be  applied  to  the  upper  or  under-surface 
of  the  stricture,  as  preferred. 

b.  Those  cutting  from  within  outwards. — A  good  representative 
of  these  instruments  is  Sir  H.  Thompson's  modification  of  Civiale's 
urethrotome.  This  has  a  bulbous  extremity,  from  which  the  blade  is 
protruded.  The  stricture  being  sufficiently  dilated  to  admit  a  No.  4  or 
5  bougie,  the  bulb  (which  forms  a  useful  sound)  is  carried  about  one- 
third  of  an  inch  beyond  the  stricture,  the  knife  projected,  and  the 
incision  made  by  drawing  it  slowly  and  firmly  outwards — to  the  dis- 
tance of  half  an  inch  to  two  inches — generally  along  the  floor  of  the 
urethra,  so  as  to  incise  the  stricture  freely.  A  metallic  bougie  is  then 
passed,  and  if  at  any  point  it  is  held  closely,  there  is  still  almost 
certainly  some  spot  which  needs  touching  with  the  blade. 


*  If  it  is  doubtful  whether  the  guide  has  reached  the  bladder,  Mr.  Hill  advised  to 
screw  on  a  No.  i  flexible  catheter  to  the  guide,  and  to  push  the  whole  onwards  till  the 
catheter  has  passed  eight  inches  inwards.  A  small  exhausting  syringe  is  then  applied  to 
the  catheter,  and  a  few  drops  of  urine  drawn  through  it. 

t  The  meatus  must  be  divided,  if  too  small  to  admit  the  wedge. 

I  After  the  first  cut  the  knife  is  withdrawn  within  the  wedge,  and  only  protruded 
when  a  tight  band  opposes  the  free  passage  of  the  wedge. 


702 


OPKHATIONS    ON    T1IK    AUDOMKN. 


After-treatment. — This  varies  very  much.  Some  Burgeons — e.g.t 
Sir  H.  Thompson  and  Mr.  Harrison — pass  at  once  and  tie  in  a  full- 
sized  catheter  for  twenty-four  or  forty-eight  hours,  passing  after  this  a 
full-sized  instrument  at  intervals.  Others — e.g.,  Mr.  B.  11:11 — draw  off 
the  urine  with  a  full-sized  catheter  after  division  of  the  stricture,  hut 
tie  none  in.  The  patient  is  ordered  not  to  micturate  for  eight  hours 
if  possible.  By  this  time  the  incision  is  protected  by  clot  and  plastic 
lymph,  and  when  the  bladder  must  he  emptied,  the  patient  pae 
water  in  a  hot  hath,  pain,  spasm,  and  risk  of  tearing  open  the  wound 
heing  thus  avoided.  The  patient  is  kept  in  hed  for  ten  days,  and 
about  the  eighth  day  a  full-sized  hougie  is  passed,  this  period  of  rest 
heing  insisted  upon  to  avoid  pain,  bleeding,  and  suppuration. 

Comparison  of  the  Two  Methods  of  Internal  Urethrotomy. — 
With  the  instruments  which  cut  from  without  inwards,  guided  by  a 
filiform  bougie,  narrower  strictures  can  be  attacked  than  by  the  bulbous- 
ended  urethrotome,  cutting  in  the  reverse  direction.  These  latter  have 
been  recommended  as  having  the  advantage  of  steadying  the  fibres  to 
be  cut  by  their  pulling  forwards  the  parts  which  attach  the  urethra  to 
the  pelvis  as  the  bulbous  end  of  the  instrument  is  drawn  out.  The 
stricture  is  thus  pulled  on  by  the  instrument  until  the  divided  stricture 
gives  free  passage  to  the  bulbous  shield  and  the  knife  protruded  from 
it.  Mr.  B.  Hill,  however,  considered  that  "  reliance  cannot  be  placed 
on  the  simple  straining  of  these  attachments  ensuring  perfect  division 
of  the  stricture  tissue.  A  Civiale's  or  any  other  urethrotome  which  cuts 
from  within  outwards  is  very  apt  to  wriggle  its  way  through  a  stricture, 
only  scoring  it,  but  not  perfectly  severing  its  fibres,  and  to  meet  this 
difficulty  the  knife  is  often  carried  more  deeply  than  is  necessary."  Mr. 
Hill  further  believes  that  by  cutting  from  without  inwards  there  is  less 
risk  "  of  making  an  incision  through  a  thin  layer  of  fibrous  tissue  into 
erectile  tissue,  in  the  belief  that  a  thick  layer  of  fibrous  tissue  exists," 
and  thus  of  causing  free  haemorrhage. 

While  myself  usually  practising  what,  on  the  whole,  I  believe  to  be 
preferable,  continuous  dilatation,  aided,  if  need  be,  by  external  urethro- 
tomy, I  have,  I  trust,  here  fairly  dealt  with  internal  urethrotomy. 
Before  leaving  this  matter  I  should  like  to  allude  to  the  question  of 
time.  Internal  urethrotomy  no  doubt  saves  time  and  trouble  also,  but 
it  must  not  be  thought  that  the  saving  is  a  large  one.  Thus,  with 
regard  to  time,  Mr.  B.  Hill  wrote*:  "It  is  indispensable  that  the 
patient  lie  in  bed  continuously  for  at  least  ten  days,  and  keep  his  room 
for  fourteen  days."  Subsequent  regular  passage  of  a  bougie  is  as 
needful  after  internal  urethrotomy  as  any  other  mode  of  treating 
stricture. 

ECTOPIA   VESICA   AND  EPISPADIAS. 

The  various  plans  that  have  been  devised  for  the  relief  of  this  most 
miserable  condition  may  practically  be  divided  into  three  groups. 
The  first  group  consists  of  plastic  operations,  which  aim  at  the  forma- 
tion of  a  new  anterior  vesical  wall  and  urethra.  The  method  associated 
with  the  name  of  Wood  has  been  most  widely  adopted.  As  will  be 
seen  by  reference  to  the  description  given  below,  the  anterior  wall  of 

*  Diet,  of  Surg.,  vol.  ii.  ]>.  72<>  See  also  the  lectures,  alike  candid  and  helpful  in 
detail,  \>y  the  same  surgeon  (Brit.  Med,  Jour  a.,  1S79.  vol.  ii.  pp.  703  et  *ey.). 


ECTOPIA    VESIC.K    AND    KIMSl'ADIAS.  703 

the  bladder  is  formed  by  skin-Haps.  The  advantages  gained  by  the 
operation,  if  successful,  are  that  a  receptacle  for  the  urine  18  formed, 
and  that  the  exposed  mucous  membrane  is  covered  in  and  protected; 
but  unfortunately  the  most  important  lower  part,  where  the  ureters 
discharge,  pouts  and  remains  exposed  to  as  much  irritation  as  ever. 
Fistulas  are  common  even  after  repeated  operations,  and  then  the 
patient  is  very  little  better  off  than  before,  because  the  urine  cannot 
be  collected  satisfactorily  by  a  urinal.  It  is  important  to  remember 
that  no  sphincter  can  be  provided,  and  therefore  no  control,  so  that  a 
urinal  must  be  worn  constantly  as  before,  even  in  the  most  successful 
cases.*  In  these  cases  the  patients  can  be  kept  dry  during  the  day, 
and  some  of  them  also  at  night,  but  the  best  urinal  is  an  offence 
and  a  danger.  In  a  few  cases  the  urine  has  been  retained  for  an  hour 
or  two,  but  various  mechanical  contrivances  designed  for  increasing  the 
retaining  power  have  not  been  attended  with  more  than  temporary 
success  as  a  rule.  Moreover,  with  the  growth  of  hair  into  the  bladder 
cystitis  is  set  up,  and  the  hairs  are  constantly  the  seat  of  phosphatic 
deposit  which  will  probably  have  to  be  removed  at  intervals. 

Attempts  have,  however,  been  made  to  form  the  new  bladder  of 
mucous  membrane  instead  of  skin,  but  stones  have  formed  even  when 
the  whole  of  the  new  bladder  has  been  lined  with  mucous  membrane 
either  of  intestinal  or  vesical  origin. 

Tizzoni  and  Poggi  successfully  removed  the  bladder  of  a  dog  and 
replaced  it  by  a  new  bladder  formed  from  a  piece  of  small  intestine, 
which  they  left  attached  to  its  mesentery  after  having  cut  it  out  of  the 
circuit  of  the  alimentary  canal.  Rutkowski  (Centr.jiir  Chir.,  No.  16, 
1899),  acting  on  this  suggestion,  successfully  made  use  of  an  intestinal 
flap  for  ectopia  in  a  boy  aged  9. 

The  following  account  of  the  operation  is  given  by  Warbasse  {Ann. 
of  Sarg.,  August,  1899) : 

"  A  median  incision,  six  centimetres  long,  was  made,  terminating  below  at  the  bladder. 
After  opening  the  abdomen,  a  «oil  of  ileum  was  brought  out  and  divided  at  two  points, 
six  centimetres  apart.  This  six  centimetres  of  intestine  was  isolated.  The  intestine  was 
united  by  an  end  to  end  anastomosis  with  two  rows  of  continuous  silk  suture,  and  replaced 
in  the  abdomen.  The  excised  segment  was  divided  longitudinally  opposite  its  mesen- 
tery, thus  forming  a  quadrilateral  ilap  about  forty  square  centimetres  in  size,  attached  to 
the  mesentery  along  its  middle.  After  detaching  the  bladder  from  the  abdominal  wall 
and  enlarging  the  bladder  opening,  the  intestinal  flap  was  sutured  by  two  rows  of  running 
suture  into  the  defect.  The  deeper  suture  of  catgut  included  the  entire  thickness  of  the 
bladder  and  intestinal  walls,  with  the  exception  of  the  mucosa.  The  outer  suture  of  silk 
was  applied  as  a  Lembert  suture.  This  gave  a  urinary  bladder  with  an  anterior  wall 
formed  from  intestinalflap  receiving  its  nourishment  through  its  own  segment  of  mesentery. 
Over  the  whole  the  abdominal  wall  was  closed.  A  catheter  was  left  in  the  urethra  for 
permanent  drainage  of  the  bladder.  The  operation  lasted  an  hour  and  a  half.  The  con- 
dition of  the  patient  immediately  after  the  operation  was  excellent.  The  post-operative 
course  of  the  case  was  ideal,  entirely  afebrile.  The  wound  healed  per  primam.  On  the 
tenth  day  the  sutures  were  removed.  Eight  weeks  after  the  operation  the  patient  was 
able  to  retain  twenty-five  cubic  centimetres  of  urine  in  the  bladder.  Under  pressure  this 
amount  could  be  increased  to  thirty  cubic  centimetres." 

*  In  a  few  cases  the  new-formed  bladder  has  been  capable  of  retaining  the  urine  for 
several  hours,  notably  one  recorded  by  Trendelenburg,  but  the  fact  remains  that  no  satis- 
factory living  sphincter  has  been  constructed.  Stones  are  most  likely  to  form  in  the 
most  continent  bladders. 


7o4 


oi'KUATIONS    ON    THE   ABDOMEN. 


In  the  second  group  of  operations  no  attempt  is  made  either  to  con- 
struct a  bladder,  or  to  provide  an  alternative  and  controllable  receptacle, 
but  the  ureters  are  transplanted  into  the  urethral  gutter,  so  that  the 
urine  can  be  conducted  more  easily  into  a  urinal.  This  operation  is 
more  successful  than  the  more  elaborate  flap  methods,  although  it  is 
less  ambitious. 

In  the  third  group  of  operations  no  attempt  is  made  to  form  a  bladder, 
but  the  course  of  the  urine  is  diverted  into  the  bowel,  which  thus  becomes 
the  receptacle  for  the  urine. 

A  number  of  surgeons  have  excised  the  vesical  mucous  membrane 
and  implanted  the  ureters  in  the  rectum  or  sigmoid.  The  chief 
objection  to  this  is  the  liability  to  infection  of  the  ureters  from  the 
bowel,  resulting  in  ascending  nephritis.  Maydl  has,  however,  largely 
overcome  the  risk  of  infection  by  implanting  the  whole  trigone  into  the 
rectum,  thus  retaining  the  valvular  orifices  of  the  ureters.  Brandsford 
Lewis  (Ann.  of  Surg.,  June,  1900),  in  a  review  of  this  subject,  quotes  a 
number  of  cases  operated  on  by  Maydl's  method.  The  following  case, 
operated  upon  by  Dr.  Herezel,  of  Buda-Pesth,  will  serve  to  illustrate  what 
may  be  hoped  for  as  a  result  of  this  operation : 

"  A  boy  five  years  old  was  operated  on  in  May,  1897.  In  March,  189S,  his  condition  was 
reported  by  the  operator  as  admirable.  Quantity  of  urine  1,000—1,200  cubic  centimetres 
in  twenty-four  hours  ;  specific  gravity  1,013  ;  slight  amount  of  albumen,  no  pus.  The  boy 
was  able  to  hold  the  urine  five  hours  at  a  time,  and  then  to  eject  it  in  a  good  stream  from 
the  rectum.  In  August,  1899  (a  year  and  a  half  after  the  operation),  the  condition  con- 
tinued as  satisfactory.  The  patient,  now  a  rapidly  growing  and  strengthening  boy, 
enjoyed  living,  retaining  his  urine  for  six  or  seven  hours  during  the  day-time,  but 
relieving  himself  oftener  at  night,  or  running  the  risk  of  wetting  the  bed  while  in  deep 
sleep." 

The  same  author  also  quotes  the  results  of  seventeen  operations  by 
Maydl's  method,  collected  by  Nove-Josserand.  There  were  two  deaths, 
one  from  shock  and  the  other  from  infection.  "  The  secondary 
accidents  noted  were  fistula?  of  the  urinary  passages  with  an  accom- 
panying localised  peritonitis,  all  of  which  cases  recovered.  Pyelo- 
nephritis, as  the  result  of  ascending  infection,  resulted  in  the  death  of 
one  case  after  a  period  of  four  months.  Urinary  continence  was  perfect 
in  all  the  cases  excepting  two.  The  patients  were  able  to  hold  their 
urine  for  at  least  three  hours,  sometimes  six  or  seven  hours,  and  in  one 
case  throughout  the  night.  The  urine  was  voided  sometimes  mixed 
with  faecal  matter,  sometimes  alone.  The  tolerance  of  the  rectal 
membrane  was  perfect." 

Dr.  Watson  (Ann.  of  Surg.,  1905,  vol.  xlii.  p.  813)  collected  42  cases 
of  Maydl's  operation,  and  found  that  nine  deaths  had  occurred  (mortality 
21  per  cent.),  and  that  three  of  the  deaths  were  attributable  to  the 
rectal  implantation  per  se. 

Dr.  Hartley  (Med.  Neics,  Aug.  29,  1903)  refers  to  46  cases,  with  a 
mortality  of  15  per  cent. 

Orloff  (Ann.  de  Mai.  de  Gen.  Urin.,  No.  11,  1902)  collected  56  cases, 
with  eleven  deaths  (mortality  17  per  cent.),  within  twenty-one  days. 

Although  the  danger  of  death  from  ascending  septic  infection  of  the 
kidneys  is  very  much  less  than  with  direct  implantation  of  the  ureters 
without  preservation  of  their  valvular  orifices,  yet  the  risk  is  a  real  and 


ECTOPIA    VKSM'.K    AND    EPISPADIAS.  705 

considerable  one.  Some  of  the  patients  have  died  from  this  cause 
within  a  few  weeks,  and  others  after  one  or  more  years.  The  dangers 
of  shock  and  peritonitis  are  also  great,  for  the  operation  is  a  long  and 
difficult  one,  which  has  sometimes  taken  over  two  hours  to  perform. 

Four  of  the  deaths  in  Orloff's  collection  were  due  to  peritonitis,  two 
to  pneumonia,  one  to  the  anaesthetic,  and  one  to  hemorrhage.  Of  the 
forty-five  who  survived  the  operation  live  died  later  from  ascending  infec- 
tion. Of  Orloff's  own  four  cases  one  died  from  this  cause  in  a  fortnight, 
and  another  after  two  years.  It  is  fair  to  state,  however,  that  a  number 
of  these  patients  were  already  suffering  more  or  less  from  renal  changes 
at  the  time  of  the  operation. 

Function. — The  rule  is  that  the  rectum  gradually  or  even  rapidly 
acquires  the  power  of  retaining  the  urine,  for  several  hours,  without 
any  appreciable  sign  of  irritation.  During  the  day  the  control  is 
almost  perfect,  but  incontinence  or  reflex  evacuation  is  not  uncommon 
at  night.  Nine  of  the  cases  collected  by  Hartley  had  been  seen  three 
3rears  after  the  operation,  and  one  after  seven  years.  Thirteen  had 
been  seen  two  years  after  the  operation. 

Complications  and  Sequela. — Seven  of  Orloff's  collected  cases  had 
developed  faecal  fistula?,  and  in  three  of  these  a  secondary  operation 
became  necessary  on  this  account.  Pneumonia  occurred  in  six  of 
Orloff's  cases,  with  two  deaths.  In  one  case  obstructive  kinking  of 
the  ureters  has  caused  death. 

In  spite  of  the  fact  that  this  operation  is  undoubtedhy  more  severe 
than  the  plastic  method,  the  immediate  and  the  late  results,  in  those 
that  survive,  are  far  better  than  those  of  the  best  of  the  older  methods. 
The  mortality  of  the  operation  is  really  greater  than  the  figures  quoted 
above  would  indicate,  and  time  has  shown  that  the  late  results  are  not 
so  perfect  as  some  surgeons  anticipated,  because  ascending  infection 
has  not  been  uncommon.  It  must  be  remembered,  however,  that 
renal  infection  has  been  frequent  after  plastic  operations,  and  that  the 
condition  of  these  patients,  if  left  alone  or  submitted  to  plastic 
operation,  is  truly  miserable,  so  that  it  is  worth  while  to  run  a 
considerable  risk  to  gain  a  tolerable  result. 

Operations.     (1.)  The  construction  of  a  bladder  :— 

(a)  Wood's  plastic  method,  and  some  modifications  of  it ;  (b)  Tren- 
delenburg's operation  ;  (2)  Sonnenburg's  operation  ;  (3)  The  diversion 
of  the  urinary  stream  into  the  intestine :  (a)  Frank's  method ; 
(b)  Maydl's  method ;   (c)  Moynihan's  method. 

(la)   Wood's  Operation. 

Acje. — The  cure  of  the  ectopia  may  be  commenced  after  the  child  is 
four  or  five,  and  should  be  completed,  if  possible,  by  puberty.  In  this 
case  the  epispadias  may  be  taken  in  hand  and  completed  before 
adolescence,  when  the  growth  of  hairs  and  sexual  desires  will  interfere 
much  with  the  union  of  the  flaps. 

Unfavourable  Conditions* — 1.  Large  size  of  the  ectopia,  with  much 
bleeding  and  some  purulent  discharge  from  the  surface.  2.  A  sickly 
condition  of  the  patient,  pointing  to  poor  powers  of  repair,  and  a 
waddling    gait,    to   wide    separation    of  the    pubes.     3.  Tendency  to 

*  For  full  information  on  all  these  matters  Mr.  J.  Wood's  articles  (Diet,  of  Surg., 
vol.  i.  p.  425,  and  Med.-Chir.   Trans.,  vol.  iii.  p.  85)  should  be  consulted. 

S. — VOL.  II.  45 


yo6 


OPKKATIONS    ON    THK    AI'.Do.MKN. 


cough.     This  increases  the  protrusion.     4.  Presence  of  large  hernia.-. 

5.  Secondary  dilatation  of  the  ureters  and  pelves  of  the  kidneys,  with 
degeneration  of  viscera.  Mr.  Wood  (loc.  supra  cit.)  shows  that  some- 
times the  ahove  complication  may  he  recognised  by  the  presence  of 
more  albuminuria  than  is  accounted  for  by  the  amount  of  cystitis.  In 
other  cases  no  such  signs  are  present.  Out  of  40  cases  a  fatal 
result,    chiefly    from    this    cause    and    undetected,    followed    in    four. 

6.  Obstinate  eczematous  rawness.  7.  Small  size  of  the  scrotum. 
This  is  rare. 

Preparatory  Treatment. — If  the  patient  has  passed  puberty,  and  the 

hair  isat  all  abundant,  depilation 


Fig.  2G8. 


should  be  practised,  and  nitric 
acid  applied  at  intervals  to  the 
groups  of  hair-follicles. 

It  may  he  well  also  to  try 
and  diminish  the  size  of  the 
ectopia  by  the  means  adopted 
by  the  late  Mr.  Greig  Smith, 
who,  for  some  weeks  previous 
to  operation,  kept  the  patient 
on  his  back,  and  the  exposed 
mucous  membrane  shielded  with 
green  "protective  "  coated  with 
dextrine,  covering  this  over  with 
horacic  lint,  and  by  this  means, 
in  one  case,  the  mucous  mem- 
brane not  only  became  less 
angry,  but  its  upper  half,  almost 
as  low  as  the  ureters,  became 
covered  with  epidermis  almost 
as  white  as  the  surrounding 
skin.  In  another  case,  also 
successfully  operated  on,  no 
preliminary  treatment  was  of 
any  avail  in  diminishing  the 
size  of  the  ectopia. 

Operation.  —  An  anaesthetic 
having  been  given,  a  median 
Hap  *  is  raised  from  the  abdo- 
minal wall  above  the  exposed 
bladder.  Its  shape  resembles  that  of  the  wooden  portion  of  a  fire 
bellows,  its  length  is  rather  greater  than  the  distance  between  the  root 
of  the  penis  and  the  upper  margin  of  the  exposed  bladder,  while  its 
root  must  be  sufficiently  broad  to  ensure  a  sufficient  blood-supply. 
In  raising  it,  care  must  be  taken  not  to  cut  it  too  thin,  and,  at  the  same 
time,  not  to  go  too  deeply  with  the  point  of  the  knife,  as  the  tissues  here 

*  The  shape  and  arrangement  of  the  flaps  are  excellently  shown  in  pi.  ii.,  Figs.  1  and  2, 
accompanying  Mr.  Wood's  paper  (Mcd.-Chir.  Trans.,  vol.  Hi.).  Some  illustrations  of  other 
flaps  in  a  paper  by  Mr.  Mayo  Robson  (Brit.  Med.  Journ.,  1885,  vol.  i.  p.  222)  will  also 
be  found  useful.  And  I  would  direct  my  readers'  attention  to  a  paper  by  the  late 
Mr.  W.  Anderson  [Cliat.  Sue.  J'rans.,  vol.  xxv.  p.  78),  which  contains,  as  might  be  expected 
some  very  helpful  drawings. 


Wood's  operation  for  ectopia  vesicas  (Binnie). 
Flap  A  is  turned  down  to  form  the  anterior 
wall  of  the  bladder,  and  D  may  be  added  to 
cover  the  urethra.  Flaps  B  and  C  are  displaced 
inwards  to  cover  the  raw  surface  of  flap  A. 


ECTOPIA    VKSM'.K    WD    EPISPADIAS. 


707 


Fig.  269. 


are  extremely  thin,  and  the  flat,  tense,  expanded  linea  alba  beneath 

is  often  very  thin,  and  thus  the  peritonaea!  sac  may  easily  he  opened. 

The  two  groin  Haps  are  next,  made,  of  founded  oval  shape,  with  hroad 
pedicles,  the  outer  boundary  of  which  is  sufficiently  carried  out  on  to 
the  thigh,  and  then  on  to  the  root  of  the  scrotum,  to  ensure  its  con- 
taining the  superficial  epigastric  and  the  external  pudic  arteries.  The 
inner  margins  of  these  flaps  join  those  for  the  central  Hap  at  ahout  its 
centre,  and  are  then  continued  down  along  the  side  of  the  urethral 
groove  for  ahout  half  its  length. 

While  these  flaps  must  be  cut  as  thick  as  possible,  care  must  be 
taken  to  avoid  any  subsequent 
hernia,  and  they  must  be  suffi- 
ciently detached  to  meet  for 
their  whole  length,  without  ten- 
sion, in  the  middle  line.  In 
raising  them  they  must  be 
handled  as  carefully  as  possible, 
whether  with  fingers  or  with 
bluntly  serrated  forceps,  so 
as  in  no  way  to  impair  their 
vitality.  All  bleeding  having 
been  stopped,  the  flaps  washed 
with  boracic  acid  lotion,  and 
their  surfaces  allowed  to  be- 
come glazed,  the  umbilical  flap 
is  first  taken  and  folded  down, 
with  its  skin  surface  towards 
the  bladder,  evenly  and  without 
tension.  It  is  then  stitched  to 
the  cut  edge  at  the  root  of  the 
penis. 

The  groin  flaps  are  then 
drawn  inwards,  placed  with  their 
raw  surfaces  upon  the  raw  sur- 
face of  the  umbilical  flap,  and 
carefully  stitched  together.  The 
sutures  should  be  many  and  mixed,  of  wire,  carbolised  silk,  fishing- 
gut,  and  horsehair.  Wire  has  the  advantage  of  being  non-irritating 
and  of  keeping  sweet  in  a  wound  which  cannot  be  kept  aseptic.  The 
sutures  should  he  left  in  for  a  fortnight,  and  in  the  case  of  children 
it  may  be  well  to  give  an  anesthetic  to  take  them  out. 

The  raw  surface  from  which  the  central  flap  was  taken  is  then  closed, 
as  far  as  possible,  with  long  hare-lip  pins  and  twisted  sutures.  The 
rest  of  this  wound  may  be  closed,  now  or  later  on,  by  Thiersch's 
method  of  skin  grafting  (Vol.  I.  p.  188). 

The  parts  are  then  painted  with  collodion  and  iodoform,  sal-alembroth 
gauze  applied,  and  the  buttocks  and  hips  smeared  with  eucalyptus  and 
vaseline.  If  any  redness  appear,  wet  boracic  acid  lint  dressings  should 
be  made  use  of. 

(1  b)  Trendelenburg's  Operation. — Prof.  Trendelenburg  (Centr.  f. 
Ckir.s  Xo.  49,  December,  1885)  published  a  case  of  extroversion  of 
the   bladder  in  which  immediate   union    of  the    lateral  margins   was 

45—2 


Wood's  operation  for  ectopia  vesicas  (Binnie). 
The  raw  surface  is  lessened  by  approximation 
of  the  edges,  and  covered  with  skin-grafts. 


;o8         OPERATIONS  ON  THE  ABDOMEN. 

obtained  by  previous  division  of  the  Bacro-iliac  synchondros*  8.  By 
entirely  freeing  the  joints  and  breaking  their  sides  free  this  Burgeon 
lias  gained  an  approximation  between  the  anterior  superior  spines  of 
two  inches  in  a  child  of  two  and  a  half.  This  approximation  is  of 
coarse  only  rendered  possible  by  the  fact  that  the  symphysis  pubis 
is  deficient  in  these  cases.  When  the  bones  are  thus  approximated 
the  lateral  margins  of  the  defect  arc  pared,  and  brought  together 
with  Butures.  This,  when  successful,  effects  a  greal  saving  of  time, 
and  secures  that  the  cavity  of  the  bladder  shall  consist,  Bave  for  a 
narrow  line  of  scar  in  front,  of  vesical  mucous  membrane  and  not  of 
scar  tissue.  As  a  result  the  formation  ofphosphatic  deposit  is  greatly 
diminished.  A  very  interesting  account  of  this  operation  has  been 
given  by  Mr.  Makins,  with  a  successful  case  {Trans.  Med.-Chir.  Soc, 
vol.  lxxi.  p.  191).  To  be  successful  the  division  of  the  synchondroses 
should  be  performed  early,  e.g.,  before  the  child  is  eight. 

Prof.  Trendelenburg  has  recently  read  a  paper  before  the  American 
Surgical  Association,  giving  his  present  views  and  the  instructive 
results  of  his  mature  experience  (Ann.  of  Sv/rg.,  1906,  vol.  xliii. 
p.  281).  He  maintains  that  the  bilateral  separation  of  the  Bacro- 
iliac  joints  in  children  before  the  seventh  or  eighth  year  is  not  the 
serious  procedure  that  some  consider  it  to  be,  and  that  it  is  very 
effectual  in  relieving  lateral  tension.  He  believes  that  transplantation 
of  the  trigone  into  the  bowel  will  be  again  abandoned  on  account  of 
the  risk  of  pyelonephrosis,  and  the  inconvenience  of  micturition  through 
the  anus,  especially  in  a  male. 

By  careful  paring  and  re-formation  of  the  neck  of  the  bladder  and 
urethra,  he  maintains  that  it  is  possible  in  at  least  some  cases  to  obtain 
more  or  less  perfect  sphincteric  control  of  the  bladder,  or  tailing  this,  to 
provide  artificial  control. 

Of  the  cases  operated  upon  by  Trendelenburg  years  ago  for  defects 
extending  from  the  umbilicus  to  the  glans  penis,  three  are  alive  and 
without  any  fistulous  openings,  but  with  a  complete  bladder  and 
urethra.  "The  bladder  when  distended  consists  oi  a  spherical  cavity 
lined  with  mucous  membrane  over  its  greater  extent.  The  passage  of 
small  concretions  is  occasionally  observed  by  these  patients,  but  the 
tendencv  to  calculus  formation  is  by  10  means  as  marked  as  in  certain 
cases  operated  upon  by  Thiersch  (Hap  method)  which  I  have  had  occasion 
to  examine. 

"  These  patients  partly  suffered  to  such  an  extent  from  the  production 
of  calculi,  incrustations,  and  ulcerations  in  the  irregular  crypts  of  the 
bladder,  that  they  demanded  operation  by  some  other  method  for  the 
relief  of  their  condition. 

"  Retention  of  urine  is  not  complete  in  any  of  my  three  cases.  These 
young  men,  therefore,  wear  a  contrivance  supplied  with  a  small  spring 
which  compresses  the  urethra  at  the  root  of  the  penis,  either  from  the 
front  or  the  back.  The  patients  are  now  students  at  college  :  they  are 
not  greatly  inconvenienced  by  the  apparatus,  and  by  proper  care  and 
attention  they  avoid  the  production  of  any  odour  which  would  serve  to 
attract  attention  to  their  condition.  If  the  spring  is  raised  the  urine 
issues  forth  in  a  stream.  On  lying  down  it  collects  in  the  bladder 
without  leakage.  One  of  the  men  remains  dry  throughout  the  night, 
he  may  be  awakened  once  or  twice  by  the   desire  to  urinate,  and  even 


ECT0P1  \    VESICA    AND    EPISPADIAS.  ?oq 

when  he  gets  up  he  can  voluntarily  retain  the  urine  for  several  minutes, 
and  then  pass  it  naturally  in  a  stream.     A  fourth  patient,  a  boy  of  five, 

could  al>(>,  when  he  tried,  retain  his  urine  for  several  hours  whin 
standing  or  walking,  hut  Later  on  at  the  time  of  his  leaving  the  clinic 
the  ability  was  lost. 

"Both  of  the  two  cases  last  mentioned  demonstrate  that  physiological 
factors  necessary  for  both  retention  and  voluntary  micturition  are 
pit  sent,  and  that  tiny  are  merely  prevented  from  functionating  in  a 
normal  manner  by  certain  mechanical  conditions.  The  reason  for  the 
failure  may  he  accounted  for  by  the  fact  that  tin.'  two  sections  of  the 
pelvis,  which  have  been  separated  at  the  sacro-iliac  synchondrosis,  have 
a  tendency  to  gradually  resume  their  former  positions;  therefore  the  neck 
of  the  bladder  and  the  prostatic  portions  of  the  urethra,  which  are  closely 
connected  with  the  puhic  hones,  are  pulled  upon  to  such  an  extent  that 
the  muscular  ring  can  no  longer  be  brought  into  play. 

"I  have  made  several  attempts  to  overcome  this  difficulty  by  mobilising 
the  pubic  bones,  with  the  help  of  the  chisel,  or  by  dissecting  widely  the 
attachments  of  the  urethra  and  the  neck  of  the  bladder  to  the  latter. 
In  no  instance  of  complete  ectopia  liave  I  been  favoured,  however,  with 
a  permanent  result.  Such  a  procedure,  moreover,  is  apt  to  lead  to  the 
production  of  a  dense  sear  along  the  vesical  neck,  which  in  the  event 
of  a  later  secondary  operation  will  be  found  a  source  of  as  great  annoy- 
ance as  the  cicatrices  in  a  hare-lip  which  has  failed  to  heal  by  primary 
union." 

Cases  of  partial  ectopia  or  of  epispadias  and  incontinence  are  more 
favourable,  and  Prof.  Trendelenburg  has  been  able  to  obtain  excel- 
lent results  in  a  few  of  these  by  paring  freely  enough  and  carefully 
suturing  the  vivified  edges  of  the  urethral  groove  or  deficiency  in  the 
lower  part  of  the  bladder.  The  margins  of  the  vesical  part  of  the  wound 
are  inverted.  During  these  procedures  the  pubic  bones  are  strongly 
retracted,  and  the  pelvis  is  elevated. 

Only  a  fine  drainage  tube  is  left  in  the  newly  completed  urethra,  for 
a  catheter  might  exert  too  much  pressure  on  the  sutured  tissues. 
The  bladder  is  drained  through  a  special  opening  until  healing  has 
occurred. 

In  the  case  of  a  female  child  with  epispadias  and  incontinence, 
Prof.  Trendelenburg  was  able  to  suture  the  pubic  bones  together 
after  separating  the  right  sacro-iliac  joint  and  suturing  the  urethra  and 
neck  of  the  bladder.  Success  did  not  attend  the  operation,  which  was 
therefore  repeated.  This  time  the  result  was  good,  and  it  remained 
perfectly  satisfactory  six  years  later. 

It  is  rarely  possible  to  complete  the  puhic  arch  in  cases  of  extensive 
ectopia,  and  "  wiring  of  the  bones,  particularly  in  hoys,  cannot  be 
advantageously  employed,  because  the  wire  comes  in  conflict  with 
both  the  bladder  and  the  penis.  In  younger  children,  moreover,  the 
wire  is  very  apt  to  cut  its  way  through  the  tissues"  (Trendelenburg, 
loc.  cit.). 

Trendelenburg  believes  that  this  approximation  can  be  best 
accomplished  by  the  gradual  effect  of  pressure  by  means  of  an  elastic 
pelvic  girdle  worn  day  and  night.  This  metljod  is  most  likely  to  be 
successful  when  adopted  after  separation  of  the  bones  at  both  sacro- 
iliac  joints.     When    the    pubic    gap    has  been    greatly  diminished,   a 


7io  OPERATIONS  ON  THE  ABDOMEN. 

plastic  operation  can  be  undertaken  for  reconstructing  a  bladder  and 
urethra. 

It  may  be  safely  concluded,  I  think,  that  the  results  of  Prof. 
Trendelenburg  are  as  good  as  any  that  can  be  obtained  by  any  plastic 
method,  even  with  the  advantage  of  unusual  skill  and  long  experience, 
but  the  functional  results  are  not  encouraging  except  in  cases  of  partial 
ectopia,  and  epispadias  with  incontinence. 

Konig  has  lessened  lateral  tension  by  dividing  the  rami  of  the  pubis  and 
ischium,  and  Schlange  has  adopted  a  similar  method. 

Segond  has  liberated  the  upper  part  of  the  bladder  without  opening 
the  peritonaeum,  and  brought  it  downwards  as  a  flap,  and  sewn  it  to  the 
refreshed  lateral  margins  of  the  urethral  gutter  and  sides  of  the  trigone. 
He  then  made  a  transverse  incision  through  the  base  of  the  pendulous 
prepuce  and  brought  the  penis  through  this  aperture.  The  prepuce 
was  then  used  to  cover  the  raw  surface  of  the  flap  on  the  dorsum  of  the 
penis.  After  this  operation  the  urine  can  be  more  easily  collected  and 
conducted  into  a  suitable  urinal. 

After-treatment. — The  patient  must  be  partly  sitting,  the  shoulders 
being  well  propped  up  and  the  knees  flexed  ;  a  bandage  passed  from 
the  knees  around  the  shoulders  will  facilitate  this.  Any  sudden 
straightening  of  himself  by  the  patient  is  fatal  to  a  good  result.  For 
the  first  few  days  small  opiates  or  injections  of  morphia  will  be 
required. 

(2)  Sonnenburg's  Operation  consists  in  transplantation  of  the  ureteral 
ends  into  the  upper  end  of  the  gutter  which  represents  the  urethra. 
The  rest  of  the  vesical  mucosa  is  resected  without  opening  the  peritonaeum. 
A  suitable  urinal  can  be  worn  after  this  procedure  with  comparative 
ease.  The  gap  in  the  parietes  can  be  closed  either  completely  or  in 
part  by  the  appropriate  use  of  flaps.  It  is  less  dangerous,  but  also  far 
less  satisfactory,  than  Maydl's  method. 

(3a)  Anastomosis  of  the  Bladder  and  Rectum. — Frank  (Ann.  of  Surg. 
vol.  xxxvii.  p.  291)  makes  an  incision  in  the  posterior  wall  of  the  bladder 
and  anastomoses  the  bladder  and  rectum  by  means  of  his  absorbable 
coupler.  Pie  then  frees  the  edges  of  the  bladder,  turns  them  in,  and 
sutures  them  together.  Dr.  Halsted  frees  and  turns  in  the  thick  mucous 
membrane  only,  leaving  the  fascia  behind,  so  that  the  peritonaeum  may 
not  be  opened.  He  uses  Murphy's  button  for  making  the 
anastomosis.       Direct  suture  is  preferable. 

The  abdominal  wall  is  then  closed  as  far  as  possible.  Senn  (loc.  <it.) 
performed  the  operation  in  two  stages,  fii'st  making  a  longitudinal 
incision  in  the  bladder,  through  which  he  drew  a  piece  of  rectum  or  lower 
part  of  the  sigmoid,  and  fixed  it  to  the  bladder  wall.  Three  days  later  the 
bowel  was  opened,  and  the  edges  of  the  mucosa  were  joined  to  the 
mucous  membrane  of  the  bladder. 

A  plastic  operation  to  close  the  bladder  was  undertaken  later,  but 
this  did  not  succeed  at  the  first  attempt. 

This  plan  is  not  so  satisfactory  as  direct  implantation  of  the  trigone 
into  the  bowel,  for  the  attempt  to  preserve  and  close  the  ectopic 
bladder  is  attended  with  more  frequent  failure  or  formation  of  fistula?, 
which  may  discharge  either  urine  alone  or  faeces  also.  It  is  probable 
also  that  calculi  will  form  in  the  vesical  diverticulum  which  com* 
municates  with  the  rectum,  unless  the  fistula  is  a  wide  one. 


ECT0P1  \    VESICAE    AMi    EPISPADIAS. 


711 


Further  it  is  not  necessary  to  save  the  whole  of  the  bladder,  for  the 
rectum  soon  affords  plenty  of  room  for  the  urine. 

(36)  Maydl's  Operation.  Transplantation  of  the  Trigone  into  the 
Sigmoid  Colon. — An  area  of  the  bladder,  including  the  trigone,  is  then 
carefully  dissected  up  and  separated  from  the  rest  of  the  bladder  and 
commencement  of  the  urethra.  The  excess  of  the  vesical  mucosa  is 
then  excised  and  the  field  of  operation  thoroughly  cleansed  before  the 
abdomen  is  opened  in  the  middle  line. 

A  loop  of  sigmoid  is  now  drawn  through  the  wound,  and  the  abdominal 
cavity  protected  by  gauze  packing.  A  longitudinal  incision  of  the 
required  length  is  next  made  in  the  right  side  of  the  exposed  loop 

Fig.  270. 


A  B 

Maydl's  operation.     (Binnie.) 

A,  The  portion  of  bladder  is  sutured  into  the  sigmoid  colon  ;  the  deep  suture 
penetrates  all  the  coats.  B,  The  deep  suture  is  reinforced  by  a  continuous 
Lembert  suture, 

of  sigmoid,  escape  of  contents  being  prevented,  if  necessary,  by  the 
application  of  clamps.  The  trigone  is  now  rotated  through  about  ninety 
degrees,  so  that  the  ureters  now  lie  above  one  another  instead  of  side 
by  side,  and  is  attached  to  the  margins  of  the  opening  in  the  sigmoid 
by  means  of  sutures. 

Two  sutures  are  used,  a  continuous  deep  one  of  catgut  piercing  all 
the  coats  in  order  to  secure  a  firm  hold  until  union  occurs,  and  a 
superficial  continuous  Lembert  or  dishing  suture  of  fine  silk  (vide 
Fig.  270  A  and  B). 

The  sigmoid  is  cleansed  and  dropped  back  into  the  abdomen.  A 
tampon  of  iodoform  gauze  is  then  passed  down  to  the  site  of  the 
anastomosis  to  provide  against  possible  leakage,  and  the  rest  of  the 
wound  closed. 

Maydl  considers  the  sigmoid  to  be  preferable  to  the  rectum  for 
implanting  the  trigone,  because  he  believes  the  risk  of  ascending 
infection  to  be  less  on  account  of  the  comparative  emptiness  of  the 
sigmoid. 

Gersuny's  modification  of  Maydl's  method  adds  to  the  severity  of  the 


712 


OPERATIONS  ON  THE  ABDOMEN. 


operation  without  conferring  any  real  advantage.  He  divides  the  bowel 
across  at  the  junction  of  the  sigmoid  and  the  rectum,  implants  the 
trigone  into  the  upper  end  of  the  rectum,  and  the  sigmoid  into  the 
wall  of  the  rectum  lower  down. 

Dr.  Peters,  of  Montreal,  successfully  transplanted  the  ureters  into 
the  rectum  extraperitonseally.  The  patient  was  six  years  of  age  at  the 
time  when  Dr.  Peters  recorded  the  case.  The  urine  could  be  retained 
in  the  rectum  for  three  hours  during  the  day  and  for  eight  hours  during 
the  night. 

(3c)  Transplantation  of  the  Whole  of  the  Ectopic  Bladder  into 
the  Wall    of    the   Eectum. — Mr.    Moynihan    (Ann.   of  Surg.,    1906, 

Fig.  271. 


^  \l Peritoneum 


■Ureteral 
catheters 


Urethral 

groove 

in  penis 


Moynihan's  method  of  transplanting  the  ectopic  bladder  into  the  anterior  wall 
of  the  rectum  (redrawn  from  the  Ann.  of  Surg.}.  The  bladder  is  carefully- 
liberated  without  opening  the  peritonaeum.  The  ureteral  catheters  are  fixed  in 
position  by  sutures. 


vol.  xliii.  p.  237)  successfully  transplanted  nearly  the  whole  of  the  ectopic 
bladder  into  the  rectum  in  a  young  man  aged  19.  "  A  plastic  operation 
had  been  performed  fifteen  years  earlier,  but  the  lower  part  of  the  vesical 
mucosa  was  still  exposed,  and  the  urine  was  discharged  upon  the  exposed 
surface.  It  was  there  caught  in  the  usual  rubber  receptacle,  of  pestilent 
odour,  and  drained  downwards  to  the  leg.  The  patient,  with  increasing 
years,  had  become  more  painfully  aware  of  the  misery  of  his  condition, 
and  begged  to  have  something,  anything,  done  to  relieve  him  of  his 
terrible  affliction." 

It  occurred  to  Mr.  Moynihan  that  "if  a  large  area  of  the  bladder 
could  be  grafted,  so  to  speak,  into  the  rectum,  the  capacity  of  the 
bowel  would  be  increased,  and  a  veritable  cloaca  formed.  My  only 
doubt  was  that  the  vascular  supply  furnished  along  the  ureters  might 
be  insufficient  for  a  large  area  of  the  bladder.     But  in  the  operation  I 


ECTOPIA    YKSM'.K    AND    EPISPADIAS. 


7*3 


now  describe  I  found  that  when  the  edges  of  the  bladder  were  trimmed 
with  scissors,  a  free  oozing  of  blood  occurred  from  the  cut  surface.  I 
therefore  was  able  to  transplant  the  entire  bladder." 

Operation. — "  The  ureters  were  first  catheterised.  Owing  to  the 
previous  constant  friction  against  the  exposed  bladder  mucosa,  which 
pouted  exuberantly,  this  little  manoeuvre  was  by  no  means  easy.  A 
catheter  was  passed  for  four  inches  into  each  ureter,  and  was  fixed  there 
by  a  single  stitch,  which  caught  up  the  tube  on  one  side  and  the  bladder 
on  the  other. 

Fig.  272. 


Sepa  rated 
Hadder 


Ureters 


Rectum 


Moynihan's  method  of  transplanting  the  ectopic  bladder  into  the  anterior  wall 
of  the  rectum  (redrawn  from  the  Ann.  of  Surg.').  The  ureters  are  not  separated 
nearly  so  freely  as  shown  in  the  figure. 


A  vertical  median  incision  was  then  made  from  the  exposed  bladder 
mucosa  towards  the  umbilicus,  the  flaps  which  had  been  turned  over  to 
the  middle  line  in  the  previous  operations  being  completely  cut  through. 
On  turning  aside  the  flaps  thus  made  the  upper  previously  covered 
mucous  surface  of  the  bladder  was  exposed  ;  it  was  found  to  be  smooth, 
thin,  and  entirely  different  in  character  and  appearance  from  that  of  the 
lower  exposed  part.  An  incision  all  round  the  margin  of  the  mucous 
membrane  of  the  bladder  was  now  made  between  the  mucosa  and  the  skin, 
and  the  incision  was  deepened  by  degrees  until  a  good  thickness  of  the 
bladder  could  be  raised  up. 

The  dissection  from  the  margin  of  the  bladder  towards  the  ureters 
was  continued  round  the  whole  circumference  little  by  little.    This  was 


7i4 


OPERATIONS  ON  THE  ABDOMEN. 


difficult  in  part  owing  to  the  fact  that  there  was  much  scar  tissue 
left  from  the  former  operations,  in  part  because  the  great  vascularity 
demanded  frequent  cessation  to  restrain  haemorrhage  by  pressure.  Tlie 
separation  above  the  pubes  was  most  difficult,  and  here  the  prostate 
had  to  he  separated  with  great  care. 

The  purpose  of  this  process  of  separation  was  to  isolate  the  whole  of 
the  bladder,  leaving  only  as  its  pedicle,  so  to  speak,  the  two  ureters. 
As  much  tissue  was  left  round  each  ureter  as  possible,  so  as  to  avoid 


Fig.  273. 


Deep  surface 
of  bladder 


Incision  into 
rectum 


Moynihan'a  method  of  transplanting  the  ectopic  bladder  into  the   anterior 
wall  of  the  rectum  (redrawn  from  the  Ann.  of  Surg.). 

the  possibility  of  damage  either  to  the  ureter  itself  or  to  its  vessels.  In 
the  annexed  diagram  (Fig.  272)  the  ureters  are  shown  clearly  defined. 
This  was  not  their  condition  during  the  operation.  The  figure  is  drawn 
only  for  the  purpose  of  making  the  details  of  the  operation  (dear.  As 
soon  as  the  bladder  was  well  isolated,  it  was  drawn  forwards  towards 
the  umbilicus  and  there  held  by  an  assistant.  In  the  bottom  of  the 
wound  the  rectum  was  now  seen,  and  above  the  peritonaea!  reflection  on 
to  it.  The  serous  covering  was  then  stripped  upwards  from  the  front 
of  the  rectum  until  four  or  five  inches  of  the  bowel  lay  exposed  at  the 
bottom  of  the  wound.    In  stripping  the  peritoneum  up  a  small  rent 


ECTOPIA    YKsici;    AND    EPISPADIAS. 


7i5 


was  made  into  it,  which  was  closed  at  once  by  a  continuous  catgut 
suture. 

The  finger  of  an  assistant  was  now  passed  into  the  rectum  to  make 
it  prominent,  and  along  tin-  anterior  surface  of  the  bowel  an  incision 
about  three  and  a  half  inches  in  length  was  made  (Fig.  273). 

The  upper  and  lower  ends  of  this  incision  and  the  mid  points  of  the 
sides  were  held  with  small  vulsella,  until  a  large  opening  was  made. 
Into  this  opening  the  bladder  was  placed,  being  turned  upside  down, 
so  that  its  former  anterior  surface  became  posterior,  and  its  former 
lower  end  became  the  upper. 

Fig.  274. 


Lower  part 
of  bladder 


Rectum 

Upper  part 
of  bladder 


Ureteral  catheters 
brought  out 
through,  anus 


Movnihan's  method  of  transplanting  the  ectopic  bladder  into  the  anterior  wall 
of  the  rectum  (redrawn  from  the  Ann.  of  Surg.).  The  bladder  has  been  rotated 
so  that  its  upper  end  is  now  lowest  and  fixed  to  the  lower  part  of  the  wound 
in  the  rectum.     The  ureteral  catheters  are  brought  out  through  the  anus. 


The  ureters,  instead  of  passing  forward  to  the  bladder,  passed  back- 
ward, and  the  catheters  passed  into  the  rectum  and  out  at  the  anus. 
The  edge  of  the  bladder  and  the  cut  edges  of  the  rectum  were  now 
sutured  together  by  two  stitches  that  were  continuous,  one  taking  the 
right  side  and  the  other  the  left  (Fig.  274).  The  sutures  were  passed 
after  the  manner  of  Lembert,  so  that  no  mucous  membrane  was  included 
in  them.  A  few  additional  interrupted  sutures  were  necessary  here  and 
there.  When  the  sutures  seemed  to  be  securely  uniting  the  bladder 
and  the  rectum,  the  wound  was  dried,  and  the  skin  edges  along  the 
original  median  incision  were  drawn  together.  At  the  upper  end  the 
edges  came  well  into  apposition,  but  about  an  inch  at  the  lower  part  had 
to  be  left  open.  The  catheter  which  had  been  introduced  into  the 
ureters  now  passed  out  of  the  anus ;  the  sphincter  had  previously  been 


yi6  OPERATIONS  ON  THE  ABDOMEN. 

stretched.  The  operation  lasted  an  hour  and  a  half.  The  after-progress 
of  the  case  was  satisfactory.  The  catheters  remained  in  the  ureters  for 
four  davs,  the  urine  being  collected  into  a  bottle.  After  their  removal 
the  urine  passed  into  the  rectum,  and  dribbled  out  at  the  aims,  which, 
owing  to  the  stretching  of  the  sphincter,  as  yet  exerted  no  control.  On 
the  seventh  day  a  little  urine  began  to  leak  by  the  abdominal  wound, 
and  this  continued  for  a  week.  On  the  fifteenth  day  an  anesthetic  was 
again  administered,  and  the  leaking  point  in  the  former  line  of  suture 
discovered  and  made  good.  From  this  day  the  wound  remained  abso- 
lutely dry,  all  urine  escaped  by  the  rectum,  and  control  gradually 
returned,  until  at  the  end  of  the  month  it  was  perfect.  Urine  was  then 
passed  by  the  rectum  about  every  two  hours.  The  interval  between  the 
acts  of  emptying  the  rectum  has  gradually  increased  until  now 
(November,  1905)  the  shortest  period  is  three  hours,  and  the  longest 
five  hours.     The  urine  is  quite  sweet  and  is  normal  on  examination. 

When  the  rectum  is  now  examined,  the  line  of  junction  between  the 
mucous  membrane  of  what  was  the  bladder  and  the  mucous  membrane 
of  the  rectum  cannot  be  distinguished.  All  feels  smooth  and  even  and 
continuous.     There  is  a  fairly  capacious  cloaca." 

In  February,  1907,  Mr.  Moynihan  very  kindly  sent  me  a  letter  which 
he  had  just  received  from  the  medical  attendant,  Dr.  Empey.  The 
following  is  an  extract  from  the  letter : — "  He  is  following  the  occupa- 
tion of  weaving,  and  presents  the  appearance  of  possessing  excellent 
health.  There  is  slight  suppuration  of  the  wound  in  front  still  going 
on,  but  nothing  of  importance.  He  requires  to  empty  the  rectum  four 
or  five  times  in  the  twent3r-four  hours.  The  longest  interval,  I  am  given 
to  understand,  is  from  three  to  four  hours  during  the  day.  He  very 
occasionally  wets  the  bed  a  little." 

HYPOSPADIAS. 

Varieties. — These  are  three,  viz. :  1.  Glandular.  The  opening  is 
here  merely  farther  back  than  usual ;  the  fhenum  is  absent,  the  glans 
broad,  flattened,  somewhat  recurved,  and  the  prepuce,  often  hood-like, 
always  in  a  condition  of  partial  paraphimosis.  2.  Penile.  Here  the 
urethra  is  especially  liable  to  open  at  one  of  the  three  following  sites : 
(a)  just  behind  the  glans;  (b)  at  the  middle  of  the  penis  ;  (r)  at  the 
junction  of  the  penis  and  scrotum.  3.  Scrotal.*  Here  the  cleft  on 
which  the  urethra  opens  may  be  either  at  the  junction  of  the  penis  and 
scrotum,  or  involve  the  scrotum  and  perinaBum,  the  former  being  called 
peno-scrotal  and  the  latter  perinaeo-scrotal. 

When  an  operation  is  under  consideration  with  a  view  of  rendering 
micturition  and  coitus  normal,  the  surgeon  must  take  into  due  considera- 
tion—  (a)  the  degree  of  the  deformity  ;  (fi)  whether  the  penis  is  fairly  de- 
veloped ;  (y)  whether  it  is  much  tied  down  ;  (8)  whether  the  testicles 
are  present  and  descended  ;  (c)  how  far  the  patient's  condition  is  made 
miserable  by  rawness  and  eczema  due  to  impeded  micturition,  and  by 
impeded  coitus,  and  how  far  there  are  reasonable  hopes  of  remedying 
these.     Four  methods  of  operating  will  be  described. 

*  The  above  is  sometimes  divided  into  two.  scrotal  and  perinaeo-scrota]. 


BYP0SPAD1  IS. 


717 


Fig.  275. 


1.  Duplay's  Operation. — The  operation  is  divided  into  the  following 
three  stages,  which  require,  in  order  to  be  successful,  much  time  and 
patience  on  the  part  of  both  surgeon  and  patient  : 

i.  Straightening  the  penis  and  formation  of  a  meatus;  ii.  Formationof 
a  canal  from  the  meatus  to  the  hypospadiac  opening;  iii.  Junction  of  the 
old  and  new  canal. 

i.  Straightening  of  the  Penis. — Tn  the  penile,  peno-,  and  perineo- 
scrotal varieties,  the  penis,  often  short,  is  recurved,*  especially  during 
erection,  by  a  band  consisting  partly  of  a  muco-cutaneous  ridge,  corre- 
sponding to  the  absent  urethra,  and  reaching  from  the  hypospadiac 
orifice  to  the  glans.  M.  Bouisson  seems  to  have  first  pointed  out  the 
importance  of  dividing  this,  which  he  did  subcutaneously.  M.  Duplay 
recommends  division  by  an  open  wound,  carrying  the  incision  as  deeply 
as  needful,  and  states  that  the  corpora  cavernosa  may  be  incised  to  a 
very  considerable  depth,  if  needful  to  secure 
this  end.  M.  Duplay's  incision  leaves  a 
lozenge-shaped  wound,  which  he  unites  by 
sutures  (Fig.  275,  B  and  C). 

At  the  same  time  the  above-named  sur- 
geon forms  a  meatus.  This  is  done  by 
paring  the  two  lips  of  the  depression  which 
represents  the  meatus,  and  uniting  these 
over  a  bit  of  catheter.  If  the  depression 
be  very  shallow,  an  incision  upward  into 
the  glans-tissue,  or  two  lateral  ones,  may 
be  needed  before  it  is  possible  to  insert  a 
catheter,  and  to  apply  sutures  round  it. 

ii.  Formation  of  a  New  Urethra. \ — The 
penis  being  held  up,  two  incisions  are  made 
a  little  outside  the  lateral  margins  of  the 
mucous  surface  corresponding  to  the  de- 
ficient urethra,  and  reaching  from  the  glans 
to  the  hypospadiac  orifice.  By  making  two 
transverse  incisions  at  either  end,  two  narrow 
quadrilateral  flaps,  a,  b,  a',  b'  (Fig.  275,  D), 
are  dissected  up  towards  the  middle  line  until,  with  their  mucous  sur- 
faces turned  inwards  and  their  raw  surfaces  outwards,  they  meet  without 
tension  over,  and  thus  shut  in  a  catheter  passed  from  the  previously 
restored  meatus  to  the  hypospadiac  orifice.  A  bougie  or  rod  can  be 
used  instead,  and  a  catheter  passed  into  the  bladder  through  the 
malplaced  urethral  orifice,  so  that  urine  is  less  likely  to  leak  by  the 
side  of  the  catheter  and  infect  the  sutures.  These  flaps  are  now 
united  with  sutures,  partly  of  fine  chromic  gut  and  partly  of  fine  car- 
bolised  silk,  cut  quite  short.  From  the  sides  of  the  penis  two 
similar  flaps,  c,  d,  c',  d'  (Fig.  275,  D),  are  dissected  up  from  within 
outwards,  till  they  can  be  sufficiently  drawn  inwards  without  tension 
to  cover  over  the  raw  surfaces  of  the  internal  flaps.     They  are  then 


(Bryant.) 


*  This  recurving  is  also  in  part  due  to  thickening  and  shortening  of  the  capsule  of  the 
corpora  cavernosa,  and  even  of  the  septum. 

t  Several  months,  at  least  five  or  six,  must  elapse  before  the  surgeon  is  certain  that  no 
recurving  will  occur.     This  disappears  very  gradually. 


718 


OPKRATIONS   ON    THK    ABDOMEN. 


carefully  united  in  the  middle  line  (Fig.  275,  E).  I  much  prefer 
horsehair  and  fishing-gut  sutures  here,  well  soaked  previously  in  warm 
carbolic  acid. 

In  operating  upon  boys — and  I  consider  nine  to  fifteen  as  the  best  age 
— I  prefer,  in  penile  hypospadias,  to  make  the  new  glans  and  restore  the 
floor  of  the  urethra  at  one  sitting.  Any  points  where  union  fails  can 
be  closed  later.  The  chief  trouble  is  the  retention  of  the  catheter  suffi- 
ciently long.    I  have  usually  found  that  after  the  third  day  the  delicate 


Fig.  276. 


Fig.  277. 


Fig.  278. 


mucous  membrane  of  a  child's  bladder  resents  the  catheter — a  very  little 
mucus  quickly  plugs  these  small  instruments — and  a  nurse  must  be 
instructed  to  pass  a  small  india-rubber  catheter  every  two  or  three 
hours.  In  the  intervals  a  short  bit  of  bougie  is  kept  in  the  new 
urethra  and  glans  to  maintain  the  patency  of  the  canal.  Iodoform 
and  collodion  with  a  dry  dressing  of  iodoform  gauze  are  the  best 
dressing. 

Mr.  Makins  describes  (Lancet,  1894,  vol.  ii.  p.  1141)  a  method  of 
restoring  the  urethra  in  hypospadias,  in  which  Thiersch's 
operation  is  ingeniously  modified.  By  the  use  of  three 
tiers  of  suture  not  only  is  the  new  urethra  built  up  firmly, 
but  the  prepuce  is  restored  as  well. 

iii.  Joining  the  Old  and  New   Urethra. — As  soon  as  the 
new  urethra  is  thoroughly  established,  quite  closed,  and 
shows  no  sign  of  contraction,  this  last  stage  may  be  under- 
taken.    The  edges  of  the  posterior  end  of  the  new  urethra 
and  those  of  the  remaining  orifice  having  been  freely  vivified, 
and  a  catheter  passed  from  the  meatus  into  the  bladder, 
the  opening  is  closed  over  it  by  sutures  as  in  stage  ii.     A  catheter — ■ 
one  of  Jaques'  pattern  is  least  painful — should  be  kept  in  the  bladder 
if  possible  till  all  is  water-tight. 

2.  Russell's  Method  {Brit.  Med.  Journ.,  Nov.  17,  1900). — Mr. 
Hamilton  Russell,  of  Melbourne,  describes  the  following  method  which 
he  has  devised  and  used  successfully  on  a  boy,  aged  9,  the  subject  of 
hypospadias  of  the  perinaeo-scrotal  type.  In  view  of  the  excellence  of 
the  result  in  the  above  case,  the  method  is  well  worth  a  trial.     The 


IIYI'OSI'AMAS 


719 


operation  is  performed  in  two  stages,  and  is  described  by  Mr.  Russell 
as  follows  : — 

First  Operation. 

A  thread  is  passed  through  the  glans  penis  to  serve  as  a  tenaculum 
and  the  glans  drawn  upwards. 

Step  I. — An  incision  through  the  frfenum  which  hinds  down  the 
glans.  This  incision  may  be  carried  at  once  right  down  the  penis,  so  as 
to  divide  the  prepuce  on  the  dorsum  by  a  circular  sweep  not  too  close 
to  the  corona.  The  tip  of  the  left  index  finger  is  inserted  into  the 
gaping  wound  in  the  concavity  of  the  penis,  and  the  structures  which 
bind  it  down  are  felt  and  divided  by  successive  cuts  with  scissors.  In 
this  way  will  be  divided  a  number  of  dense  fibrous  bands  and  portions 
of  the  sheaths  of  the  corpora  cavernosa,  and  the  scissors  must  be  freely 
used  until  the  penis  is  quite  released  and  can  be  drawn  out  straight. 
There  will  now  be  a  great  length  of  raw  surface  exposed  between  the 
extremity  of  the  perinaeal  urethra  and  the  glans,  and  the  median  sulcus 


Fig.  279. 


Fig.  280. 


between  the  corpora  cavernosa  may  be  deepened  by  a  little  careful 
dissection,  and  removal  of  the  remains  of  the  longitudinal  fibrous  bands 
that  have  been  divided  (Fig.  277  ;  the  shaded  portion  shows  the  shape 
of  the  raw  surface  exposed.) 

Step  II. — Perforation  of  the  glans  for  the  reception  of  the  glandular 
urethra  : — A  tenotomy  knife,  with  the  edge  turned  towards  the  dorsum 
of  the  organ,  is  thrust  through  the  substance  of  the  glans,  close  to  the 
under-surface  ;  the  structure  is  incised  freely  towards  the  dorsum, 
leaving  a  capacious  channel  through  its  substance.- 

Step  III. — The  incision  indicated  by  the  dotted  lines  e  e'  (Figs.  277 
and  278),  starting  near  to  the  extremity  of  the  perinaeal  urethra,  about 
one-third  of  an  inch  or  less  from  the  cut  margin  of  the  skin,  the  incision 
is  carried,  always  parallel  to  the  cut  margin,  over  the  dorsum  of  the 
penis  to  the  corresponding  point  on  the  opposite  side.  By  this  incision 
a  strip  of  prepuce  will  be  marked  out  which  surrounds  the  penis  in  a 
manner  closely  resembling  a  clergyman's  stole  (Figs.  277  and  278). 
This  loop  of  skin  is  then  detached  from  its  connections  everywhere 
except  at  its  extremities,  and  slipped  over  the  end  of  the  penis,  exactly 


720  OPERATIONS  ON  THE  ABDOMEN. 

as  b  clergyman  removes  his  stole.  The  loop  of  prepuce  is  tlien  simply 
manipulated  so  thai  the  cutai us  surfaces  are  placed  in  apposition, the 

raw  surfaces  being  turned  outwards;  a  sinus-forceps  is  passed  through 
the  channel  in  the  glans,  the  loop  seized  and  pulled  through  (Fig.  279). 
The  redundant  portion  of  the  loop  is  then  cut  off,  and  the  two  lateral 
portions  of  the  new  urethra  fixed  in  position  by  one  or  two  stitches  at 
the  meatus  (Fig.  280). 

Step  IV. — Adjustment  and  suturing  of  the  preputial  flaps.  On  the 
dorsum  of  the  penis  this  is  just  a  simple  procedure,  as  in  circumcision. 
On  the  under-surface  of  the  organ,  where  the  prepuce  is  made  to  cover 
over  the  two  edges  of  the  new  urethra, these  edges  should  be  included  in 
the  sutures,  so  that  in  each  suture  four  cutaneous  edges  are  brought 
together,  namely,  two  of  prepuce  and  two  of  new  urethra  (Fig.  280). 
Before  finally  tying  these  sutures  inspection  should  he  made  of  the 
spot  where  the perinaeal  urethra  hecomes  continuous  with  the  new  penile 
urethra;  a  nipple-like  projection  of  skin  is  likely  to  he  present  at  this 
place,  and  should  he  snipped  off  with  scissors. 

The  posterior  (or  dorsal)  edges  of  the  new  urethra  will  he  adjusted  in 
the  mesial  sulcus  between  the  corpora  cavernosa,  and  will  not  require 
any  suturing.  The  sutures  having  heen  tied,  a  narrow  bandage  of 
iodoform  gauze  may  he  then  wound  round  the  organ,  and  left  undisturbed 
for  several  days.  The  result,  when  completed,  is  portrayed  in  Fig.  280. 
It  is  scarcely  necessary  to  remark  that  no  rod  of  any  kind  should  he 
inserted  in  the  new  urethra.  Should  there  he  any  defect  in  the  success 
of  this  operation,  it  would  he  wise  to  remedy  it  before  finally  proceeding 
to  the  closure  of  the  perinseal  urethra. 

Second  Operation  :  Supra-pubic  Cystotomy  and  Closure  of  the 
Perinaeal  Urethra. 

This  last  is  really  by  far  the  most  difficult  part  of  the  whole  proce- 
dure, and  demands  care,  skill,  and  experience  in  this  kind  of  plastic 
work.  To  the  operator  who  brings  these  qualities  to  the  task,  however, 
success  will  come  easily.  There  is  one  point  of  paramount  importance 
to  the  success  of  this  part  of  the  operation.  It  is  necessary  to  define 
accurately  the  ridge  where  the  urethral  mucous  membrane  merges  into 
the  skin  of  the  perinseum  ;  the  separation  between  the  two  must  be 
made  exactly  at  this  ridge,  and  it  is  best  accomplished  by  taking  a 
delicate  pair  of  scissors  and  cutting  off  the  crest  of  the  ridge  all  the  way 
round.  It  will  be  necessary  to  incise  the  skin  of  the  perineum 
posteriorly  to  a  small  extent,  in  order  to  expose  the  hinder  margin  of 
the  urethral  orifice.  The  reason  for  such  great  precision  on  this  point 
is,  that  if  any  of  the  perineal  skin  be  left  attached  to  the  urethral 
margin  at  any  spot,  the  attempt  at  closure  will  certainly  fail  at  this 
point;  while  if,  on  the  other  hand,  the  incision  is  so  made  as  to  leave 
any  portion  of  the  urethral  wall  attached  to  the  perineal  skin,  that  will 
be  a  sacrifice  of  urethral  wall  which  can  by  no  means  be  afforded.  The 
edges  of  the  urethra  should  now  fall  naturally  together  when  the  thighs 
are  approximated,  and  they  need  not  be  sutured.  The  perinaeal  skin 
should  be  undercut  slightly  and  approximated  by  a  few  sutures,  and  the 
wound  dressed  with  a  layer  of  gauze  and  collodion.  Should  healing  have 
taken  place  throughout,  the  bladder  drain  may  be  removed  in  a  fortnight. 

3.  Beck's  Operation. — This  is  suitable  for  cases  in  which  the 
malplaced  urethral  orifice  is  not  far  behind  the  glans. 


HYPOSPADIAS. 


721 


The  distal  part  of  the  urethra  is  isolated  and  mobilised  as  shown  in 
Fig.  281,  bo  that  it  can  be  brought  forwards  and  sutured  either  to  the 
urethral  groove  on  the  nnder-snrfa.ce  of  the  glans,  or  the  anterior  end 


Fig.  281. 


Fig.  282. 


Beck's 


Beck's  operation.     (Binnie.) 


The 


of  a  perforation  made  in  the  latter  (Ochsner  (vide  Fig.  282). 
skin  is  then  sutured  over  the  urethra. 

(4)  Van  Hook  andMayo's  Operation. — Dr.  C.  H.  Mayo  (Journ.  Amer. 
Med.  Assoc,  April,  1901)    pulls  the  prepuce  well  forward,  and  fashions 


Fig.  283. 


Baw  surface. 


Urethra. 

New  tube  lined 
with  skin. 


Scrotum. 
Glans  penis. 


(After  C.  H.  Mayo.) 

from  it  and  from  the  dorsum  of  the  penis  (if  necessary)  a  flap  about 
one  inch  wide  and  two  and  a  half  inches  long.  The  flap  is  left  attached 
at  its  base  near  the  corona  of  the  glans,  and  its  edges  are  sewn  together, 
so  that  a  tube  lined  with  skin  is  formed  (vide,  Fig.  283). 

s. — vol.  11.  46 


722 


OPERATIONS    OX    THK    AHDOMKX. 


A  tunnel  is  then  made  with  a  narrow-bladed  knife,  which  is  passed 
through  the  glans,  above  the  urethral  groove,  and  out  near  the  mal- 
plaeed  urethral  orifice  near  the  root  of  the   penis.     The  new-formed 

Fig.  284. 


Malplaccd  urethral 
orifice 


Extremity  of  new 
tube  of  skin. 


Base  of  tube. 


New  meatus. 


(After  C.  H.  Mayo.) 


tube  is  then  drawn  through  the  tunnel  and  fixed  with  sutures  both  at 
the  glans  and  at  its  exit  (vide  Fig.  284). 

The  gap  upon  the  dorsum  of  the  penis  is  closed. 


End  in  end  anastomosis 
of  the  urethra. 


Self-retaining  catheter. 


(After  C.  H.  Mayo.) 


About  ten  days  later  the  base  of  the  flap  is  severed  just  in  front  of 
the  glans,  and  a  new  meatus  is  thus  formed. 

At  a  second  operation  the  urethra  is  opened  in  the  perineum,  and  a 
self-retaining  female  catheter  inserted  (vide  Fig.  285)  and  left  in  for 
about  a  week. 


KIM  SPA  1)1  AS. 


723 


The  extremity  of  the  old  urethra  is  mobilised  and  implanted  into 
the  open  end  of  the  new  part,  and  the  skin  wound  closed.  As  sonic 
urine  often  leaks  into  the  urethra  in  front  of  the  catheter,  it  is  well  to 
pass  several  strands  of  silkworm  gut  or  horsehair  through  the  urethra 
and  out  alongside  the  catheter  in  the  perineal  opening.     (Fig.  285.) 


EPISPADIAS. 

I  shall  not  give  any  really  full  account  of  the  different  attempts  to 
cure  this  rare  condition.  For  some  points  of  practical  importance  I 
would  refer  my  readers  to  the  remarks  on  hypospadias  (p.  716). 

Any  attempt  at  curing  epispadias  should  be  divided  into  three  stages, 
thus  : — 

i.  Straightening  the  Penis. — While  the  penis  is  short,  recurved,  so  as 
to  lie  in  contact  with  the  abdominal  wall,  it  is  no  use  trying  to  com- 
plete the  defective  urethra.  Attempts  should  be  made  to  straighten 
the  penis  by  dividing  it  subcutaneously  close  to  the  pubes,  each  corpus 
cavernosum  being  cut  separately.     In  the  only  case  in  which  I  practised 


Making  a  canal  in  the  meatus.     (After  Esmarch  and  Kowalzig.) 

this,  in  a  patient  aged  17  the  haemorrhage  was  easily  controlled  by 
dry  gauze  and  light  pressure,  but  very  sharp  tenotomes  must  be 
employed,  as  the  erectile  tissue  offers  much  less  resistance  than  a 
tendon.  Each  corpus  cavernosum  should  be  divided  completely,  and 
as  cleanly  as  possible.  The  penis  must,  for  some  time,  be  kept  fastened 
down.  Improvement  in  its  position  takes  place  gradually,  together 
with  increase  in  its  length,  this  being  eventually  more  marked  the 
earlier  the  operation  is  performed. 

ii.  Making  a  Canal  in  the  Glans  Penis. — Two  deep  incisions  are 
made  parallel  to  the  urethral  groove  ;  a  glass  rod  is  then  laid  in  this 
groove ;  the  lateral  flaps  are  brought  up  and  sutured  over  the  rod 
(vide  Fig.  286). 

iii.  Completion  of  the  Deficient  Urethra  from  the  Glans  to  the  Epispa- 
diac  Opening. — The  simplest  way  of  effecting  this  is  by  the  method 
of  Thiersch  and  Duplay,  much  as  in  hypospadias,  to  the  account  of 
which  I  would  refer  my  readers.  Two  narrow  quadrilateral  flaps, 
extending  from  the  meatus  to  the  epispadiac  orifice,  are  marked  out 
and  dissected  up  from  without  inwards  on  either  side  of  the  open 
urethra,  both  being  left  attached  in  the  middle  line.  These,  turned 
with  their  mucocutaneous  surface  inwards  over  a  small  Jaques 
catheter,  to  form  the  new  urethra,  and  their  raw  surfaces  outwards, 
are  united  in  the  middle  line  with  numerous  points  of  sutures  cut 
short  and  buried  (p.  287).  Thin  flaps  dissected  up  from  within  out- 
wards from  off  the  dorsum  and  sides  of   the  penis  are    then  drawn 

46 — 2 


7-1 


OPERATIONS   <)N 


ABDOMEN. 


inwards,  raw  surfaces  being  thus  opposed  to  raw  surfaces,  and  kept  in 
situ  liv  numerous  points  of  suture  The  continuity  <>f  the  glandular 
and  penile  urethra  is  established  at  this  operation. 

iv.  Junction  of  the  Old  ami  New  Canal  by  Cloture  of  tlie  Epispa- 
diac  Opening. — This  is  effected  by  freely  refreshing  the  surrounding 
parts  and  suturing  them  carefully,  or  a  flap  with  its  raw  surface  may 


Fig.  287. 


Fig.  288. 


Thiersch's  operation  for  epispadias.     (After  Esmarch  and  Kowalzig.) 

be  used  (Cheyne).     Before  the  union  is    complete  several  operations 
may  be  required  both  for  this  condition  and  hypospadias. 

A  modification  of  liussell's  operation  for  hypospadias  might  also  be 
used  here,  and  the  method  of  Van  Hook  and  Mayo  is  also  equally 
applicable  (p.  721). 

CIRCUMCISION  (Figs.  289,   290,  291.) 

Trivial  as  this  operation  seems,  it  is  so  important,  especially  in 
adults,  to  secure  speedy  healing,  that  it  will  be  briefly  alluded  to  here. 

Indications. — This  operation  is  still  not  practised  often  enough, 
especially  amongst  poorer  patients,  and  many  practitioners  still  treat 
phimosis  as  a  matter  of  but  little  importance.  Hospital  surgeons 
have,  only  too  often,  opportunities  of  seeing  the  following  results  follow 
from  the  above  course: — (a)  Balanitis  and  adhesions,  (b)  Paraphi- 
mosis, from  the  forcible  retraction  of  a  phimosed  prepuce,  (c)  From 
the  impediment  to  micturition,  urethral  and  vesical  irritation,  and  even 
cystitis,  may  be  set  up,  simulating  the  symptoms  of  stone,  (d)  Hernia 
and  prolapsus  recti.  (c)  The  sexual  feelings  too  early  induced, 
and  bad  habits.*  (/)  Impediments  to  intercourse.  (#)  Intensified 
gonorrhoea,  chancres,  &c.     (h)  Epithelioma. 

*  Prof.  Sayrc  (Orthopadic  Sun/cry,  p.  14)  describes  cases  in  which  paralysis  of  certain 
groups  of  muscles,  leading  to  talipes  and  other  deformities,  followed  on  early  sexual  excite- 
ment, due  to  phimosis.     See  also  the  case  recorded  by  Mr.  ELilton  (Rest  caul  Pain,  p.  276). 


CIRCUMCISION. 


725 


later  on 
mosis  is 
(2)    Not 


*-&c. 


«,  b,  Shows  the  line  of  incision  by  which  the 
prepuce  is  removed,  e,  The  point  of  constric- 
tion of  the  mucous  membrane  which  causes  the 
phimosis.  The  finer  dotted  line  shows  the  mu- 
cous membrane  lining  the  prepuce  and  covering 
the  glans.     (Davies-Colley.) 


Operation. — This  may  be  performed  in  many  different  ways,  but  the 
following  points  must  be  remembered  in  every  ease  :  (1)  To  remove 
enough  of  the  mucous  layer  of  the  prepuce.  If  this  be  not  done,  some 
tension  on  the  glans  remains, 

and    this    leads,   especially    in  |,,i;-  289 

adults,  to  troublesome  erec- 
tions which  interfere  very  much 
with  the  process  of  healing; 
some  degree  of  phi- 
certain  to  persist, 
to  leave  too  much 
tissue  about  the  frsenum. 

Sir  Henry  Howse  (Guys 
Hosp.  Rep.,  1873,  p.  239)  has 
drawn  attention  to  the  fact 
that  the  cellular  tissue  at  this 
spot  is  loose,  and  that  the 
presence  of  the  frsenal  artery 
makes  probable  the  gathering 
of  blood  and  inflammatory  effu- 
sion at  this  spot.  In  children 
this  is  a  matter  of  less  impor- 
tance, but  in  adults  it  may  lead  to  the  formation  of  a  tediously  persistent 
lump,  interfering  with  the  function  of  the  organ. 

(3)  Not  to  remove  too  much  of  the  prepuce.  Thus  it  is  always  well, 
in  adults  especially,  to  leave  enough  to  cover 
easily  the  sensitive  papilla  with  which  the 
corona  abounds.  Again,  in  the  diminutive 
penis  of  infants  it  is  very  easy  to  remove  so 
much  as  to  nearly  flay  the  body  of  the  organ. 
The  following  is  a  very  simple  mode  of 
operation :  The  prepuce  having  been  sepa- 
rated as  much  as  possible  from  the  glans 
with  the  finger  and  thumb,  or  a  stout  probe, 
a  pair  of  dressing-forceps  is  lightly  placed 
on  the  penis  at  a  level  with  the  corona ; 
the  glans  being  next  allowed  to  slip  back, 
the  forceps  are  closed,  and  all  the  prepuce 
in  front  of  the  instrument  is  cut  off  with  a 
sharp  scalpel  used  with  a  rapid  sawing  move- 
ment. The  following  directions  given  by  the 
late  Mr.  Davies-Colley  (Guy's  Hosp.  Rep., 
1892,  p.  164)  are  worth  remembering  at  this 
early  and  most  important  stage  of  the  opera- 
tion :  "  The  incision  should  begin  upon  the 
dorsum,  at  a  point  corresponding  to  that 
part  of  the  glans  which  is  ball- way  between 
the  meatus  and  corona.  The  incision  should 
be  made  downwards  and  forwards,  so  as  to  leave  a  sharp  point  in 
the  middle  of  the  under-surface  (Figs.  289,  290).  The  object  of  this 
pointed  projection  is  to  fill  up  subsequently  the  triangular  interval, 
which  is  otherwise  left  when  the  portion  of  the  mucous  membrane  of 


Fig.  290. 


The  pointed  process  of  skin 
(//)  is  shown  adjusted  in  the 
angle  left  by  the  remains  of 
the  frasnum.  The  dotted  line 
(J>,  d,  e)  shows  the  edge  left  on 
the  skin  and  the  triangular  bare 
surface  which  has  to  heal  by 
granulation  unless  precautions 
are  taken  to  preserve  the  tri- 
angular flap  of  skin  as  directed 
above.     (Davies-Culley.) 


726         OPERATIONS  ON  THE  ABDOMEN. 

the  prepuce,  to  which  the  free num  is  attached,  is  removed.  The  blades 
being  lit  once  removed,  the  mucous  membrane  is  (hen  slit  up  with  a 
director  and  scissors  or  a  sharp-pointed  bistoury,*  this  incision  running 
up  to,  but  not  beyond,  the  corona.  The  mucous  membrane,  if  still 
adherent,  must  be  peeled  in  two  flaps  from  off  the  glans,  this  detach- 
ment being  best  effected  by  the  finger  and  thumb,  or  by  a  stout  probe 
swept  round.  The  cut  edges  of  the  prepuce  are  then  rounded  off  with 
scissors,  which  follow  the  curve  of  the  glans  as  far  as  the  fraenuin. 
Just  a  frill  of  mucous  membrane,  and  no  more,  should  be  left  all  the 
way  round  the  corona  (Fig.  291).  Enough  prepuce  should  be  left  to 
cover  over  the  corona-papillae,  and  to  admit  of  easy  stitching."  All 
bleeding  must  be  stopped,  especially  in  adults,  or  extravasation  of 
blood  in  the  loose  connective  tissue  leads  to  tension,  cutting  through 
of  sutures,  and  sloughing.  By  drawing  the  skin  backwards  with  the 
left  hand,  the  bleeding  arteries  are  exposed,  and  clamped  with  pressure 

forceps,  which  are  either  left  on  for 
Fig.  291.  about   a   minute    or    twisted.      This 

systematic  search  for  and  clamping  of 
the  bleeding  points  saves  much  pos- 
sible   trouble    and    annoyance    from 
reactionary    haemorrhage.       Chromic 
gut    and    horsehair    make    the    best 
sutures.     Very  fine  needles  should  be 
used,  and  the  sutures  passed  quickly 
through  skin  and  mucous  membrane 
with  a  stabbing  movement,  and   with- 
The  penis  after  the  edge  of  skin  has     out   bruising  the  edges   with  forceps, 
been  sutured  to  the  frill  of  mucous  mem-     In  passing  the   sutures  any  bleeding 
brane  left  along  the  corona.     (Davies-     points    must    be    transfixed,    and    the 
Colley.)  abundant   cellular  tissue  kept  in  its 

place  with  the  point  of  a  probe.  This 
cellular  tissue  must  on  no  account  be  cut  away,  as  in  it  run  the  vessels 
to  the  prepuce.  The  fraenum  is  now  attended  to,  the  prepuce  which  is 
still  attached  here  being  cut  away  carefully  by  V-shaped  cuts,  pointing 
forwards,  and  leaving  just  enough  flaps  to  carry  the  sutures,  and  no 
more.  The  frsenal  artery  can  usually  be  secured  by  transfixing  it  with 
one  of  the  sutures ;  if  not,  it  is  readily  tied  with  a  fine  chromic  gut 
ligature. 

I  much  prefer  interrupted  sutures  of  chromic  gut  for  circumcision.  A 
continuous  suture  often  gives  good  results  in  healthy  subjects,  but  the 
former  has  the  great  advantage  that  one  or  two  can  be  removed,  if 
needful,  without  interfering  with  the  rest.  The  majority  soften  away. 
One  of  the  following  dressings  will  be  found  the  best: — A  strip  of 
dry  aseptic  gauze  is  wrapped  round  the  wound  at  the  operation, 
for  this  stops  any  haemorrhage  well.  A  pad  of  antiseptic  wool  is 
then  placed  over  the  penis  and  kept  in  position  by  the  pyjamas,  or  in  a 
child  by  the  diaper.  This  protects  the  sensitive  glans  and  the 
wounded  penis  from  injury  and  irritation.  The  dressing  is  removed 
in  a  warm  bath  after  two  days,  and  then  replaced  by  an  aseptic  gauze 

*  It  is  well  at  this  stage  to  make  tension  on  the  loose  prepuce  with  two  pairs  of 
dissecting  forceps,  and  thus  secure  a  clean  section. 


IMPUTATION    OF    TIIK    PENIS. 


727 


strip  lined  with  boracic  ointment.  This  is  very  comfortable,  and 
is  easily  removed  in  a  warm  bath  without  causing  any  pain.  Any 
dressing  is  apt  to  get  soaked  with  urine,  and  should  be  replaced  daily 
or  oftener  in  infants.  When  the  parts  are  at  all  swollen,  or  where 
erections  are  likely  to  be  troublesome,  I  prefer  boracic  acid  dressings, 
two  layers  of  boracic  acid  lint  wrung  out  of  an  iced  saturated  solution 
of  the  lotion.  The  deeper  layer  has  a  hole  cut  to  allow  of  micturition, 
and  is  only  removed  by  the  surgeon ;  the  outer  one  envelops  the  whole 
penis,  and  may  be  removed  and  rewetted  by  the  patient,  though  usually 
it  is  sufficient  for  him  to  keep  it  wet  by  dropping  on  a  little  lotion  from 
time  to  time.  For  children  I  do  not  like  a  gauze  dressing  saturated  with 
either  collodion  or  tinct.  benzoin.,  for  both  are  irritating,  also  difficult  to 
remove.  Urine  generally  soaks  under  them  after  a  day  or  two  and 
decomposes  between  the  glans  penis  and  the  crusted  dressing.  Erections 
are  frequent  and  painful  with  these  unyielding  applications. 

After  circumcision  the  patient  should  rest  as  much  as  possible.  Thus 
an  adult  should  stay  in  bed  for  forty-eight  hours  and  keep  on  the  sofa 
for  a  week,  alternate  stitches  being  removed  at  intervals.  If  he  insist 
on  getting  about  too  early,  he  must  run  the  risk  of  the  parts  remaining 
long  cedematous  and  tender.  And  for  this  reason,  with  hospital  patients, 
who  have  to  come  backwards  and  forwards,  early  and  complete  healing 
is  not  to  be  expected. 


AMPUTATION    OP    THE    PENIS  (Figs.292— 295). 

Indication. — Epithelioma  of  Penis. — I  would  refer  my  readers  to  the 
remarks  made  in  Vol.1.,  p.  578,  on  the  pre-cancerous  stage  in  epithelioma 
of  the  tongue.  Though  epithelioma  of  the  penis  is  much  less  common, 
lives  are  here  also  too  often  lost  by  allowing  the  case  to  go  beyond  this 
stage.  Any  suspicious  excoriation,  ulceration,  or  wart  should  be  early 
destroyed  with  the  acide  nitrate  of  mercury,  or  excised.  Where,  after 
this  treatment,  satisfactory  healing  does  not  take  place,  early  and 
thorough  removal  of  the  part  should  be  performed.  There  should  be  no 
dangerous  waiting  because  the  surgeon  is  unable  to  satisfy  himself 
whether  the  case  is  one  of  inflammatory  induration  or  infiltration  from 
new  growth.  In  such  cases,  especially  where  there  is  a  doubtful  history 
of  syphilis,  much  valuable  time  has  been  often  lost  with  drugs,  which, 
even  if  the  lesion  does  date  back  to  some  long-past  syphilis,  are  quite 
useless  if  epitheliomatous  ulceration  has  set  in.  Furthermore,  the 
longer  ulceration  continues,  the  more  extensively  will  the  inguinal 
glands  be  involved.  In  such  cases,  though  the  penis  may  be  satis- 
factorily operated  upon,  disappointment  will  speedily  follow,  owing  to 
the  outbreak  in  the  inguinal  regions.  Scarcely  any  surgical  case  pre- 
sents a  close  more  distressing,  both  to  the  patient  and  those  around  him, 
than  one  of  breaking  down  of  epitheliomatous  glands,  owing  to  the 
hideous  ulceration,  the  noisome  discharge,  and  the  steady  decay  of 
bodily  strength. 

In  a  very  few  cases,  when  the  disease  commences  around  the  meatus, 
it  may  still  be  possible  to  remove  the  affected  part  without  interfering 
with  the  body  of  the  penis.  It  seldom  happens,  however,  that  we  see 
the  case  early  enough  for  this,  and  it  is  usually  necessary  to  remove  the 


728  OPERATIONS   ON   TlIK   ABDOMEN. 

whole  of  the  glans  and  more  or  less  of  the  corpora  cavernosa.  Before 
doing  this  the  prepuce,  unless  it  admits  of  being  retracted,  should 
invariably  be  laid  open,  so  as  to  expose  the  growth  and  make  quite  sure 
of  its  real  nature.  The  parts  should  be  cleansed,  as  far  as  possible,  by 
shaving  the  pubis  and  applying  fomentations  to  the  penis  for  two  or 
three  days  before  the  operation.  When  the  patient  is  anaesthetised,  the 
surface  of  the  growth  is  seared  with  the  thermocautery  to  avoid  septic 
and  malignant  infection  of  the  wound. 

Operations. 

I.  Circular  Amputation. — This  gives  good  results,  though  not 
equal,  in  my  opinion,  to  those  which  follow  the  flap  method.  The 
vessels  being  commanded  by  a  rubber  tubing  used  as  a  tourniquet,  the 
skin  is  drawn  a  little  forward  to  prevent  any  superabundance  afterwards, 
and  the  amputation  is  effected  by  a  single  sweep  of  the  knife.  The 
vessels  and  the  urethra  are  treated  as  directed  below. 

II.  Flap  Amputation  (Figs.  292,  293). — This  method  has  been  fol- 
lowed by  rapid  healing,  and  has  given  an  excellently  covered  stump  in 

Fig.  292. 


Flap  amputation  of  the  penis.  The  appearance  of  the  stump,  with  the  urethra 
slit  up  and  stitched  in  situ,  is  shown  above.  The  ilap  has  been  raised  too  near 
the  disease  below. 

the  eleven  cases  in  which  I  have  made  use  of  it.  Hemorrhage  having 
been  provided  against  by  one  of  the  above-given  means,  the  surgeon 
enters  a  narrow-bladed  knife,  at  a  point  well  behind  the  disease,  between 
the  corpus  spongiosum  and  the  corpora  cavernosa,  and  then  cuts  forwards 
and  downwards  for  about  three-quarters  of  an  inch.  From  this  small 
inferior  flap  the  urethra  is  dissected  out.  A  flap  of  skin  is  now  cut  from 
the  dorsum  and  sides  of  the  penis,  resembling  in  miniature  the  upper 
skin-flap  in  amputation  of  the  thigh.  This  flap  being  held  back,  the 
corpora  cavernosa  are  divided  vertically  upwards  on  a  level  with  the 
point  of  transfixion.  Any  vessels  which  can  be  seen  are  now  tied  with 
chromic  gut  or  boiled  silk.  On  removal  of  the  drainage-tube, 
clamped  with  Spencer  Wells's  forceps,  and  securing  any  spirting 
vessels,  free  oozing  often  takes  place,  but  ceases  spontaneously.  All 
haemorrhage  being  arrested,  the  upper  flap  is  punctured,  and  the  urethra 
drawn  through  the  face  of  the  flap,  slit  up,  and  stitched  in  situ.  The 
two  flaps,  upper  and  lower,  are  then  united  by  a  few  points  of  carbolised 
silk  and  horsehair  suture. 

This  method  secures  a  natural  skin-covering  for  the  severed  corpora 
cavernosa,  and  prevents  the  delay  and  irritation  which  healing  by  granu- 


AMPUTATION    <>K    TIIK    I'KMS. 


729 


lation  entails.  A  similar  operation  was  long  ago  suggested  by  Prof. 
Miller,  of  Edinburgh,  but  this  surgeon  cut  his  flap  from  below.  If,  as 
I  have  recommended,  the  flap  is  taken  from  above,  the  skin  will  be 
found  to  fall  into  position  more  readily  over  the  raw  surfaces  of  the 
corpora  cavernosa.  After  all  these  operations  the  patient  should  pass  a 
short  piece  of  bougie  at  regular  intervals. 

III.  Galvanic  Cautery. — I  am  as  much  against  this  method  here  as 
in  the  case  of  the  tongue  (Vol.  I.  p.  600).  The  dread  of  haemorrhage 
still  induces  some  to  resort  to  it.  It  is  not,  however,  a  sure  preventive. 
Sharp  bleeding  has  followed  a  few  hours  after  the  operation,  and  also, 
later  on,  during  the  detachment  of  sloughs.  Furthermore,  this  operation 
leaves  a  much  more  troublesome  and  sloughy  wound  than  the  knife. 


Fig.  293. 


A  case  of  amputation  of  the  penis  by  the  flap  method  one  year  and  a  half  after 
the  operation.  Scars  of  operations  for  the  removal  of  glands  (enlarged  inguinal 
glands  were  removed  at  the  time  of  the  operation)  are  seen  in  either  groin.  The 
two  dots  mark  the  points  where  drainage-tubes  were  brought  out.  The  patient 
died  two  years  after  the  amputation  of  gland  disease.  There  never  was  any  re- 
currence in  the  penis.     (Diseases  of  Male  Organs  of  Generation.) 

This  is  not  a  matter  of  slight  importance  in  these  patients,  in  whom, 
usually  advanced  in  years  or  prematurely  aged,  pulled  down  in  health, 
and  often  depressed  in  mind,  tedious  healing  of  the  wound,  which  it 
is  difficult  to  keep  sweet,  involves  keeping  the  patient  on  his  back  for 
a  considerable  time,  with  the  risks  of  broncho-pneumonia,  erysipelas, 
&c.  The  need  of  a  special,  expensive  instrument,  and  the  unpleasant 
fcetor  of  the  operation,  are  also  objections. 

If  the  surgeon  make  use  of  it,  a  No.  4  or  6  catheter  should  first  be 
passed ;  the  loop  of  wire  is  then  tightened  around  the  penis,  well  behind 
the  disease,  and  kept  there  by  one  or  two  pins.  When  the  current  is 
passed,  care  must  be  taken  that  by  tightening  the  wire  very  slowly  and 
watching  the  amount  of  heat  the  vascular  structures  are  not  severed  too 
quickly,    otherwise  haemorrhage,  very  difficult    to  arrest  on  a  seared 


730 


OPERATIONS    ON    TIIK    ABDOMEN. 


surface,  is  certain  to  follow.  The  catheter  is  cut  through  by  the  heated 
wire,  and  the  urethra,  thus  maintained  patent, is  slit  up  and  stitched  as 
directed  above. 

Occasionally  severer  operations  are  entirely  justifiable. 

Thus,  where  the  penis  is  involved  as  far  hack  as  the  scrotum,  the 
entire  penis  should  he  extirpated,  it'  the  inguinal  glands  are  not  Beriously 
involved,  and  if  the  powers  of  repair  are  satisfactory.  The  patient 
being  in  lithotomy  position,  the  scrotum  is  to  he  split  deeply  along  the 
whole  length  of  the  raphe,  and  the  corpus  spongiosum  carefully  dis- 
sected out.  This  step  may  he  facilitated  hy  passing  a  large  sound. 
AVhen  the  triangular  ligament  is  exposed,   the  above  instrument  is 

Fig.  294. 


V 


Appearance  of  parts  after  amputation  of  two-thirds  of  the  penis  by  splitting 
the  scrotum.  The  patient  refused  castration.  The  urethra  is  at  the  lowest  part 
of  the  scar.     {Diseases  of  Male  Organs  of  Generation.) 

removed,  and  the  corpus  spongiosum  which  has  been  dissected  out  is  cut 
through,  enough  being  left  to  bring  out  in  the  perinaeum.  By  means 
of  a  blunt  dissector,  the  crura  are  then  detached  on  either  side  from  the 
pubic  arch,  and,  the  incision  being  prolonged  around  the  penis  above, 
the  suspensory  ligament  is  divided,  and  the  dorsal  arteries  secured. 
The  cut  end  of  the  corpus  spongiosum  is  now  slit  up  and  stitched  in  the 
posterior  part  of  the  scrotal  incision,  and  all  the  rest  of  the  wound  closed 
by  sutures.  Drainage  must  be  provided  by  a  small  tube,  or  by  horse- 
hair drains.  Similar  operations  to  the  above  have  been  performed  on 
several  occasions,  but  the  important  modification  of  dissecting  off  the 
crura,  and  thus  ensuring  complete  removal  of  the  cancerous  organ  and 
its  capsule,  was  brought  before  the  notice  of  English  surgeons  by  Mr. 
Gould  {Lancet,  May  20,  1882,  p.  821). 


AMI'l  TATION    OK    THE    PENIS. 


731 


In  most  cases  of  amputation  of  the  penis  the  patients  will  be  wise  in 
consenting  to  castration — an  operation  which  will  add  in  many  cases 
Largely  to  their  comfort,  and  at  a  very  slightly  increased  risk  (Wheel- 
house,  Brit.  Med.  Journ.,  1886,  vol.  i.  p.  187). 

Question  of  removing  Enlarged  Glands. — These  should  always  be 
extirpated  at  the  same  time  as  the  amputation  of  the  penis,  together 
with  as  much  of  the  lymphatic  vessels  and  surrounding  cellular  tissue 
as  possible,  preferably  in  one  piece  in  order  to  avoid  the  escape  of 
cancer  cells  into  the  wound.     As  long  as  the  glands  are  involved  by 

Fig.  295. 


The  appearance  of  the  parts  a  month  after  complete  amputation  of  the  penis, 
castration,  and  removal  of  enlarged  glands.  The  opening  of  the  urethra  is  not 
seen,  being  situated  at  the  perimeo-scrotal  junction.  The  dots  mark  the  counter- 
punctures  for  drainage-tubes.     (Diseases  of  Male  Organs  of  Generation.) 


growth  only,  hard  and  separate  from  each  other,  it  will  be  comparatively 
easy  to  accomplish  this,  and  thereby  add  materialhr  to  the  prolonga- 
tion of  the  patient's  life.  But  where  they  contain  not  only  secondary 
deposits,  but  also  inflammatory  matter,  owing  to  ulceration  having  set 
in  at  the  seat  of  the  primary  lesion,  satisfactory  removal  of  the  glands 
is  always  a  matter  of  great  difficulty  and  often  impossible,  owing  to 
their  softness  and  tendency  to  break  down,  to  their  adhesions  to  their 
capsules,  and  the  matting  of  these  to  the  surrounding  parts,  the  vascu- 
larity of  which  is  increased,  and  tendency  of  the  overlying  skin  to 
become  adherent.  When  the  growth  becomes  adherent  to  the  femoral 
or  iliac  vessels,  no  attempt  should  be  made  to  remove  it,  for  the  main 


7$2  OPERATIONS   ON   THE   ABDOMEN'. 

vein  may  have  to  be  sacrificed,  with  resulting  oedema  of  the  leg.  The 
removal  is  very  likely  to  be  incomplete,  and  to  be  quickly  followed  by 
recurrence  and  hemorrhage. 

In  all  such  operations  especial  care  should  be  taken  to  ensure 
asepsis,  and  to  avoid  laceration  of  the  tissues,  as  sloughing  and  super- 
ficial gangrene  or  delayed  union  are  apt  to  follow  these  operations, 
which  open  up  important  fascial  planes. 

Antiseptic  dressings  are  the  safest  to  use  in  this  region. 

For  much  fuller  information  on  this  and  many  other  points  I  may 
refer  my  readers  to  my  Diseases  of  the  Male  Organs  of  Generation, 
pp.  707—745- 


CHAPTEE   XIV. 
OPERATIONS  ON  THE  SCROTUM  AND  TESTICLE. 

RADICAL   CURE   OF  HYDROCELE.*— VARICOCELE.— 
ANASTOMOSIS    OP    THE  VAS    DEFERENS.— CASTRATION.— 

ORCHIDOPEXY. 

RADICAL  CURE   OF  HYDROCELE. 

In  a  paper  written  thirty  years  ago  (Lancet,  Sept.  I,  1877),  I  drew 
attention  to  the  uncertainty  of  the  radical  cure  of  hydrocele  by  iodine 
injection  as  usually  practised.  Thus,  out  of  44  cases  treated 
with  solutions  of  iodine  and  potassium  iodide  at  Guy's  Hospital,  I 
found  that  the  treatment  failed  in  8  cases,  and  that  in  2  it  failed 
twice. 

Latterly  I  believe  that  surgeons  have  recognised  that  the  risk  of 
recurrence  is  greater  than  that  of  excessive  inflammation,  and  thus 
stronger  solutions  have  been  made  use  of — e.g.,  the  Edinburgh  tincture 
of  iodine — and  some  of  the  injection  has  been  allowed  to  remain.  As  it 
is  still  a  fact,  however,  that  no  one  method  of  cure  can  always  be  relied 
upon  as  radical  for  this  troublesome  complaint,  the  four  following 
will  be  mentioned  here,  viz.  : 

i.  Partial  Excision,    ii.  Eversion  of  the  Sac.    iii.  Iodine 
Injection,    iv.  Injection  of  Carbolic  Acid. 

With  the  great  strides  that  have  been  made  towards  the  perfection 
of  aseptic  surgery,  injection  of  irritants  has  become  less  and  less 
common,  so  that  at  the  present  time  it  is  rarely  performed.  Under 
aseptic  conditions  excision  of  the  parietal  part  of  the  sac  is  no  more 
dangerous  than  injection,  and  it  is  far  more  certain  to  cure.  More- 
over, it  is  no  longer  necessary  to  use  a  general  anaesthetic  in  all 
cases,  for  safe  and  efficient  local  anaesthesia  suffices  when  the  former 
is  contra-indicated  or  declined.  There  are  still  many  elderly  patients, 
however,  who  wish  for  nothing  more  than  the  temporaiy,  and  some- 
times prolonged,  relief  that  simple  tapping  affords.  Others  decline 
all  cutting  operations.  In  them,  and  under  circumstances  which  are 
unfavourable  for  resort  to  radical  operations,  injection  may  still  be 
tried,  and  therefore  a  description  of  this  method  is  retained  in  this 
book,  although  the  writer  does  not  use  injections  in  any  case. 


*  The  methods  of  injection  given  below  refer  to  hydrocele  of  the  tunica  vaginalis  and 
to  encysted  hydrocele.  Antiseptic  incision  and  partial  excision  of  the  sac  is  applicable  to 
all  varieties  of  hydroceles,  including  the  congenital. 


734  OPERATIONS  ON  THE  ABDOMEN. 

I.  Partial  Excision  of  the  Sac. —  This  latter  is  often  spoken  of  as 
excision  of  the  tunica  vaginalis.  As  the  parietal  layer  of  the  serous 
membrane  can  alone  be  removed,  I  prefer  the  above  title. 

(A)  Advantages. 

(i)  Its  greater  certainty.  While  it  is  right  to  remember  that  no 
method  can  be  absolutely  relied  upon  as  radical,  and  that  hydroceles  have 
recurred  even  after  incision  and  partial  excision  of  the  sac,*  there  can 
be  little  doubt  that  this  must  be  extremely  rare,  since  after  efficient 
removal  of  the  parietal  layer  of  the  tunica  vaginalis  the  cavity  must, 
with  very  few  exceptions,  be  entirely  obliterated.  A  method  which 
further  removes  a  large  part  of  this  secreting  surface  must  a  priori  be 
surer  than  those  methods  which  do  their  work,  as  it  were,  in  the  dark, 
in  which  the  drainage  must  needs  be  imperfect,  the  quantity  of  the 
irritant  employed  necessarily  limited,  it  being  thus  always  left  doubtful 
how  far  the  injection  has  been  weakened,  by  dilution  or  chemical  change, 
and  how  far  folds  of  the  inner  surface  of  the  tunica  vaginalis  have  escaped 
inflammation  at  all.  On  this  account  I  prefer  to  make  use  of  partial 
excision  in  all  cases  where  the  general  condition  of  the  patient  is  satis- 
factory, and  where  he  is  willing  to  lay  up  for  a  short  time. 

The  cases  to  which  this  method  appears  to  me  to  be  especially- 
suitable  are  those  where  (a)  iodine  or  carbolic  acid,  has  previously 
failed,  (/3)  where  the  sac  is  very  large  or  has  very  thick  walls.  Where 
the  sac  is  simply  very  large,  but  not  much  thickened,  it  can  be  safely 
and  successfully  injected,  if  this  is  preferred,  by  tapping  first  and  then 
allowing  only  an  interval  of  two  or  three  weeks  to  elapse  before  the  sac 
is  injected.  But  if  the  walls  are  much  thickened,  there  are  the  risks 
that  after  tapping  they  cannot  collapse  readily,  and  so  be  brought  in 
contact  with  the  irritant,  and  while  in  a  sac  like  this  it  is  always  un- 
certain if  the  due  amount  of  inflammation  will  be  secured,  there  is  also 
a  risk  that,  owing  to  the  little  vascularity  of  a  thickened  sac,  sloughing 
may  take  place,  (y)  Where,  on  account  of  ill-health  or  age,  the  risk  of 
inflammation  after  injection  of  an  irritant  is  especially  to  be  dreaded. 
(8)  Where  the  surgeon  is  desirous  of  exploring  the  sac  of  the  tunica 
vaginalis,  as  in  cases  where  enlargement  of  the  testis  of  a  doubtful 
nature  coexists  with  hydrocele,  and  does  not  yield  to  ordinary  treat- 
ment, where  a  haematocele  has  supervened,  on  a  hydrocele,  or  in  the 
much  rarer  cases  of  loose  bodies  in  the  sac  of  the  tunica  vaginalis.  («) 
Where  several  hydrocele,  co-exist — e.g.,  either  double  hydrocele  of  the 
tunica  vaginalis,  or  a  vaginal  and  encysted  hydrocele.  (£)  In  certain 
cases  of  hydrocele  complicated  with  hernia — e.g.,  (i)  in  young  subjects, 
where  a  radical  cure  of  both  is  desired  ;  (2)  in  much  older  patients,  where 
the  hernia  is  irreducible,  where,  especially  in  unhealthy  patients,  there 
is  a  risk  of  the  inflammation  set  up  by  the  injection  extending  to  the 


*  On  this  point  a  valuable  paper  by  Mr.  H.  Morris,  followed  by  an  interesting  dis- 
cussion (Med.-Chir.  Soc.,  Feb.  28,  1888),  should  be  consulted  (Brit.  Med.  Journ.,  March  3, 
1888).  Two  cases  of  recurrence  after  partial  excision  of  the  sac  were  related.  Mr. 
Pollock  mentioned  one  even  more  extraordinary.  This  recurred  repeatedly — i.e.,  after 
two  injections  with  iodine,  the  introduction  of  a  silver  wire  seton,  and  "ample  sup- 
puration"; finally,  the  sac  was  laid  open  and  lint  inserted  for  a  fortnight.  The 
hydrocele  again  recurred  and  the  patient  declined  any  further  treatment  than  simple 
tapping. 


RADICAL   CURE    OF    BYDROCELE. 


735 


sac  of  the  hernia.  (>;)  In  cases  of  congenital  hydrocele  a  careful  incision 
with  antiseptic  precautions  will  be  safer  than  any  other  method  of 
radical  cure  if  the  pressure  of  a  truss  for  the  obliteration  of  the  com- 
munication with  the  peritoneal  sac  cannot  be  persevered  with.  And 
the  same  course  will  be  wise  in  the  case  of  encysted  hydroceles  of  the 
cord,  when  their  important  surroundings,  mobility,  and  their  difficult 
fixation  before  injection  are  considered. 

(B)  The  disadvantages  of  this  method  must  next  be  considered, 
(i)  As  pointed  out  in  my  paper  in  1877,  it  undoubtedly  involves  more 
trouble  than  that  by  injection.  While  it  can  be  completed  in  a  quarter 
of  an  hour,  some  anaesthetic  will  be  required,  and  there  is  the  trouble 
of  the  subsequent  dressings,  and  there  is  also  more  need  of  absolute 
rest.  Thus  the  patient  will  be  confined  to  his  bed  for  a  week  or  ten 
days,  and  after  this  will  have  to  keep  quiet  on  a  sofa  or  in  an  armchair. 
(2)  With  regard  to  the  amount  of  subsequent  orchitis,  pain,  swelling, 
&c,  1  am  of  opinion  that  this  varies,  but  not  as  much  as  after  iodine 
injection.  In  the  early  days  of  this  method — the  Schnitt  method  of 
Volkmann — when,  after  incision  of  the  tunica  vaginalis,  this  cavity  was 
carefully  plugged  with  strips  of  aseptic  gauze  to  promote  changes  in 
the  serous  membrane,  orchitis  to  a  painful  degree  was  not  uncommon  ; 
but  of  late  years,  when,  after  incision  of  the  sac,  the  parietal  layer  of 
the  tunica  vaginalis  is  gently  detached  from  the  scrotum  and  cut  away 
close  to  the  epididymis  and  the  testis,  I  have  been  extremely  struck  by 
the  very  small  amount  of  pain  suffered,  in  spite  of  the  disturbance  and 
the  handling  entailed  of  the  parts  concerned.  (3)  With  regard  to  the 
duration  of  the  after-treatment,  this  is  in  favour,  but  not  so  distinctly 
as  would  appear  at  first  sight,  of  the  injection  method.  With  regard  to 
the  injection  of  carbolic  acid,  this  is  most  certainly  so  (p.  739).  Iodine 
has  also  an  advantage  in  time  less  clearly  marked.  Thus,  after  injection 
with  carbolic  acid,  the  patient  may  perhaps  not  have  to  lay  up  at  all. 
After  forty-eight  hours  he  will  probably  be  able  to  follow  his  employ- 
ment if  not  an  arduous  one.  After  the  use  of  iodine  the  patient  will 
probably  be  able  to  get  about  after  the  first  week.  But  these  dates  are 
only  approximate.  Even  with  regard  to  carbolic  acid,  it  is  impossible  to 
read  through  a  large  number  of  cases  reported  by  American  and  other 
surgeons  without  seeing  that  inflammatory  reaction,  crippling  to  loco- 
motion, does  occur  more  frequently  than  would  be  gathered  from  the 
reports  of  those  surgeons  who  have  advocated  it  most  strongly.  And 
again,  as  is  shown  above,  while  carbolic  acid  is  extremely  convenient, 
it  is  clear  that  there  is  no  absolute  certainty  about  it,  and  that  repeated 
injections  have  been  called  for  in  many  cases.  After  iodine  injection 
the  scrotum  is  often  not  its  natural  size,  and  the  patient  not  free  from 
all  encumbrance  till  between  the  second  and  the  third  weeks.  By  the 
latter  date,  after  partial  excision  of  the  sac,  the  patient  will  be  quite 
well  and  able  to  get  about.  (4)  As  to  the  risks  of  haemorrhage, 
cellulitis,  and  sloughing,  which  have  been  described  by  some  writers, 
I  can  only  say  that  I  have  never  seen  them  in  an  experience  of  21 
cases  of  antiseptic  incision  and  of  antiseptic  incision  and  excision 
of  the  sac. 

Operation. — The  patient  having  been  prepared  for  the  operation,  the 
parts  shaved  and  well  cleansed  with  soap  and  water  used  with  a  flannel, 
and  then  washed  with   a  dilute  solution  of  carbolic  acid  or  mercury 


736 


OI'KHATIONS    ON    TIIK    ABDOMEN. 


perchloride,*  ether  or  A.C.E.  is  given.  The  surgeon,  the  scrotal  tunics 
being  made  tense  by  his  left  hand  or  by  an  assistant,t  incises  them 
down  to  the  hydrocele  from  the  top  to  the  bottom  of  the  swelling,  and 
then,  before  opening  this,  arrests  any  bleeding  points  by  applying 
Spencer  Wells's  forceps.  The  hydrocele  is  then  opened  sufficiently  to 
admit  a  finger,  which  makes  out  definitely  the  position  of  the  testicle  ; 
the  tunica  vaginalis  is  then  freely  but  carefully  slit  up  with  blunt- 
pointed  scissors.  As,  when  the  hydrocele  is  opened,  the  fluid  escapes 
with  much  force,  the  sac  at  once  collapses  into  folds,  and  scissors  will  be 
found  preferable  to  the  knife.     The  incision  into  the  tunica  vaginalis 

should  be  as  free  as  is  safe,  for  a  free 
incision  will  at  once  admit  of  rapid  removal 
of  the  parietal  layer  and  a  thorough  exami- 
nation of  the  recesses  of  the  serous  sac. 
If  a  small  one  only  is  made,  owing  to  the 
contraction  of  the  dartos,  the  above  steps 
will  be  found  impossible.  Further,  a 
large  incision  is,  b}^  the  above,  soon  folded 
into  a  little  space,  and  heals  as  quickly  as 
a  small  one.  Spencer  Wells's  forceps  are 
then  applied  to  every  bleeding  point  in 
the  cut  edges  of  the  sac.  The  forceps  on 
either  side  serving  to  widely  open  out  the 
wound,  the  testis  and  epididymis  are 
examined  for  any  cysts,  sometimes  present 
about  the  head  of  the  latter.  The  inner 
surface  of  the  tunica  vaginalis  is  carefully 
scrutinised  for  any  fibrous  bodies  attached 
or  loose  in  any  of  its  folds,  or  for  false 
membranes  and  thickenings.  As  any  of 
these  may,  by  keeping  up  irritation,  lead 
to  a  recurrence  of  the  hydrocele,  they 
should  be  dealt  with,  the  cysts  being 
snipped  away  after  ligature  of  their  pedi- 
cles with  fine  catgut.  The  parietal  layer 
of  the  tunica  vaginalis  is  now  gently 
detached,  or  peeled  awa}^  from  the  scrotum 
as  far  as  is  safe — i.e.,  close  up  to  the 
epididymis  on  the  outer,  and  to  the  back  of  the  testicle  on  the  inner, 
side.  Along  these  limits  it  is  snipped  away  with  scissors,  and  forceps 
applied   to    all   bleeding   points  (vide  Fig.  296.).      To   facilitate   the 


Radical  cure  of  hydrocele,  to 
show  the  extent  to  which  the 
tunica  vaginalis  is  removed.  (From 
Lockwood's  Ha //in,  Hydrocele, 
ami  Varicocele?) 


*  As  it  is  of  the  utmost  importance  that  there  should  be  no  irritation  or  erythema 
6et  up,  which  may  cause  discomfort  and  subsequent  restlessness  and  also  suppuration 
and  slowness  of  healing,  the  antiseptic  solutions,  which  are  all  irritants,  should  be  used 
both  before  or  during  the  operation,  as  dilute  as  is  safe  to  the  very  delicate  scrotal  skin 
— e.g.,  carbolic  acid  1  in  30  and  mercury  perchloride  1  in  4,000.  For  the  same  reason 
no  scrubbing  with  a  nail-brush  is  advisable.  These  may  seem  trifles,  but  they  may 
have  a  very  important  bearing  on  the  after-result.  To  promote  relaxation  of  the 
dartos  and  prevent  contraction,  and  thus  curling  in  of  the  skin,  warm  solutions  should 
be  used. 

t  The  position  of  the  testis  should  first  be  made  out  by  translucency.  The  more 
showy  step  of  opening  the  hydrocele  at  one  cut  might  endanger  the  cord  and  testicle. 


RADICAL   (JURE   OF   HYDROCELE.  y^y 

detachment  and  minimise  haemorrhage,  care  must  be  taken  to  find  the 
proper  layer,  and  to  keep  in  contact  with  the  dense  white  tunic. 

It'  any  false  membranes  are  now  present  over  the  testicle  and 
epididymis  or  the  small  part  of  the  parietal  tunica  vaginalis  that 
remains,  these  are  to  be  detached  with  a  sharp  spoon.  The  bleeding 
which  follows  may  be  smart  and  require  very  hot  saline  solution  or 
firm  pressure  with  a  sponge. 

Mr.  Lockwood  recommends  that  the  top  of  the  incision  should  lie 
a  full  inch  from  the  root  of  the  penis  ;  that  any  upward  prolongation 
of  the  hydrocele  along  the  cord  should  be  dissected  out;  that  in  cases 
where  the  origin  is  doubtful,  or  where  the  hydrocele  is  large  and  of 
long  standing,  and  the  testicle  may  be  wasted,  it  is  wise  to  obtain 
permission  beforehand  to  remove  the  testis.  Mr.  Lockwood  finds  it 
easier  to  separate  the  tunica  vaginalis  while  still  distended.  It  is,  he 
believes,  quite  unnecessary  to  paint  the  tunica  vaginalis  vera  with 
chemical  irritants,  or  to  injure  it  mechanically.  On  this  point  readers 
should  refer  to  the  footnote  at  p.  736. 

At  one  time  it  was  considered  to  be  necessary  to  suture  the  remaining 
edges  of  the  tunica  vaginalis  to  the  skin  for  three  or  four  days,  and 
even  to  apply  chemical  irritants  to  the  visceral  serous  membrane,  but 
experience  has  shown  that  these  procedures,  which  delay  healing,  are 
not  essential  to  success.  It  is  better  to  drop  the  testicle  back  into  the 
scrotum  and  to  close  the  skin  wound  in  the  usual  way  with  horsehair  or 
catgut.  In  some  cases  it  is  wise  to  leave  a  temporary  gauze  drain  in 
the  lower  part  of  the  wound,  for  otherwise  a  hsematoma  may  follow  the 
removal  of  a  large  hydrocele,  but  this  is  best  prevented  by  firm 
bandaging.  Kecurrences  after  this  method  are  very  rare.  Immediate 
closure  of  the  whole  wound  in  this  way  results  in  more  rapid  healing 
and  earlier  convalescence.  The  sutures  having  been  introduced,  it 
only  remains  to  dust  a  little  iodoform  over  the  wound,  dry  this  most 
scrupulously,  and  apply  the  dressings.  Whatever  material  is  used,  care 
must  be  taken  that  the  dressings  should  supply  the  following  con- 
ditions— viz.,  they  must  be  aseptic,  duly  compressive,  and  unirritating. 
They  are  secured  in  place  by  firm  and  even  bandaging  with  a  double 
spica.  While  this  is  applied  care  must  be  taken  that  the  scrotum  is 
kept  well  up  on  to  the  pubes.  This  is  a  cardinal  point,  and  must  be 
attended  to  not  only  now,  but  later  on,  at  and  after  each  dressing.  It 
prevents  oedema,  bagging,  and  inflammation,  and  thus  also  pain,  and 
hastens  rapid  repair  of  the  wound.  When  the  dressings  are  in  situ,  a 
pad  of  carbolised  tow  should  be  kept  over  the  anus,  to  prevent  flatus 
or  freces  contaminating  the  closely  adjacent  wound.  If  the  skin  incision 
has  been  closed,  the  wound  will  be  healed  in  a  week ;  by  the  fifth  or 
seventh  day  the  patient  may  get  on  to  a  sofa,  and  by  a  date  varying 
from  the  fourteenth  to  the  twenty-first  day  he  may  usually  begin  to  get 
about  with  a  suspender.  As  the  repair  with  aseptic  wounds  is  rapid, 
but  often  filamentous  and  weakly,  I  advise  the  use  of  a  suspender  for 
six  months  or  a  year  after  the  operation,  and  longer  if  occasions  arise 
for  hard  exercise,  such  as  riding,  &c. 

Hydroceles  of  the  canal  of  Nuck  and  encysted  hydroceles  of  the  cord 
are  best  excised  if  they  give  rise  to  pain  or  inconvenience.  Encysted 
hydroceles  of  the  epididymis  rarely  attain  a  size  large  enough  to  cause 
much  trouble.     When  they  do  they  may  be  excised,  care  being  taken  to 

s. — vol.  11.  47 


738  OPERATIONS  ON  THE  ABDOMEN. 

remove  the  whole  sac.  No  operation  is  to  he  undertaken  for  the 
multiple  small  cysts  that  form  in  some  elderly  men  as  a  degenerative 
change. 

II.  Eversion  of  the  Tunica  Vaginalis  (Juboulay). — Under  local  or 
general  anesthesia,  the  tunica  vaginalis  is  exposed  anteriorly,  and  incised 
sufficiently  to  allow  the  testicle  to  he  brought  out.  Traction  is  made 
upon  this  organ  while  the  scrotum  is  held.  Thus  the  tunica  vaginalis 
becomes  completely  everted,  so  that  its  serous  surfaces  lace  outwards. 
It  is  secured  in  this  position  by  means  of  two  or  three  catgut  sutures, 
which  are  passed  near  the  edges,  which  are  now  posterior  and  surround 
the  spermatic  cord.  Care  must  be  taken  that  the  stitches  do  not 
compress  or  injure  the  cord.  Sutures  are  not  always  necessary  when 
the  opening  into  the  tunica  vaginalis  is  made  only  just  large  enough  to 
allow  the  testicle  to  be  prolapsed.  The  testicle  is  then  replaced  in 
the  scrotum  and  the  wound  closed.  The  endothelial  surface  of  the 
serous  sac  now  faces  the  scrotal  fibrous  and  areolar  tissues,  to  which  it 
generally  becomes  adherent  in  a  short  time. 

At  first  it  was  considered  to  be  necessary  to  shell  the  unopened  tunica 
vaginalis  and  the  testicle  out  of  the  scrotal  coverings,  in  order  to  obtain 
proper  eversion,  but  this  step  is  superfluous,  and  is  attended  with  more 
or  less  haemorrhage.  Longuet  also  made  a  new  cavity  for  the  testicle 
between  the  connective  tissue  layers  of  the  scrotum,  but  this  is  attended 
with  dislocation  of  the  axis  of  the  organ,  and  is  not  necessary. 

This  ingenious  and  simple  operation  is  not  so  successful  as  might  be 
imagined,  for  recurrence  has  followed  it,  and  a  serous  sinus  has 
persisted.  In  other  cases  the  cord  has  been  injured  or  seriously  com- 
pressed. But  Major  Fullerton  tells  me  that  it  is  frequently  and 
successfully  used  in  India. 

Longuet  records  22  cases  without  recurrence,  and  Dudley  Tait 
(Ann.  of  Sun/.,  1901,  vol.  xxxiii.,  \\  305)  records  3  cases.  It  is 
not  stated  how  long  these  patients  were  observed.  The  operation  has 
not  found  much  favour  in  England, because  excision  of  the  parietal  part 
of  the  tunica  vaginalis  is  a  more  certain  and  radical  procedure.  In 
view  of  the  comparative  simplicity  of  the  operation,  however,  it  is  worth 
trying  for  some  thin-walled  hydroceles. 

III.  Iodine  Injection.* — Supposing  the  patient  be  healthy,  not  pre- 
maturely aged,  and  amenable  to  directions,  the  surgeon  often  begins 
with  this  as  less  painful,  requiring  no  open  wound  or  dressing,  and, 
finally,  as  necessitating  much  less  the  recumbent  position. 

I  have  at  p.  733  drawn  attention  to  the  frequency  with  which  recur- 
rence is  liable  to  take  place  if  dilute  injections  are  used.  Elsewhere 
I  have  written  as  follows :  "  While  I  believe  that  the  absolute  certainty 
of  iodine  injection  has  been  overestimated,  yet  there  is  no  doubt  that 
failure  is  too  often  courted  by  want  cf  the  following  precautions:  (a) 
the  use  of  a  too  dilute  solution  ;  (h)  not  bringing  the  solution  in  con- 
tact with  the  whole  of  the  sac  ;  {<■)  not  withdrawing  all  the  hydrocele 
fluid  ;  (d)  injecting  large  hydroceles  immediately  alter  they  are 
emptied  ;  (e)  making  use  of  iodine  in  unsuitable  cases — viz.,  hydroceles 
with  thick  walls." 

*  A  10  per  cent,  solution  of  chloride  of  ziuc  and  .1  variety  of  other  irritants  have  been 
injected,  and  catgut  has  also  been  introduced  through  the  cannula. 


KADICAL    crKK    OK    II  YI>K<  H'KLK.  7  ;., 

The  method  of  injection  with  iodine  should  be  carried  out  as  follows: 
The  patient's  bowels  are  cleared  out  for  a  day  or  two  before,  and  it  is 
well  for  him  to  rest  with  his  hydrocele  well  supported  for  twenty-four 

hours  previous  to  the  injection.  The  fluid  is  first  most  carefully  drawn 
off  with  a  medium-sized  trocar,*  The  surgeon  then,  by  means  of  a 
syringe  with  a  platinum  nozzle  accurately  fitting  the  cannula,  injects 

steadily  two  to  three  drachms  of  the  tincture  of  iodine  (Edin.  Pharm.), 
taking  care  first  that  the  cannula  is  well  within  the  cavity  of  the  tunica 
vaginalis.  I  now  plug  the  cannula  with  a  small  wooden  spigot,  while  the 
affected  side  of  the  scrotum  is  gently  manipulated  and  shaken  so  as  to 
bring  the  fluid  in  contact  with  all  the  interstices  and  folds  of  the  serous 
membrane.  In  five  or  ten  minutes  the  cannula  is  withdrawn,  and  in  most 
cases  it  is  quite  safe  to  leave  in  the  above-given  amount  of  iodine.  The 
puncture  is  kept  carefully  closed  around  the  cannula  while  this  is  taken 
out,  and  then  closed  with  iodoform  and  collodion.  A  feeling  of  heat  is 
noticed  during  the  injection,  sometimes  amounting  to  sickening  pain, 
referred  also  to  the  inguinal  and  lumbar  regions,  and  the  neck  of  the 
bladder.  Faintness  is  not  very  infrequent,  and  it  is  thus  well  to 
tap  and  inject  the  patient  while  he  stands  at  the  end  of  a  sofa,  or 
lies  down. 

The  after-treatment  depends  on  the  amount  of  inflammation.  In 
most  cases  there  is  too  little  rather  than  too  much  of  this.  It  usually 
appears  within  two  or  three  hours,  and  if  it  be  slight  or  delayed,  the 
patient  should  be  told  to  walk  about  a  little,  and  the  sac  again  fre- 
quently manipulated.  The  patient  should  be  kept  to  his  bed  or  sofa  for 
a  day  or  two,  the  scrotum  supported,  and  plain  diet  given.  There 
should  be  no  hurry  to  employ  ice,  this  only  being  made  use  of  if  the 
swelling  threatens  to  be  great.  Morphia  may  be  given  freely.  Within 
four  or  five  days  usually  the  patient  may  get  about  wearing  a 
suspender.  He  should  be  prepared  for  a  return  of  the  swelling  after 
the  injection,  otherwise  he  will  be  disappointed  at  what  he  considers  a 
recurrence  of  his  disease.  The  swelling,  as  a  rule,  disappears  in  three 
to  four  weeks. 

In  the  case  of  a  double  hydrocele,  if  the  patient  be  healthy  and  not 
advanced  in  years,  it  is  quite  safe  to  inject  both  sacs  at  the  same  time, 
but  in  elderly  or  weakly  subjects  antiseptic  incision  will  be  the  safest 
course  if  the  patient  desires  an  operation,  otherwise  an  interval  should  be 
allowed  between  the  two  tappings. 

IV.  Carbolic  Acid. — This  method  was  introduced  in  1881  by  Dr. 
Levis,  of  Philadelphia  (Boston  Med.  and  Surg.  Journ.,  1881,  vol.  cv. 
p.  540).  The  following  advantages  have  been  claimed,  and  in  my  opinion 
largely  substantiated  :  (a)  It  is  less  painful  than  iodine,  (ft)  It  is  more 
certain.  Thus  carbolic  acid  produces  almost  uniformly  the  proper 
degree  of  inflammation,  neither  falling  short  of  nor  exceeding  that  need- 
ful for  producing  plastic  lymph,  (y)  There  is  less  risk  of  sloughing. 
(8)  The  patient  is  only  kept  from  his  employment  for  a  day  or  two, 
and  sometimes  for  a  shorter  time  than  this,  or  even  not  at  all. 

While  the  above  advantages  of  carbolic  acid  injection  over  that  by 
iodine,  especially  the  fact  that  it  entails  a  much  shorter  rest  and  absence 

*  By  some  a  solution  of  cocaine  is  now  injected.  I  prefer  not  to  use  this,  if  possible 
so  that  no  dilution  of  the  iodine  injection  may  occur. 

47—2 


740  OPERATIONS   ON   THE    ABDOMEN. 

from  business,  have,  in  my  opinion,  been  largely  substantiated,  it  is 
certain  that  complications  and  undesirable  sequelae,  while  less  frequent, 
are  not  so  entirely  uncommon  as  some  partisans  of  this  method 
would  have  us  believe,  (i)  Recurrence. — With  regard  to  this  matter, 
I  would  point  out  that  a  large  number  of  cases  have  been  published 
as  radical  cures  within  a  year  or  so  of  the  first  introduction  of  the 
method.  Thoughtful  surgeons  who  have  seen  much  of  radical  cure  of 
hydroceles  will  not  need  that  I  should  refer  them  to  the  remarks  which 
1  have  made  on  the  rebellious  nature  of  many  hydroceles,  and  how  they 
must  be  carefully  watched  for  an  extended  period  before  a  radical  cure 
can  really  be  claimed.  It  is  beyond  the  bounds  of  probability  that 
while  a  hydrocele  will  recur  after  careful  incision  and  drainage,  and 
even  after  incision  and  partial  incision  of  the  sac,  injection  of  carbolic 
acid  will  be  invariably  and  permanently  successful.  And  it  is  interesting 
to  note  that  in  America  itself,  where  this  method  has  been  most  largely 
used,  and  where  surgeons  have  had  the  largest  opportunities  of  watching 
its  results,  they  are  not  in  entire  accord  as  to  its  value. 

Thus  Dr.  Bull,  of  New  York  (Ann.  of  Surf/.,  July,  1886,  p.  35),  in  a 
paper  recommending  antiseptic  incision,  writes  :  "  It  is  a  striking  fact 
that,  of  the  13  cases  I  have  met  with,  2  had  been  treated  unsuccess- 
fully in  this  way.  As  it  attempts  a  cure  by  the  same  process  as 
that  incited  by  iodine,  an  adhesive  inflammation,  I  see  no  reason  to 
believe  that  it  will  ever  yield  much  better  results."  Dr.  R.  F.  Weir,  in 
the  discussion  that  followed  on  the  reading  of  the  above  paper,  said  he 
had  used  carbolic  acid  injections  over  sixty  times.  Occasionally  relapses 
had  occurred,  not  in  a  large  proportion,  however,  as  be  could  recall 
only  four  or  five  instances,  and  in  those  the  patients  were  cured  by  a 
repetition  of  the  same  treatment.  In  three  of  those  the  injection  was 
repeated  too  soon,  as  subsequent  experience  showed  that  a  longer  delay 
would  probably  have  resulted  in  a  cure.  Helferich,  of  Griefswald 
(Tlterap.  Monatsschrift,  1890),  has  tested  carbolic  acid  injection  by 
Levis's  method  in  over  30  cases,  with  known  results  in  27;  21  were 
cured,  6  relapsed,  all  of  these  latter,  save  one,  being  cured  by  a  fresh 
injection.* 

(2)  Much  Reaction.  Cellulitis  and  Suppuration. — It  is  right  to  say 
that  in  some  of  the  cases  in  which  these  have  followed  on  the  injection  of 
carbolic  acid  an  excessive  quantity  seems  to  have  been  employed.  Thus 
Dr.  R.  Abbe  (New  York  Med.  Journ.,  Dec.  22,  1883)  reports  that  he 
injected  three  drachms  of  carbolic  acid  and  glycerine  into  a  large  hydro- 
cele sac,  and  that  acute  suppuration  followed,  requiring  incision,  which 
cured  the  hydrocele.  He  allows  that  the  above  quantity  is  excessive, 
one  drachm  always  sufficing.  Dr.  Weir  (loc.  supra  cit),  in  one  ease  in 
which  the  iodine  treatment  had  failed,  injected  three  drachms  of 
carbolic  acid  ;  this  was  followed  by  the  usual  absence  of  pain,  but  with 
recurrence  of  the  swelling  in  a  few  days,  which  went  on  to  suppuration, 
and  after  incision  of  the  sac  shreds  and  large  masses  of  membrane 
were  discharged,  gangrene  of  nearly  the  entire  tunica  vaginalis  being 
produced. 

*  Mr.  Southam  {Lancet,  1887,  vol.  ii.  p.  515)  mentions  a  case  which  recurred  within 
a  month  of  the  injection  with  carbolic  acid,  and  was  then  treated  by  antiseptic  incision 
and  partial  excision  of  the  sac. 


RADICAL   CURE    OF    HYDROCELE. 


74i 


The  above  cases  of  Weir  and  Helferich  show  that  accidents  have 
followed  even  when  the  amount  of  carbolic  acid  used  is  small.  They 
BUggesI  that,  considering  the  comparatively  recent  introduction  of  this 
method,  and  the  restricted  number  of  surgeons  by  whom  it  has  been 
used,  complications  are  at  least  as  frequent  as  after  iodine  injection. 

(3)  Carbolic  Acid  Poisoning. — Most  writers  have  distinctly  stated 
that  this  does  not  occur.  It  is  certainly  extremely  rare,  as  it  is  probable 
the  surfaces  are  sealed  by  the  carbolic  acid. 

But  1  >r.  >) .  Murphy,  at  a  discussion  at  the  New  York  Association  {New 
York  Med.  Record,  June  20,  1891),  said  he  had  known  of  three  or  four 
cases  in  which  carbolic  acid  used  in  this  way  was  followed  by  bad  effects, 
especially  on  the  kidneys.  He  had  seen  one  case  terminate  fatally,  and 
he  could  not  attribute  this  death  to  anything  but  carbolic  acid  poisoning. 
He  did  not  know  how  much  carbolic  acid  was  used.  I  know  of  one 
case  of  death  from  pulmonary  embolism  a  few  days  after  injection  of 
carbolic  acid.     Hemorrhage  into  the  sac  may  also  occur. 

The  Injection. — After  the  usual  tapping  Dr.  Levis,  by  means  of  a 
syringe  which  has  a  nozzle  sufficiently  long  and  slender  to  reach 
entirely  through  the  cannula,  injects  about  a  drachm  (of  crystals)  of 
carbolic  acid,  which  must  be  kept  liquid  by  a  5  or  10  per  cent,  addition 
of  glycerine  or  water.  The  former  should  be  preferred.  No  more 
fluid  is  to  be  used  for  dilution  than  is  absolutely  necessary.  Liquefac- 
tion by  heat  is  inadmissible,  as  solidification  is  in  this  case  liable  to 
follow  in  the  cannula.  As  soon  as  the  carbolic  acid  is  lodged  in  the  sac 
the  scrotum  is  freely  manipulated,  so  as  to  diffuse  the  carbolic  acid 
uniformly.  A  sense  of  warmth  is  produced,  quickly  followed  by  decided 
numbness. 

My  own  experience  is  too  limited  to  be  of  any  value.  Of  late  years 
I  have  used  antiseptic  incision  with  partial  excision  of  the  sac,  and  have 
been  so  well  satisfied  with  it  as  to  prefer  to  use  it  wherever  the  patient 
can  lay  up.  But  where  this  is  objected  to,  I  have  used  iodine  and  car- 
bolic acid,  but  the  latter  only  in  11  cases.  None  have  recurred  to 
my  knowledge,  and  some  have  been  watched  for  over  three  years. 
There  is  no  need  of  Levis's  special  instrument.  What  is  essential  is 
to  use  carbolic  acid  liquefied  with  glycerine,  not  to  inject  more  than 
one  drachm,  and  to  lodge  it  well  within  the  tunica  vaginalis.  This 
may  be  done  by  means  of  one  of  the  large  exploring  hypodermic  needles, 
which  hold  60 — 100  minims.* 

The  needle  attached  to  the  syringe  is  first  lodged  safely  in  the  cavity 
of  the  hydrocele,  which  is  then  tapped  in  the  ordinary  way  with  a  fine 
hydrocele-trocar.  When  the  sac  has  been  thoroughly  emptied,  the 
cannula  is  withdrawn,  and  the  syringe,  previously  cleansed,  containing 
the  solution  must  be  screwed  on  to  the  needle,  which  has  been  kept  in 
situ  and  the  solution  injected.  However  this  is  done,  the  carbolic  acid 
must  be  brought  in  as  complete  contact  as  possible  with  the  interior  of 
the  sac  by  manipulating  the  scrotum,  turning  this  from  side  to  side, 
upside  down,  &c.  I  have  employed  strapping  or  suspension  with  cotton 
wool  packing  later,  as  after  the  use  of  iodine. 

*  I  learnt  the  value  of  these  in  small  hydroceles,  as  in  those  of  the  cord,  or  the  infantile 
variety  in  boys,  from  the  late  Mr.  Berkeley  Hill  {Brit.  Med.  Journ..  1SS6,  vol.  i.  p.  1164). 
Following  Mr.  Hill,  1  have  also  given  an  anaesthetic  in  children. 


742  OPERATIONS    ON    THE   ABDOMEN. 


VARICOCELE. 

Indications. — While  palliative  treatment  will  be  sufficient  in  the 
great  majority  of  cases,  if,  at  the  same  time,  due  attention  is  paid  to 
the  general  health,  the  occupation  and  habits  of  the  patient,  and,  where 
this  is  required,  to  his  sexual  hygiene,  an  operation  will  be  justifiable 
in  the  following  cases  : 

(i)  Where  the  patient  is  precluded  from  entering  one  of  the  public 
services,  or  any  occupation  involving  much  activity  in  the  upright 
position.  Thus,  out  of  the  28  cases  in  which  I  have  operated, 
12  were  private  cases,  of  which  9  were  applying  for  and  passed  into 
the  army  or  navy,  and  I  was  a  medical  man,  operated  upon  for 
double  varicocele  ;  of  16  hospital  cases,  1  was  desirous  of  entering 
the  police  and  subsequently  did  so  ;  1  was  a  goods-guard  on  probation, 
and  found  that  a  large  left-sided  varicocele  threatened  to  spoil  his 
prospects,  the  aching  pain,  which  invariably  followed  the  jumping  in 
and  out  of  his  brake  van,  being  only  relieved  by  the  patient's  lying 
down,  and  being  inevitably  brought  on  again  by  the  next  station.  This 
man  stopped  me  on  London  Bridge  some  five  years  after  to  say  that 
he  was  in  regular  employment  as  a  goods-guard,  married,  and  the 
father  of  two  children.  Five  others  were  shop  assistants,  and  2  were 
gardeners.  (2)  In  any  case  where  the  varicocele  persists  or  steadily 
increases,  in  spite  of  treatment,  and  where  it  is  accompanied  with  much 
distress,  annoyance,  or  pain,  or  where  it  interferes  with  some  justifiable 
pursuit,  such  as  riding  ;  (3)  where  the  patient  is  going  to  reside  in  a 
hot  climate,  where  a  small  varicocele  soon  enlarges  from  want  of 
support  from  the  atonic  cremaster  and  dartos  ;  (4)  where  the  surgeon 
has  satisfied  himself  that  the  testicle  is  undergoing  atrophy  ;  (5)  where 
the  varicocele  is  accompanied  by  frequent  seminal  emissions  and  much 
mental  misery.  In  the  two  last  given  indications,  great  caution  must 
be  shown  before  operation  is  resorted  to,  and  the  last  is  the  most 
doubtful  of  all.  Where  the  patient  is  clearly  a  hypochondriac,  or  a 
monomaniac  in  genital  matters,  no  operation  is,  of  course,  to  be 
thought  of.     It  is  certain  to  be  a  failure. 

The  choice  of  operation  is  a  very  large  one,  but  as  I  consider  that 
one  alone  has  been  proved  to  be  alike  efficient  and  simple,  I  shall  not 
occupy  my  space  with  an  account  of  any  others,  or  with  the  history  of 
the  operation.  Like  so  much  else  in  operative  surgery,  the  only 
efficient  and  simple  operation  for  varicocele  dates  to  the  great  discovery 
of  Lord  Lister.* 

Excision. — This  operation,  performed  with  the  parts  well  in  sight, 
has  the  very  great  advantage  of  allowing  the  surgeon  to  carry  out 
each  step  with  precision,  to  include  what  he  thinks  safe,  and  no  more; 
it  does  away  with  the  risk  of  transfixing  a  vein,  and  its  possibly 
disastrous  results  of  septic  thrombosis;  it  requires  very  few  and  simple 
instruments ;  while  Lord  Lister's  teaching  has  enabled  us  to  perform 
it  without  the  risks  of  haemorrhage,  cellulitis,  and  blood-poisoning, 
which  were  so  terribly  frequent  in  operations  on  veins  performed  before 
his  da}'. 


*  Sir  Henry  Howse  drew  attention  to  the  method  of  aseptic  excision  in  varicocele 
ijlmj's  Hosp.  Reps.  1887,  vol.  xxiii.  p.  408). 


VARICOCELE.  743 

For  a  few  days  before,  the  bowels  should  be  kept  well  open,  and  the 
diet  should  be  light  and  limited.  The  parts  should  be  shaved  and 
thoroughly  cleansed  with  soap  and  water,  and  then  lotio  hvdr.  perch. 
i — 4,000  (p.  736).  It  is  well  to  perform  the  cleansing  twelve  hours 
before,  and  to  keep  a  compress,  wet  with  the  above  lotion,  on  up  to  the 
time  of  the  operation.  The  patient  having  been  amesthetised  with 
ether  or  A.C.E.  mixture  and  the  field  of  operation  isolated  with  aseptic 
towels,  the  vas  deferens  is  isolated,  and  either  kept  so  by  two  fingers 
of  the  left  hand,  or  handed  over  to  an  assistant,  who  stands  on  the 
opposite  side  to  the  surgeon.  In  either  case  the  latter  makes  the  veins 
prominent  by  grasping  the  affected  side  of  the  scrotum  and  protruding 
the  varicocele.  The  skin  incision,  which  should  be  about  an  inch  and 
a  half  long,  may  be  made  in  one  of  two  ways,  either  in  the  scrotum 
directly  over  the  site  of  the  varicocele,  or  above  the  scrotum  and  in 
front,  commencing  at  the  external  abdominal  ring  and  running  down- 
wards towards  the  scrotum.  If  the  latter  plan  is  adopted  it  will  be 
found  that  the  varicocele  is  quite  easily  pushed  up  into  the  wound,  and 
it  has  the  advantages  of  rendering  the  operation  more  convenient, 
whilst  the  wound  is  more  easily  sutured  and  heals  more  certainly  and 
readily  than  one  which  involves  the  skin  of  the  lower  part  of  the 
scrotum.  Further,  the  spermatic  veins  are  less  numerous,  and  more 
easily  separated  from  the  vas,  than  lower  down,  and  the  tunica  vaginalis 
is  very  unlikely  to  be  opened.  The  exposed  skin  around  the  wound  is 
covered  with  aseptic  lint,  which  is  fastened  to  the  edges  of  the  wound 
with  tissue  forceps,  so  that  neither  instruments  nor  sutures  may  touch 
the  skin.  The  surgeon  either  wears  gloves,  or  scrupulously  avoids 
touching  any  of  the  tissues  with  his  fingers,  but  does  all  the  work, 
including  the  threading,  holding  and  tying  of  the  ligatures,  wTith  suitable 
instruments. 

Care  should  be  taken  to  avoid  opening  the  tunica  vaginalis.  If, 
however,  it  is  opened,  the  opening  should  be  taken  up  with  Spencer 
Wells's  forceps  and  tied  up  with  fine  catgut,  or  it  may  be  left  without 
treatment.  If  the  wound  runs  an  aseptic  course,  this  complication 
will  give  very  little  trouble.  With  one  or  two  strokes  of  a  keen-edged 
scalpel  the  packet  of  veins  is  exposed  and  is  then  carefully  opened. 
The  surgeon  then  passes  a  steel  director  first  at  the  upper  and  then 
at  the  lower  angle  of  the  wound  through  the  packet  so  as  to  leave 
less  than  a  third  of  the  veins  behind  it.  Along  the  director,  which 
thus  keeps  a  track  open  and  easily  found,  an  aneurysm-needle,  or 
eyed  probe,  carrying  a  medium-sized  ligature  of  sterilised  catgut,  is 
passed.  This  is  then  tied  firmly  round  the  included  veins.  If  the 
incision  has  been  made  an  inch  and  a  half  long,  and  the  upper  and 
lower  angles  of  the  wound  are  well  retracted,  no  difficulty  will  be 
experienced  in  placing  these  ligatures  near  enough  to  the  external 
abdominal  ring  and  testicle  respectively  to  ensure  removal  of  a  sufficient 
extent  of  the  enlarged  veins.  After  each  of  the  ligatures,  upper  and 
lower,  has  been  tied  securely  and  cut  short,  a  pair  of  scissors  is  run 
along  the  director,  and  the  packet  is  cut  through  about  a  quarter  of  an 
inch  from  each  ligature.  The  portion  of  varicocele  thus  included  is 
then  removed  by  carefully  clipping  it  out  with  a  pair  of  scissors ;  any 
cross  branches  which  may  now  be  divided  are  secured  with  fine  chromic 
gut.    An  extremely  important  step  comes  next.     With  a  sharp-pointed 


7|  |         OPERATIONS  ON  THE  ABDOMEN. 

half-curved  needle,  carrying  medium-sized  chromic  gut,  the  Burgeon 

brings  into  accurate  apposition  the  two  ends  of  the  stumps, the  ligature 
being  passed  through  the  centre  of  each  stump  dost;  to  the  correspond- 
ing ligature.  As  it  is  tightened  an  assistant,  with  a  sharp-pointed 
probe,  brings  the  cut  ends  of  the  veins  on  the  face  of  each  stump 
snugly  and  precisely  together.  The  object  of  this  most  important 
detail  is  to  permanently  shorten  the  cord,  and  to  restore  the  natural 
suspension  of  the  testicle.*  It  is  obviously  quite  impossible  in  any 
subcutaneous  method.  I  have  practised  this  detail  since  1887,  but  as 
Sir  William  Bennett  was  the  first  to  draw  attention  to  this  Btep  (Lancet, 
February,  1891),  the  credit  of  showing  the  importance  of  it  must  be  his. 
The  sutured  cord  is  replaced  in  the  bottom  of  the  wound.  When  the 
skin  is  much  relaxed,  I  finish  the  operation  by  removing  widely,  by  two 
elliptical  incisions,  the  skin  on  either  side  of  the  small  wound  which 
has  been  made,  the  apes  of  the  incisions  being  placed  well  up  over  the 
external  ring.  I  think  it  well  to  adopt  this  step,  as  I  believe  it  helps 
to  brace  up  the  relaxed  parts ;  but  it  is  not  of  the  least  use  by  itself, 
and  it  is  much  less  needed  now  if  the  above-given  precaution  of  ligatur- 
ing together  the  vein-stumps,  and  thus  shortening  the  cord,  is  taken. 
And  the  same  may  be  said  of  another  step  which  should  be  taken  before 
the  close  of  the  operation — i.e.,  ligature  and  removal  of  any  very  en- 
larged scrotal  veins,  a  step  which  I  always  adopt  when  the  patient's 
attention  has  dwelt  on  these.  The  whole  wound,  superficial  and  dee]), 
is  then  carefully  scrutinised,  and  every  bleeding  point  being  secured  is 
thoroughly  dried.  The  edges  of  the  wound  are  then  carefully  adjusted 
with  horsehair  sutures,  the  tendency  to  inversion  being  borne  in 
mind. 

Antiseptic  dressings  are  then  applied,  due  facilities  being  provided 
for  the  patient's  micturition.  In  securing  the  dressings  in  situ,  care 
should  be  taken  to  keep  the  scrotum  well  up  on  to  the  pubesby  bringing 
the  turns  of  the  spica  from  below  upwards  and  not  in  the  reverse 
direction.  I  generally  change  the  dressings  at  the  end  of  the  third  day, 
immediately  after  the  first  action  of  the  bowels,  and  again  at  the  end 
of  the  first  week,  to  remove  alternate  sutures.  At  this  date  the  patients 
may  get  on  to  a  sofa,  but  I  insist  on  their  maintaining  the  recumbent 
position  for  two  or  three  weeks.  Aseptic  union,  forming  quickly  and 
without  the  medium  of  granulations,  remains  weak  for  a  long  time.  If 
the  stumps  of  the  cord  have  been  sutured  together  there  is  much  less 
need  for  the  patient  to  wear  a  suspender  afterwards  ;  but  to  give  the 
operation  every  chance,  and  to  save  all  drag  and  tax  upon  parts  which 
have  very  recently  united,  I  generally  advise  that  a  suspender  be  worn 
for  three  months.  In  addition  to  the  support  which  I  believe  to  be 
advisable  while  the  sutured  stumps  of  the  cord  are  being  firmly  knit 
together,  I  am  of  opinion  that  the  continuance  of  support  to  the  parts 
for  a  while  prevents  a  too  rapid  melting  away  of  the  little  nodular  mass, 
which,  callus-like,  marks  the  seat  of  the  operation. 

The  points  to  which  I  attach  most  importance  in  the  operation  are 
maintenance  of  strict   asepsis  throughout,  suturing  together  the  two 


*  The  same  object  may  be  less  perfectly  attained  by  leaving  one  of  the  ends  of  each 
ligature  uncut,  and  then  tying  those  cud-  together  ;  the  apposition  is  not  so  good  ae  thai 
obtained  by  the  method  already  described. 


VARICOCELE.  745 

stumps,  and  bo  shortening  the  cord  and  providing  for  suspension  of  the 
testicle,  arrest  «>t'  all  haemorrhage,  thorough  drying  out  of  the  wound, 
and  the  careful  application  of  an  antiseptic  dressing,  so  as  to  keep  the 

scrotum  well  up  on  to  the  pubes.  1  look  upon  these  details  as  most 
necessary  it'  rapid  healing  is  to  be  made  certain  of,  and  cellulitis, 
epididymo-orchitis,  and  hydrocele  prevented. 

Mr.  Bennett  {loc.  supra  cit.),  in  his  operation  for  varicocele,  advocates 
some  different  and,  in  two  instances,  far  more  radical  steps.  Thus  (o) 
he  does  nol  open  the  general  sheath  immediately  surrounding  the  veins, 
as  by  leaving  it  intact  he  makes  certain  of  passing  the  ligature  around 
all  the  affected  veins,  as  none  of  these  ever  lie  outside  the  fascia. 
Furthermore,  the  fascia,  if  not  opened,  better  carries  the  weight*  of  the 
dependent  testicle.  (ft)  Mr.  limnett  considers  that  the  view  generally 
held  that  the  spermatic  artery  is  displaced  with  the  vas  deferens,  and 
thus  kept  out  of  the  way,  is  a  mistake  ;  in  reality  the  artery  remains 
with  the  veins.  Furthermore,  Mr.  Bennett  holds  that  the  artery  is 
usually,  and  may  always  be,  safely  divided  with  the  veins,  for  as  long  as 
the  wound  remains  aseptic  the  artery  to  the  vas  deferens  "  and  some 
outlying  branches  of  the  spermatic  artery,  one  of  which  sometimes 
comes  off  high  up  and  so  may  easily  escape  division,  are  sufficient  to 
carry  on  the  blood  supply  to  the  testicle,  and  to  prevent  any  risk  of 
atrophy." 

AVhile  Mr.  Bennett's  plan  is  justified  by  the  results  obtained  by  his 
own  practised  hands,  I  feel  that,  writing  as  I  am  for  those  who  may  not 
have  had  many  opportunities  of  operating  for  varicocele,  I  ought  to  point 
out  certain  grave  risks  which  I  consider  to  be  at  least  possible,  if  the 
above  teaching  is  widely  followed. 

First,  as  to  division  of  all  the  veins,  I  will  say  at  once  that  perhaps  I 
am  prejudiced  unduly  by  the  unfortunate  result  of  one  case,  which  I 
mention  below.  While  I  admit  that  recurrence  of  the  varicocele  may  be 
brought  about  b}r  removal  of  too  few  of  the  veins,  I  feel  strongly  that 
inclusion  of  all  of  them  in  the  ligature  involves  a  much  graver  risk. 
Further,  I  cannot  agree  with  Mr.  Bennett  that  it  is  safe  to  trust  to  the 
artery  of  the  vas,  or  branches  of  the  spermatic  which  may  come  off 
sufficiently  high  up  to  be  available,  and  some  small  unimportant  anas- 
tomotic branches  passing  from  the  sub-vaginal  tissue.  Mr.  Bennett 
allows  that  these  vessels  are  small  and  delicate,  and  points  out  that  any 
inflammation  about  the  parts  may  be  sufficient  to  choke  them,  sloughing 
or  wasting  of  the  organ  following  as  a  necessaiy  result. 

Thus,  while  in  no  way  criticising  Mr.  Bennett's  modifications  of  the 
operation  when  practised  by  himself,  I  strongly  advise  my  junior 
readers  to  make  use  of  the  simpler  and  very  efficient  method  given  at 

P-  743- 

The   chief  risks  and  causes   of   failure  in  the   operation    are   as 

follows  : — 

I.  Sepsis  and  its  Results. — The  risk  of  these  was  always  present 
with  the  old  subcutaneous  operations,  however  modified.  It  is  by  no 
means  to  be  lost  sight  of  with  the  open  operation  performed  with  the 
advantages  of  modern  surgery.  The  operation,  although  it  may  appear 
to  be  trivial,  is  not  one  to  be  undertaken  lightly,  and  it  should  not  be 

*  This  is  rendered  of  less  importance  by  the  suture  which  unites  the  vein  stumps. 


746  OPERATIONS   on    THE    ABDOMEN. 

performed  except  under  aseptic  conditions,  lest  cellulitis,  septic  throm- 
bosis, or  even  sloughing  of  the  testis  occur.  Short  of  these  catas- 
trophes, suppuration  around  the  ligature  may  occur  unless  catgut  is 
used  instead  of  silk,  and  the  precautions  mentioned  at  p.  743  are 
observed.  A  troublesome  stitch  sinus  results,  and  frequently  a 
hydrocele  of  the  tunica  vaginalis  develops  in  such  cases.  I  have  seen 
several  patients  who  have  had  to  submit  to  a  radical  operation  for 
hydrocele,  the  sequela  of  excision  of  varicocele. 

II.  Inclusion  of  too  many  Veins. — That  this  is  a  real  danger  is 
shown  by  a  case  of  mine  which  I  published  (Si/at.  of  Sun/.,  vol.  iii. 
p.  571).  A  transient  hydrocele  may  develop  from  removal  of  too  many 
veins,  but  a  permanent  hydrocele  is  very  rarely  seen  apart  from  a 
definite  history  of  stitch  abscess. 

III.  Atrophy  of  the  Testis. — This  may  occur  from  destruction  or 
injury  of  the  sympathetic  nerves  of  the  testis,  which  run  with  the  vas. 
In  order  to  avoid  this  rare  sequela,  care  must  be  taken  to  leave  the 
vas  well  alone  ;  it  is  not  necessary  to  touch  it  at  all. 

IV.  Division  or  Laceration  of  the  Vas  Deferens. — This  has 
happened  to  careless  operators  more  commonly  than  would  be  sus- 
pected from  publications.  Atrophy  of  the  testis  does  not  occur  if  the 
injury  is  limited  to  the  vas  deferens.  The  accident  is  most  likely  to 
happen  from  want  of  care  in  separating  the  lower  coiled  part  of  the 
duct  from  amongst  the  bulky  mass  of  veins  near  the  epididymis. 

V.  Recurrence  of  the  Varicocele. — I  am  of  opinion  that  if  operation- 
cases  were  more  thoroughly  followed  up  afterwards,  this  sequela  would 
be  found  to  be  more  common  than  is  thought  to  be  the  case.  It  is 
especially  likely  to  follow  the  subcutaneous  method  where  the  patient 
is  allowed  to  get  up,  or  is  hurried  out  of  the  hospital  to  make  room  for 
another  case  as  soon  as  the  wound  is  healed.  To  prevent  this  risk  of 
recurrence  Mr.  Bennett  lays  stress  on  the  need  of  removing  the  entire 
plexus  of  spermatic  veins.  As  I  have  been  unfortunate  enough  to  meet 
with  a  case  in  which,  in  spite  of  care  taken,  too  many  veins  were 
ligatured  and  removed,  I  cannot  agree  with  Mr.  Bennett  (p.  745). 
Another  instance  of  what  appears  to  be  recurrence,  but  which  is  really 
an  escape  of  the  upper  part  of  the  spermatic  plexus,  may  be  due  to  the 
upper  ligature  being  applied  too  low  down  (Bennett).  In  this  case  the 
part  of  the  plexus  between  the  upper  ligature  and  the  external  ring 
remains  full,  and  may  give  trouble  for  a  time,  though  it  gradually  shrinks. 

Insecure  knotting  of  the  ligature,  or  not  using  reliable  material,* 
may,  of  course,  lead  to  recurrence  after  any  method  in  which  ligatures 
are  used,  but  the  veins  are  not  also  divided.  It  may  be  truly  said  that 
the  accidents  and  sequehe  mentioned  above  are  avoidable  by  careful 
and  aseptic  operating,  but  the  danger  of  their  occurrence  is  still  real 
enough  to  justify  the  warning  that  this  apparently  simple  operation 
is  not  to  be  performed  without  due  care,  and  under  circumstances 
which   are  favourable  for  aseptic  work. 

ANASTOMOSIS    OF    THE    VAS    DEFERENS. 

A  divided  vas  deferens  may  be  anastomosed  by  slitting  the  distal 
cut  end  for  about  an  inch,  so  that  two  flaps  are  formed  by  two  incisions, 

■    M  p.  Bennett  prefers  kangaroo-tail  tendon  ligatures. 


CASTRATION.  747 

one  on  cadi  side  of  the  vas.  One  of  these  incisions  is  then  carried  up 
a  little  further  (halt*  an  inch),  and  the  obliquely  pared  testicular  end  of 
the  duct  is  then  laid  in  contact  with  the  Lumen  of  the  urethral  part,  and 
secured  with  very  line  catgut  sutures.     The  equal  tails  of  the  urethral 

end  are  then  wrapped  round  the  testicular  part  of  the  vas,  and  sutured 
in  position.  Layers  of  fascia  are  then  wrapped  round  the  anastomosis 
and  fixed  in  position  by  sutures  (Lynn  Thomas,  Brit.  Med.  Joum.,  1904, 
vol.  i.  p.  13). 

Lydston  (Ann.  of  Surg.,  vol.  xliv.  p.  92)  passes  a  thread  of  silk- 
worm gut  into  both  ends  of  the  vas,  and  brings  one  end  of  the  thread 
out  through  the  side  of  the  proximal  part  of  the  tube,  and  later  through 
the  skin.  The  ends  of  the  vas  are  brought  together  by  two  catgut 
sutures,  and  the  anastomosis  is  reinforced  by  folding  the  "sheath  of 
the  cord  "  around  the  vas  and  securing  it  in  apposition  by  means  of  ;i 
continuous  catgut  suture.  The  silkworm-gut  thread  is  removed  after 
ten  days. 

CASTRATION   (Fig.   297). 

Indications. 

I.  Growths  of  the  Testicle. 

Diagnosis  of  Malignant  Disease  of  the  Testis. — As  the  records  of 
surgery  contain  many  instances  of  mistakes  under  able  hands — hema- 
toceles removed  for  malignant  disease,  and  malignant  disease  opened 
for  hematoceles — a  few  hints  may  not  be  out  of  place  here  on  the  subject 
of  castration. 

Contra-indications. — Castration  should  not  be  performed  when  the 
cord  is  extensively  involved,  when  masses  can  be  felt  deep-seated  in 
the  iliac  fossa  and  lumbar  region,  when  there  is  any  evidence  that  the 
liver  or  lungs  are  involved,  or  when  the  jaundiced  sallow  tint  and 
rapid  emaciation  point  to  the  disease  having  become  general.  In  cases 
at  all  advanced,  though  the  patient  might  be  rid  of  an  encumbrance, 
the  operation  would  be  very  liable  to  be  followed  by  a  low  form  of 
peritonitis,  or,  before  the  wound  was  healed,  swelling  would  probably 
appear  in  the  inguinal  region,  and  the  growth  soon  f ungate  through 
the  wound. 

The  following  are  the  points  on  which  most  reliance  may  be  placed  : 

Continuous,  and  often  quickly  progressing,  solid  enlargement  of  the 
testicle  or  epididymis  without  inflammation.  Sometimes  this  progress 
is  much  slower  ;  occasionally  it  may  seem  to  be  in  abeyance,  but  careful 
watching  with  frequent  examinations  (and  these  are  the  key  to  obscure 
cases)  will  show  that  the  enlargement  is  progressing  in  spite  of  treat- 
ment. Failure  of  well-directed  treatment.  Where  the  swelling  is  small, 
still  oval  in  shape,  and  smooth  and  firm  in  outline,  a  brief  trial  of 
mercury  or  potassium  iodide  ma}'-  be  made,  combined  with  carefully 
applied  Leslie's  strapping,  but  where  in  a  week  there  is  no  result,  or 
where  the  case  is  of  longer  duration,  and  delay  will  very  likely  be  fatal, 
an  exploratory  incision  with  antiseptic  precautions,  followed,  if  need  be, 
by  immediate  castration,  will  be  the  wiser  course.*  Consistence.  This 
is  rarely  for  long  the  same  all  over  the  swelling.     Even  if  a  firm,  slow 

*  I  may  warn  my  younger  readers  of  the  temporary  improvement  which  potassium 
iodide  sometimes  seems  to  bring  about  even  in  malignant  swellings. 


748  OPERATIONS  ON  THE  ABDOMEN. 

growth  seem  uniform  and  recall  orchitis,  a  careful  examination  will 
usually  find  one  or  two  spots  which  are  more  elastic  than  the  rest. 
Usually  the  softening  at  places  where  cystic  or  degenerative  changes 
are  taking  place  is  well  marked.  But  it  may  ; require  somewhat 
prolonged  watching  to  detect  one  or  two  at  first  lowly  rising  projections 
or  bosses  which  foretell  that  the  tunica  albuginea  is  becoming  thinned 
at  tins  spot.  Of  enlargement  of  the  cord,*  fulness  of  the  scrotal  veins, 
adhesion  of  the  scrotal  tunics,  increasing  aches  and  painfullness,  I  say 
nothing,  as  they  are  evidence  that  the  disease  is  entering  into  a 
later  stage. 

An  exploratory  incision  is  to  be  preferred  to  the  use  of  a  trocar,  as 
being  more  certain  to  give  information.  A  trocar  may  enter  a  solid 
part  or  withdraw  some  scanty  mucoid  fluid.  Sometimes  the  amount 
of  blood  which  flows  through  the  cannula  of  a  trocar  thrust  into  a 
testicle,  the  subject  of  rapidly  growing  malignant  disease,  is  so  great 
as  to  lead  to  the  supposition  that  it  must  be  a  hematocele.  In  such 
cases,  however,  the  diminution  of  the  swelling  is  not  so  proportionate 
to  the  flow  of  blood  as  it  would  be  in  hematocele.  Furthermore,  the 
blood  is  usually  bright,  not  dark  and  altered,  as  in  hematocele. 

Prognosis. — It  will  be  seen  that  the  prognosis  is  always  grave, 
extremely  so  in  the  softer  and  more  rapid  growths.  Kocher  goes  so  far 
as  to  say  with  regard  to  these  that  no  case  of  really  permanent  cure  of 
encephaloid  carcinoma  is  known.  In  medullary  sarcomata,  especially  in 
children,  the  prognosis  is  almost  as  gloomy.  But  while  the  above 
opinion  is  only  too  true  of  the  majority  of  cases,  a  sufficient  number 
have  been  recorded  to  show  the  benefit  which  may  follow  on  castration, 
even  in  the  soft  forms  of  sarcomata.  Kober  collected  105  cases  of 
sarcoma  of  the  testis,  out  of  which  9  were  known  to  be  free  from 
recurrence  over  three  years  after  the  operation. 

Mr.  Meade,  of  Bradford,  removed,  in  1846,  the  testicle  of  a  patient  aged  40  for  a 
swelling  which  had  lasted  about  nine  months  (Lond.  Med.  <•'</:. ,  vol.  xliv.  p.  702). 
Nine  years  later  the  patient  remained  free  from  an}'  return  of  the  disease.  In  the 
museum  of  St.  George's  Hospital  is  a  specimen  of  a  testicle  converted  into  a  mass  of 
soft  malignant  growth,  with  large  caseating  patches,  which  Mi.  Caesar  Hawkins 
removed  from  a  patient  aged  45,  the  enlargement  having  lasted  two  years.  Twelve 
years  later  this  patient  was  alive,  and  in  good  health.  In  the  Med.  Times  and  Qaz. 
188C,  vol.  ii.  p.  287,  a  ease  of  Mr.  Cock  is  mentioned  in  which  a  patient  remained  in 
good  health  for  six  years  alter  castration  for  "  medullary  Cancer,"  being  then  lost  sight  of 
in  consequence  of  his  emigrat  ion  to  Australia. 

While  these  cases  are  most  encouraging,  I  fear  they  are  exceptional. 
It  will  be  noticed  that  in  one  a  swelling  had  lasted  nine  months,  and 
in  another  two  years.  If  it  be  thought  that  such  cases  show  that  no 
limit  can  be  fixed  beyond  which  castration  must  be  useless,  the 
following  must  be  remembered.  First,  is  it  possible  that  the  earlier 
enlargement  was,  for  some  time  at  least,  inflammatory?  Secondly, 
as  a  rule,  in  the  softer  sarcomata,  enlargement  of  the  Lumbar  glands 
will  be  present  by  the  end  of  the  first  year  of  the  growth,  and  often 
earlier. 


*  I  quite  agree  with  Mr.  Butlin  (loc.  supra cit.)  that  early  enlargement  of  the  cord  is 
met  with  in  inflammatory  conditions  of  the  testicle,  and  is  here  a  contra-indication  to 

malignant  disease. 


CASTRATION. 


749 


As  m  rule,  the  retro-peritona>al  glands  and  viscera  will  be  involved 
by  extension  and  secondary  deposits  within  six  months  of  the  time  of 
castration.  And  this  result  is  the  more  disappointing  because  the 
testicle,  a  tree,  floating  organ,  and  one  placed  independently  in  a  fibrous 
capsule,  appears  to  he  remarkably  favourably  placed  tor  the  radical 
removal  of  malignant  disease.  The  intimate  association  of  the  organ 
with  the  lymphatic  system,  both  within  itself  and  with  those  within  the 
abdomen,  and  the  facility  with  which  these  are  early  implicated, 
handicap  us  terribly  here. 

But  if,  as  happens  most  frequently,  the  disease  recurs  elsewhere 
after  castration,  a  useful  life  may  yet  he  prolonged  ;  the  patient,  rid  of 
a  wearisome  encumbrance,  is  made  more  comfortable  ;  and  towards  the 
close  death  from  internal  deposits  of  malignant  disease  is  not  accom- 
panied with  the  same  distress  both  to  the  patient  and  those  around 
him  as  when  the  disease  is  situated  externally.  In  proof  of  the  tem- 
porary benefit  of  castration,  Mr.  Curling  (Diseases  of  the  Testis,  p.  342) 
relates  the  case  of  an  eminent  barrister,  wdio  for  two  years  and  a  half 
after  the  removal  of  a  testicle  for  soft  cancer  was  able  to  continue  the 
practice  of  his  profession  to  the  great  advantage  of  his  family,  death 
ultimately  taking  place  from  extension  to  the  lumbar  glands. 

II.  Tubercular  Testicle. — I  am  of  opinion  that  castration  should  be 
performed  much  earlier  in  this  disease  than  is  usually  the  practice,  in 
order  to  prevent  the  spread  of  the  disease  along  the  vas  deferens  to 
other  parts  of  the  genito-urinary  tract.  The  infection  travels  upwards 
to  vesiculse  seminalis  and  not  in  the  reverse  direction  (Baumgarten, 
German  Surg.  Congress,  1901).  Early  excision  of  the  epididymis  and 
the  diseased  part  of  the  vas  deferens  may  prevent  the  upward  spread, 
but  it  often  fails  to  prevent  local  recurrence.  Natural  cures  are  so  few, 
dissemination  is  so  frequent  and  so  grave,  whether  to  the  bladder  and 
kidneys,  vesicula3  seminales,  or  prostate,  or  to  the  lungs,  while,  on  the 
other  hand,  castration  is  nowadays  so  safe  an  operation,  that  it  should 
not  be  deferred.  Von  Bruns  (Cent.  f.  Cltir.,  July  20,  1901)  analyses 
the  results  of  11 1  castrations  for  tuberculosis  of  the  testicle.  The 
operations  were  performed  at  Tubingen  during  the  previous  fifty  years. 
Forty-six  per  cent,  of  the  patients  submitted  to  unilateral  orchidectomy 
remained  cured  from  three  to  thirty-four  years,  and  56  per  cent,  of  those 
submitted  to  castration  or  removal  of  both,  testicles  were  free  of  recurrence 
for  from  three  to  thirty  years. 

Early  phthisis  should  not  interfere  with  removal  of  a  tubercular 
testis  which  resists  treatment,  and  prevents  the  patient  getting  open-air 
exercise,  and  weakens  his  health  by  discharge.  Owing  to  the  condition 
of  the  lungs,  chloroform  should  be  here  given,  instead  of  ether. 

Tubercular  disease  of  the  prostate  is  a  source  usually  of  such 
extreme  misery,  that  any  existing  cause  in  the  testis  should  be  removed 
veiy  early.  Moreover,  from  what  we  have  learnt  from  castration  in 
enlarged  prostate  (p.  682),  removal  of  tubercular  testes  may  prevent  or 
greatly  delay  deposit  of  tubercle  in  the  prostate. 

I  have  only  space  to  mention  briefly  the  indications.  (1)  Where 
erasion  fails  in  lesions  still  limited  to  the  epididymis.  If  one  or  more 
discharging  fistulas  still  persist  here,  especially  if  the  patient  is  not  in  a 
position  to  avail  himself  of  a  repetition  of  erasion  and  dela}r,  castra- 
tion   should    be    performed,    slight    as   the    mischief   appears   to    be, 


750  OPERATIONS    ON    THE    ABDOMEN. 

especially  if  they  affect  the  patient's  health  or  interfere  with  the 
outdoor  exercise  so  necessary  in  these  cases.  It  is  only  too  probable 
that  minute  deposits  are  already  making  their  way  into  the  testicle  itself 
by  spreading  along  the  rete,  a  condition  impossible  to  recognise  by 
external  manipulation.  (2)  Where  after  erasion  any  fistula  has  bealed, 
hut  careful  watching  of  the  patient,  always  to  be  insisted  on,  detects 
the  existence  of,  it  may  he,  slight  hut  persistent  swelling  in  the  scrotum, 
with  night  sweats  and  loss  of  flesh.  These  may  point  to  mischief  in 
the  remains  of  the  sexual  gland,  and  not  necessarily  to  disease  in  the 
prostate,  &c,  or  in  the  lungs.  (3)  Where  the  body  of  the  testicle  is 
involved.  When  this  remains  enlarged,  and  liahle  to  attacks  of 
inflammation,  castration  should  be  performed.  (4)  Where  the  testicle 
remains  atrophied  and  riddled  with  fistula? ,  one  or  more  of  which 
persist  in  discharging,  removal  of  a  useless  and  dangerous  organ  should 
he  practised.  (5)  When  a  hydrocele*  is  present,  especially  if  purulent. 
When  both  testes  are  involved,  it  is  rarely  justifiable  to  remove  the 
two.  In  young  subjects  the  worst  may  be  removed,  and  the  diseased 
epididymis  and  vas  deferens  may  he  excised  on  the  least  affected  side, 
the  testicle  being  saved  for  its  internal  secretion. 

[f  the  va>  is  healthy  it  may  l>e  worth  while  to  implant  its  open  end  into  the  rete  testis 
or  the  globus  major  it'  that  body  is  healthy,  as  in  Hayne'scase  (Ann.  of  Surg.,  1905,  vol.  xli. 
p.  745).  The  anastomosis  failed  in  this  case,  for  the  semen  contained  im  spermatozoa. 
Martin,  however,  was  more  successful,  for  normal  semen  was  discharged  after  the  vas  had 
been  grafted  into  the  tail  of  the  epididymis. 

The  experiments  of  Bolojuhoff  upon  animals  had  already  proved  the 
possibility  of  successfully  joining  the  vas  to  the  epididymis  or  testicle. 

III.  Syphilitic  Testis. — Here,  owing  to  the  specifics  which  we  possess, 
castration  is  much  more  rarely  called  for.  The  indications  can  readily 
be  judged  of  from  those  above  given. 

IV.  Old  Hematocele. 

Indications. — Failure  of  previous  treatment,  especially  in  a  man  of 
middle  life  whose  activity — e.g.,  in  riding — is  much  interfered  with. 

The  frequency  with  which  malignant  disease  follows  on  repeated 
injury  and  irritation  of  the  testicle  is  well  known  (Rindfleisch,  Path. 
Hist.,  vol.  ii.  p.  197). 

V.  Retained  Testis. 

Indications. — (1)  When  such  a  testis  is  the  seat  of  malignant  disease. 
(2)  When  it  seriously  cripples  the  patient  by  the  recurrent  attacks  of 
inflammation  associated  with  it.  (3)  When  the  testis  gets  twisted  or 
strangulated  and  necrotic,  as  the  result  of  a  long  meso-testis  which 
commonly  exists  in  these  cases.  (4)  When  a  co-existing  hernia  cannot 
be  kept  up  by  a  truss  owing  to  the  presence  of  the  testis,  a  radical  cure 
of  the  hernia  should  be  undertaken,  and  if  the  patient  be  well  over 
puberty,  the  testis  should  be  removed,  for  it  is  very  unlikely  to  he 
functional,  and  therefore  it  is  not  worth  attempting  to  place  and  keep 
it  in  the  scrotum.  In  a  child  under  these  circumstances,  especially 
if  he  wishes  later  to  enter  one  of  the  public   services,  it  is  important 

*  On  the  subject  of  tubercular  hydrocele,  of  the  influence  <>f  co-existing  disease  in  the 
■  uhe  seniinales,   prostate,  and   lungs,  on  castration,    I    must   refer  my   readers  to 
chapter  vi.of  T7te  Diseases  of the  Male  Organs  of  Generation. 


CASTRATION. 


75i 


to  save  the  organ  and  perform  orchidopexy,  as  well  as  a  radical  cure 
of  the  hernia. 

VI.  Enlarged  Prostate. — This  operation,  which  was  much  resorted  to 
a  few  vcars  ago  chiefly  through  the  work  done  by  Prof.  -I.  William 
White,  of  Philadelphia  (Ann.  of  Surg.,  1893,  and  July,  1895),  has  been 
abandoned  owing  to  the  high  mortality  which  attended  it,  and  the 
uncertainty  and  incompleteness  of  the  relief  derived  from  it  (vide 
p.  682). 

Much  rarer  indications  are  : — VII.  Insanity,  chronic  epilepsy,  dc, 
kept  up  by  onanism.*  VIII.  Injury.  IX.  The  radical  cure  of  hernia 
— i.e.,  when  the  operation  cannot  he  completed  without  removal  of  the 
testis,  owing  to  the  firm  adhesions  of  the  sac  to  the  cord,  especially 


Fig.  297. f 


Castration,  scrotal  incision  for  large  growths  and  septic  conditions.  The  cord 
is  transfixed  and  tied  with  two  interlacing  catgut  sutures,  and  one  of  these  is 
afterwards  tied  round  the  whole  cord.  The  upper  end  of  the  incision  is  shown 
too  far  in. 

when  this  occurs  in  a  patient  approaching  middle  age.     It  is  always 
well  here  to  obtain  leave  for  castration. 

Operation  (Fig.  297). — Cases  in  which  sinuses  and  adhesion  of  the 
scrotum  exist,  or  very  large  growths  have  to  be  removed.  The  absence 
of  any  hernia  on  the  side  operated  on  having  been  ascertained,  and 
the  parts  duly  shaved  and  cleansed,  the  surgeon  protrudes  the  testicle 
with  his  left  hand  so  as  to  make  the  overlying  tissues  tense,  and  divides 
them   from  the   external   abdominal   ring,  prolonging  his  incision   as 


*  On  these  subjects  I  may  refer  my  readers  to  chapter  xii..  p.  477.  of  Diset ises  of  the 
Male  Organs  of  Generation. 

t  In  malignant  disease  the  incision  should  be  carried  up  much  higher  into  the  groin 
an. I  the  cord  tied  close  to  the  internal  ring.  To  prevent  a  hernia  the  layers  should  be 
sutured  according  to  the  directions  given  at  p.  87. 


752 


OPERATIONS  ON  THE  ABDOMEN. 


required  so  as  to  ensure  free  and  easy  drainage.*  In  cases  where  the 
Bkin  is  involved  by  a  growth,  ulcerated  by  a  hernia  testis,  or  invaded 
by  tubercle,  two  elliptical  incisions  should  be  made,  well  wide  of  the 
disease,  and  meeting  above  and  below.  The  first  incision  having 
exposed  the  cord  above,  this  is  defined,  and  the  scrotal  tunics  are 
quickly  shelled  oft'  with  the  right  hand,  while  the  testis  is  still  further 
protruded  with  the  left.f  The  spermatic  cord  is  now  isolated  as  high 
as  may  be  needful,  the  inguinal  canal  being  carefully  opened  upon  a 
director,  if  this  is  necessary  to  get  above  the  disease.  An  aneurysm- 
needle,  threaded  with  a  double  ligature  of  stout  sterile  catgut,  is 
passed  through  the  cord,  the  loop  of  the  ligature  cut,  the  needle 
withdrawn,  and,  the  cord  having  been  tied  in  two  halves,  the  ends  of 

Fig.  298. 


w 


Castration  through  an  inguinal  incision  for  clean  cases,  and  for  growths  which 
are  not  very  large. 

one  ligature  are  cut  short,  while  those  of  the  other  are  tied  round  the 
whole  cord  to  ensure  that  no  vessel  escapes.  The  cord  is  then  clamped 
and  divided  below,  but  not  too  near  to  the  ligatures,  which  may  otherwise 
slip.  If  no  bleeding  occurs  the  ends  of  the  ligature  can  be  cut  short, 
and  the  cord  thus  allowed  to  recede  out  of  sight.  The  cord  should 
not  be  divided  before  the  ligature,  for  the  latter  is  useful  to  keep  the 
stump  of  the  cord  from  receding  before  it  is  certnin  that  the  vessels 
have  been  efficiently  controlled.  The  ligatures  being  thus  embedded 
in  the  cord  substance,  there  is  no  risk  of  their  slipping,  and  if  they  be 
tied  as  tightly  as  possible  (by  looping  the  ligatures  round  two  pairs  of 


»  Kocher  makes  a  transverse  incision  across  tlu>  lower  pole  of  the  tr-ti>  in  septic  cases 
and  large  tumours.  The  incision  is  parallel  to  mosl  <>f  the  large  Bcrotal  vessels,  ami  little 
bleeding  occurs,  and,  above  all.  the  drainage  is  excellent. 

t  There  is  often  an  adhesion  below  between  the  testis  and  (lie  fundus  of  the  scrotum 
(Fig.  297).    This  represents,  according  to  some,  the  remains  "f  the  mesorchium. 


ORCHIDOPEXY.  753 

scissors  or  forceps),  there  is  no  danger  of  after-suffering.  Other 
methods  consist  in  securing  the  vessels  alone,  singly  by  torsion,  or  by 
chromic  gut,  or  by  fixing  the  cord  in  the  upper  angle  of  the  wound 
with  a  clamp.  The  mode  of  ligature  above  given  is  much  more  speedy 
and  also,  1  am  certain,  perfectly  efficient.  Securing  each  vessel  is 
tedious,  as  it  is  needful  to  make  sure  of  everyone,  even  when  they  are 
not  enlarged,  a  condition  not  infrequent  in  growths.  If  any  of  the 
arteries  are  left  unsecured,  dangerous  bleeding  when  tin-  cord  retracts 
upwards,  calling  for  laying  open  of  the  canal,  is  very  probable. 

The  cord  having  been  secured  and  divided  well  above  the  disease, 
the  mass  is  shelled  out  and  removed.  The  wound  is  then  examined  in 
the  case  of  a  soft,  rapid  growth,  and  where  a  tubercular  testis  has 
threatened  to  fungate,  any  suspicious  skin  must  be  clipped  away,  and  a 
sharp  spoon  freely  used. 

A  few  scrotal  vessels,  notably  one  in  the  septum,  may  require  securing. 
The  wound  is  then  closed  with  salmon  gut  and  horsehair,  pains  being 
taken  to  meet  the  tendency  of  the  scrotal  edges  to  invert. 

Every  precaution  should  be  taken  during  and  after  the  operation 
to  promote  rapid  healing,  especially  in  hospital  practice.  Patients  who 
have  to  submit  to  castration  are  often  reduced  in  health,  and  septic 
sinuses  are  often  present,  so  that  suppuration  is  apt  to  occur  unless  great 
care  is  taken  to  sterilise  the  parts  as  far  as  possible,  and  to  provide 
efficient  drainage ;  moreover,  septic  thrombosis  may  easiby  follow  a  wound 
made  in  a  region  so  abounding  in  lymphatics  and  loose  cellular  tissue. 
Just  before  the  operation  the  sinuses  should  be  cauterised,  so  that 
they  ma}'  not  infect  the  wound. 

In  clean  cases,  and  those  with  only  moderate  enlargement,  I  think 
very  highly  of  Kocher's  incision,  which  is  made  over  the  lower  part  of 
the  inguinal  canal  and  the  external  abdominal  ring  just  below  which 
the  intercolumnar  and  the  cremasteric  fasciae  are  divided  and  the  cord 
exposed  high  up  and  ligatured  and  divided  as  described  above.  The 
canal  must  be  opened  in  tuberculous  and  malignant  disease.  The 
testicle  is  then  shelled  out,  all  haemorrhage  stopped,  the  wound 
completely  sewn  up,  and  the  dressings  applied  firmly  to  prevent  any 
oozing.  The  advantages  of  Kocher's  incision  have  been  enumerated  at 
P-  743- 

ORCHIDOPEXY. 

Indications  for  Operation. — (1)  The  co-existence  of  a  hernia,  which 
cannot  be  retained  properly  on  account  of  the  malplacement  of  the 
testis.  In  very  nearly  all  the  cases  a  potential  hernial  sac  exists,  so 
that  a  hernia  may  develop  at  any  time  in  those  in  which  the  serous 
canal  is  sufficiently  wide  or  distensible.  Such  a  hernia  is  peculiarly 
apt  to  become  strangulated  on  its  first  descent. 

(2)  Attacks  of  pain,  either  from  twisting  of  a  long  mesorchium, 
which  is  commonly  present,  or  from  nipping  at  the  external  ring,  or 
pressure  within  the  canal.  Strangulation  and  gangrene  of  the  testicle 
may  occur  from  twisting. 

(3)  Age.  It  is  rarely  of  use  to  attempt  to  bring  the  testis  clown  after 
puberty  (vide  infra).  It  is  better  to  remove  it  after  this  age,  when  it 
causes  trouble. 

s. — vol.  11.  48 


754  OPERATIONS    ON    THE    A.BDOMEN. 

(4)  The  BiirgeoD  may  decide  to  perform  orchidopexy  in  a  child  even 
it' tin  testis  is  a  good  deal  smaller  than  the  other  was  when  it  is  known 
thai  the  hoy  is  intended  for  the  army  or  navy  later  on. 

(5)  Retention  in  the  canal  or  at  the  external  ring,  but  not  when  the 
testis  is  within  the  abdomen. 

The  following  account  of  this  operation  is  extracted  from  that  given 
in  Diseases  of  the  Male  Organs  of  Generation. 

One  or  two  preliminary  questions  arise  here:  What  is  the  value 
of  the  retained  or  ectopic  testicle?  At  what  age  ought  the  operation 
to  be  performed '?  These  may  be  answered  together.  It  will  be 
seen  by  reference  to  the  account  given  at  p.  45  Diseases  of  Male  Organs 
of Generation  of  the  condition  of  the  retained  or  ectopic  testicle,  if  nothing 
be  done,  that  the  following  are  certain  :  (a)  that  such  a  testicle 
ultimately  becomes,  and  usually  before  adult  life  is  reached,  physio- 
logically useless;  (b)  that,  as  some  of  the  cases  I  have  given  show, 
during  the  early  years  of  life  the  testicle,  though  ill  developed,  may 
be  capable,  under  more  natural  surroundings,  of  becoming  a  useful 
organ  ;  (c)  that  the  period  in  which  the  testicle  passes  from  a  pro- 
bably useful  into  a  useless  state  must  be  an  uncertain  one,  varying  with 
the  attacks  of  inflammation,  &c.  Most  French  surgeons  have  advised 
deferring  the  operation  until  the  age  of  about  16,  as  up  till  this  time  a 
retained  testicle  may  still  descend.  While  this  is  true,  I  should  strongly 
advocate  resort  to  operation  at  an  earlier  date,  a  step  which  I  have  taken 
in  the  cases  given  below,  on  the  following  grounds  :  It  must  always  be 
quite  uncertain  at  what  date  structural  changes  marring  the  efficiency 
of  a  testicle  have  set  in.  These  must  depend  on  the  number  of  recurrent 
inflammatory  attacks,  and  children  are  certainly  not  exempt  from  these. 
Again,  in  cases  complicated  with  a  hernia,  the  longer  an  operation  is 
deferred  the  more  difficult  will  it  be  to  ensure  a  radical  cure.  Moreover, 
a  condition  of  this  kind,  interfering  as  it  may  do  with  activity  and 
enjoyment  of  life,  schooling,  apprenticeship,  &c,  should  be  put  right  as 
soon  as  possible.  Finally,  if  the  testicle's  growth  and  development  are 
to  be  furthered  by  the  transplantation — and  this  is  one  great  object  of 
the  operation — it  is  surely  more  probable  that  this  end  will  be  secured 
by  bringing  the  testicle  into  its  natural  home  before  puberty,  that 
important  epoch,  and  its  consequent  sexual  changes  have  set  in.  I 
should  prefer  operating  between  the  ages  of  8  and  9,  though  in  the 
case  of  the  children  of  the  poor,  where  time  is  of  great  importance,  I 
should  consider  it  quite  justifiable  to  operate  earlier,  especially  if  there 
has  been  any  attack  of  pain,  or  if  a  troublesome  hernia  co-exists.  Before 
the  age  of  2  or  3  years  the  small  size  of  the  parts,  their  fragility  as  far 
as  holding  sutures  go,  and  the  difficulty  of  maintaining  asepsis  are 
contra-indications  to  operative  interference. 

The  following  account  will  be  found  to  apply  both  to  the  case  of  a 
child  and  that  of  an  adolescent. 

The  bowels  having  been  well  moved  for  a  day  or  two  before,  the  parts 
duly  cleansed  and  shaved  if  needful,  an  incision  is  made  with  the  ex- 
ternal ring  for  its  centre,  as  retention  near  this  spot  is  the  condition 
most  frequently  calling  for  operation.  This  incision  can  be  prolonged 
upwards  and  downwards  if  needful,  but  needless  weakening  of  the 
abdominal  wall  can  often  be  avoided  by  dragging  up  or  down  the  two 
angles  of  the  wound  with  retractors,  invaginating  the  scrotum,  &c. 


ORCHIDOPEXY. 


755 


In  oases  of  inguinal  retention  the  testicle  is  reached  after  division  of 
the  externa]  oblique  and  intercolumnar  fascia. 

The  following  points  have  now  to  be  inquired  into : — What  is  the 
arrangement  of  the  peritonaeum?  Is  the  serous  sac  which  surrounds  the 
testicle  continuous  with  and  common  to  the  peritoneal  cavity  or  separated 
from  it  hy  obliteration  of  the  funicular  portion  in  part'/'  The  sac 
around  the  testicle  or  any  prolongation  upwards  having  been  opened, 
the  above  question  is  settled.  It'  the  peritonseal  process  is  open,  it 
should  be  divided  circularly  with  great  care,  so  as  to  avoid  the  cord,  a 
little  above  the  testicle.  While  the  lowest  part,  thus  left,  is  fashioned 
by  a  few  catgut  sutures  into  a  tunica  vaginalis,  the  upper  part  is  freed 
most  carefully  from  its  surroundings  as  high  as  the  internal  ring,  where 
it  is  secured  by  ligature  or  torsion,  as  the  surgeon  prefers.  If  the  peri- 
toneal canal  is  found  to  be  closed  in  the  inguinal  canal  and  above  the 
testicle,  it  must  be  treated  by  the  steps  already  given  after  its  closed 
lower  end  has  been  found  and  the  process  freed.  Care  must  always  be 
taken  to  extirpate  this  process  as  far  as  possible  and  to  close  it 
thoroughly,  as  by  this  precaution  an  important  obstruction  is  placed 
in  the  way  of  the  testicle's  remounting.  Is  a  hernia  present?  If  so, 
any  adhesions  to  the  testicle  being  separated,  this  is  returned  in  the 
usual  way.  But  the  presence  of  a  hernia  must  always,  especially  where 
there  is  any  doubt  as  to  the  condition  of  the  testicle,  incline  the  surgeon 
to  sacrifice  the  testicle  and  his  hope  of  transplantation,  and  thus  make 
sure  of  radically  curing  the  far  more  important  trouble.  Will  it  be 
possible  to  bring  the  testicle  satisfactorily  down  into  the  scrotum  ? 
How  best  will  it  be  retained  there  ?  All  adhesions  should  be  divided 
as  freely  as  possible,  the  position  of  the  cord  being  first  defined.  Where 
the  cord  seems  at  first  short,  careful,  sustained  downward  traction  will 
often  be  of  much  assistance.  When  the  testicle  has  been  coaxed  or 
pushed  through  the  external  ring,  a  bed  must  be  prepared  for  it,  if 
needful,  with  the  finger  in  the  scrotum.  This  is  then  invaginated 
with  the  tip  of  a  finger,  and  the  tissues  thus  presented  sutured  to  the 
testicle  with  chromic  gut.  The  suture  should  always  be  passed  boldly, 
dipped  well  into  the  connective  tissue  of  the  invaginated  fundus  scroti 
on  the  one  hand,  and  into  the  tunica  albuginea  of  the  testicle  or  the  tail 
of  the  epididymis  on  the  other.  I  prefer  this  method  of  invagination  to 
that  of  passing  the  suture  through  the  scrotum  from  without  inwards, 
then  next  into  the  tunica  albuginea,  then  out  of  the  scrotum  again,  and 
tying  the  ends  over  a  pad  of  gauze.  Finally,  when  the  testis  is  in 
situ,  the  internal  oblique  and  conjoined  tendons  are  sewn  down  to  the 
upturned  edge  of  Poupart's  ligament  in  front  of  the  cord.  The  cord  is 
not  dislocated,  because  that  would  make  it  too  short  to  reach  into  the 
scrotum.  The  cord  should  be  sutured  to  the  pillars  of  the  ring  with 
fine  catgut  or  silk,  the  vas  and  the  spermatic  artery  also,  if  possible, 
being  made  out  and  inspected.  Then  this  ring  should  be  carefully 
closed  with  catgut,  its  pillars  being  first  defined. 

After  the  testicle  has  thus  been  fixed  the  wound  is  carefully  dried, 
all  bleeding  arrested,  the  wound  closed,  and  the  dressings  applied. 

"Writing  in  igoi,  Mr.  Jacobson    wishes    to    state    that    his    later 
experience  tends  to  show  that  this  operation  is  of  very  little  value. 

*  In  the  great  majority  of  cases  the  funicular  process  is  patent,  i.e.,  a  potential  hernial 
sac  exists,  am  I  this  is  one  of  the  chief  reasons  for  operating. 

48—2 


756         OPERATIONS  ON  THE  ABDOMEN. 

Supposing  a  Bcroturn  to  be  present,  everything  depends  on  whether  the 
conl  is  long  enough  to  allow  of  the  testis  resting  in  the  scrotum  without 
any  tension.  As  a  rule  to  which  there  are  very  few  except  ions,  this  is 
not  the  case.  <  > n L  of  seven  cases  he  has  had  only  one  permanent  and 
real  success. 

A  l)  iy,  set.  ii.  with  iliac  retention  on  the  right  Bide,  had  been  refused  admission  to  the 
Royal  Navy.  The  scrotum  was  developed.  At  the  operation  a  rery  unusual  condition 
was  Eound,  viz.,  a  loop  of  lax  consl  ituents  of  the  cord  where  they  met  at  the  internal  ring. 
T!i>'  testis  was  easily  brought  down  ami  secured  in  the  scrotum,  the  layers  of  the  abdominal 
wall  being  sutured  much  as  in  the  radical  cure  of  hernia.  Two  years  later  the  boy  was 
serving  on  the  North  American  station. 

On  the  other  hand,  Mr.  Jacobson  has  known  a  testis  fixed  in  the 
scrotum  reascend  a  year  and  a  half  later,  during  the  pyrexia  of  an 
attack  of  influenza. 

The  tendency  of  the  testicle  to  retract  and  even  to  re-enter  the 
inguinal  canal  is  so  great,  that  I  have  adopted  the  following  method 
in  several  cases  with  gratifying  results.*  An  inguinal  incision  is  made 
and  the  canal  is  opened  in  all  cases.  The  cremasteric  and  infundibuli- 
form  fascia)  are  incised  freely  and  separated  from  the  cord.  The 
funicular  process  of  peritonaeum  is  followed  up  beyond  the  internal 
ring,  transfixed,  ligatured,  and  divided  as  described  at  p.  77. 

The  cord  and  testis  are  then  freed,  and  traction  is  made  upon  them, 
while  any  retaining  bands  of  cremasteric  and  infundibuliform  fasciae  are 
divided,  scissors  beginning  antero-externally.  If  necessary,  some  of 
the  veins  are  then  divided  between  two  pressure  forceps  and  tied  with 
catgut,  more  being  divided  until  the  testis  can  be  easily  placed  in  its 
natural  position  without  any  tension.  The  vas  is  rarely  too  short  to 
allow  this,  so  that  it  is  not  necessary  to  adopt  Wood's  method  of  sepa- 
rating the  globus  major  from  the  testis  and  fixing  the  latter  upside  down 
in  the  scrotum.  If  the  vas  is  not  long  enough,  a  little  traction  and 
gentle  blunt  dissection  around  it  above  the  internal  ring  will  liberate 
some  of  the  pelvic  part  of  the  duct. 

Care  must  be  taken  not  to  divide  or  injure  the  delicate  connective 
tissues,  vessels,  and  sympathetic  nerves  which  surround  the  vas  itself, 
lest  atrophy  of  the  testicle  ensue.  In  two  of  my  cases  little  else  than 
the  vas  and  the  structures  mentioned  were  left  undivided,  and  yet  the 
testis  came  to  no  harm  beyond  some  transient  orchitis.  The  internal 
oblique  and  conjoined  tendons  are  then  sewn  down  to  the  deep  surface 
of  Poupart's  ligament.  The  cord,  or  what  remains  of  it,  is  not  dislo- 
cated, so  that  it  may  not  be  shortened.  The  wound  in  the  external 
oblique  is  closed,  care  being  taken  to  make  quite  a  small  external  ring. 

The  fibrous  tissues  of  the  cord  may  be  sutured  to  the  margins  of  the 
ring  in  some  cases.  The  parietal  part  of  the  tunica  vaginalis  is  excised, 
so  that  the  testicle  may  adhere  to  the  scrotal  tissues,  instead  of 
slipping  up  within  a  serous  sac.     A  new  bed  is  made  for  the  testicle  by 

*  No  claim  of  originality  is  made  for  this  operation,  which  is  a  composite  one,  based 
on  the  work  of  others.  Dr.  Bevau  {.hum.  Amer.  Med.  Atsoe.,  Sept.  19,  1903) 
describes  a  similar  method,  but  he  does  not  remove  the  parietal  tunica  vaginalis,  nordoes 
he  take  the  same  measures  to  prevent  the  reascenl  of  the  testis.      Dowden  [Brit,  Med. 

Journ.  April  29,  1905)  has  removed  the  parietal  tunica  vaginalis  and  scraped  the  visceral 

Layer. 


m:ciiii>nPKXY. 


757 


means     of    a    gloved'      linger     passed    down     into     the    scrotam. 

A  stout  catgut  suture  threaded  on  a  long  straight,  needle  is  passed 
from  side  to  side  through  the  part  of  the  testicle  which  can  he  brought 
lowest,  hut  well  away  from  the  epididymis  and  the  vas  deferens.  The 
two  ends  of  the  thread  are  then  brought  out  through  the  Lower  end  of 
the  new  scrotal  sac,  by  means  of  the  long  straight  needle  which  is 
guided  by  the  linger.  Traction  is  made,  upon  hoth  ends  so  as  to  bring 
the  testis  down  to  its  normal  position.  The  suture  is  tied  loosely  overa 
small  piece  of  cyanide  gauze  placed  outside  the  scrotum. 

At  the  end  of  the  operation  the  long  ends  are  fastened  to  a  circlet  ;t 
placed  low  down  upon  the  opposite  thigh,  which  is  kept  fixed  to  the  bed. 

The  suture  is  only  tied  sufficiently  tightly  to  keep  the  testicle  and 
scrotum  well  down  during  the  healing  of  the  wound,  and  for  about 
a  week  or  ten  days  afterwards ;  cyanide  powder  is  dusted  over  the 
scrotal  punctures. 

The  after-treatment  is  very  important,  for,  as  the  new  connective 
tissues  in  the  depth  of  the  healed  wound  along  the  cord  tend 
inevitably  to  contract,  the  testicle  is  drawn  upward  towards  the  groin. 
This  slow  but  powerful  force  must  be  counteracted  by  daily  traction  for 
at  least  three  or  four  months,  one  or  both  parents  being  carefully 
instructed  how  to  do  this  and  also  impressed  with  the  importance  of  it. 

Mr.  Corner  (Brit.  Med.  Journ.,  June  4,  1904)  prefers  replacement 
of  the  retained  testis  within  the  abdomen  to  orchidopexy,  because 
he  believes  that  the  retained  testis  rarely  becomes  functional,  and  that 
the  internal  secretion  of  the  organ  is  retained  just  as  well  after 
abdominal  replacement.  I  do  not  agree  with  these  views,  but  prefer 
to  j>erform  orchidopexy  for  suitable  cases,  for  this  is  more  likely  to  be 
followed  by  development  of  the  testis,  if  undertaken  well  before  the 
age  of  puberty.  Experiments  upon  animals  tend  to  show  that  the 
normal  testis  atrophies  if  replaced  within  the  abdomen  before  the  age 
of  maturity. 

*  Gloves  are  used  because  absolute  asepsis  is  essential  for  the  success  of  the  operation. 
Failure  of  asepsis  may  lead  to  sloughing  of  the  testis, 
t  This  is  simpler  and  better  than  a  wire  scrotal  cage. 


CHAPTER  XV. 
OPERATIONS  ON  THE  ANUS  AND   RECTUM. 

FISTULA.— HAEMORRHOIDS.— FISSUKE.— PROLAPSUS.— 

EXCISION      OF      THE     RECTUM.— IMPERFORATE      ANUS. — 

ATRESIA    ANI.— IMPERFECTLY    DEVELOPED    RECTUM. 

FISTULA. 

Varieties. — As  these  have  a  very  practical  bearing  upon  the  operation, 
the)'  must  be  alluded  to  here. 

i.  Complete,  ii.  Blind  External. — Here  an  external  opening  only 
exists,  though  in  a  considerable  number  of  cases  the  internal  opening  is 
overlooked,  iii.  Blind  Internal — An  opening  through  the  mucous 
membrane  is  here  the  only  one.  This  is  the  rarest,  but  an  important 
variety,  as,  if  overlooked,  it  is  certain  to  be  troublesome. 

A  discoloured  dot  or  patch  of  skin  sometimes  marks  the  place  where  an 
external  opening  may  occur.  Mr.  Lund  (Hunt.  Lect.,  p.  88)  relates  a 
case  in  which  a  very  chronic  and  slowly  advancing  blind  internal  fistula 
had  excited,  by  its  extreme  end,  just  enough  inflammatory  thicken- 
ing of  the  skin  to  imitate  a  keloid  growth,  for  which  it  was  ut  first 
mistaken. 

Situation  of  Openings. — Both  of  these  are  usually  within  an  inch, 
more  often  half  an  inch,  of  the  anus.  The  internal  one  may  be  detected 
as  a  slight  depression  or  papilla  by  the  finger,  or  by  the  speculum,  or, 
in  obscurer  cases,  by  the  sigmoidoscope. 

Horseshoe  Fistula. — Here  an  external  opening  on  either  side  com- 
municates with  a  single  internal  one,  often  at  the  back.  This  is  an 
uncommon,  but  an  important  variety,  for  if  it  is  found  necessary  to 
cut  through  the  sphincter  ani  at  both  sides,  some  loss  of  power  is  very 
likely  to  ensue.  This  risk  should  be  explained  to  the  patient,  and  the 
shallower  fistula  should  be  scraped,  while  the  deeper  is  freely  incised. 
If  it  is  necessary  to  cut  the  sphincter  on  both  sides,  the  knife  should  be 
employed  on  two  distinct  occasions,  time  being  given  for  the  first  to 
heal.*  It  is  better  to  make  a  free  opening  on  one  side,  and  to  scrape 
and  pack  the  other  limb  of  the  fistula  from  the  opening. 

Multiple  Fistula. — This  condition  should  always  cause  a  suspicion  of 
stricture,  or  extensive  ulceration — e.g.,  syphilitic,  &c. 


*  Mr.  Cripps  {Dis.  of  Rectum  and  A/n/s.  p.  1651  -hows  that  if.  in  women,  tlie  Bphinctei 
is  cut  through  anteriorly  where  it  decussates  with  the  sphincter  vaginae,  incontinence  «>f 
freces  is  very  likely  to  take  place. 


FISTULA.  759 

Fistula  with  Tuberculosis. — Where  a  fistula  presents  an  external 
opening  with  undermined,  livid  edges,  where  the  tubera  ischii  stand 
out  prominently  from  emaciated  nates,  and  where  the  hair  of  the  part  is 
long  and  curled,  tuberculosis  is  always  to  he  suspected,  even  if  no  history 
of  cough  or  haemoptysis  is  given. 

Question  of  Operating  on  Phthisical  Patients. — While  each  case  must 
he  decided  by  itself,  the  following  remarks  may  he  useful : — 

Where  the  phthisis  is  advanced,  the  cough  incessant,  the  fistula 
multiple  or  branched,  an  operation  is  out  of  the  question.  On  the 
other  hand,  where  the  physical  signs  are  little  marked,  night  sweats 
slight  or  absent,  where  the  fistula  interferes  with  the  patient  taking 
the  all-essential  exercise,  where  the  power  of  repair  is  good,  an 
operation  is  indicated. 

In  cases  intermediate  between  the  above,  each  one  must  be  decided 
upon  its  own  merits. 

Before  operating  the  surgeon  should  remember  that  repair  is  here 
often  sluggish,  the  mental  condition  much  depressed.  He  should  do  all 
he  can  to  improve  the  general  condition  before  and  after  the  operation. 
And  if  this  can  be  performed  in  sunny  weather,  or,  better  still,  at  the 
seaside,  so  that  the  patient  can  soon  have  fresh  air  in  the  recumbent 
position,  so  much  the  better. 

Operation. — For  a  few  days  before  the  operation  the  diet  should  be 
restricted,  and  the  bowels  emptied  by  aperients.  The  hour  of  the 
operation  should  be  so  arranged  as  to  give  time  for  the  enema,  which 
should  be  given,  to  come  away.  The  patient  being  under  an  amesthetic, 
and  either  on  his  side  with  the  knees  well  flexed,  or  in  lithotomy 
position,  the  surgeon  introduces  lightly  a  fine  Brodie's  probe.  In  the 
case  of  a  complete  fistula,  the  internal  opening  being  hit  off  (p.  758),  the 
point  of  the  probe  is  felt  for  by  the  finger  and  hooked  out  of  the  anus. 
If,  after  careful  examination,  the  surgeon  is  satisfied  that  no  internal 
opening  exists,  he  makes  one  by  finding  the  exact  spot  at  which  the 
coats  of  the  bowel  are  most  thinned,  and  thrusting  the  point  of  the 
probe  through  here. 

In  the  case  of  a  blind  internal  fistula  the  internal  opening  must  be 
found  with  a  speculum,  and  the  probe,  curved,  passed  from  this  so  as  to 
project  beneath  the  skin.  In  every  case  the  whole  length  of  the  sinus 
between  skin  and  bowel  must  be  completely  laid  open.  When  this  has 
been  done,  very  careful  examination  is  made  for  other  sinuses  by  the 
introduction  of  the  probe,  and  by  pressure  with  the  finger,  which 
squeezes  out  any  discharge,  and  feels  for  indurated  tracks.  Wherever 
these  run  they  must,  if  possible,  be  laid  open.  I  have  already  (p.  758) 
alluded  to  the  question  of  dividing  the  sphincter  in  two  places.  It  is 
also  important  not  to  carry  the  incision  higher  into  the  bowel  than  is 
absolutely  necessary  ;  but  free  drainage  must  be  provided  by  prolonging 
the  incision  far  enough  outwards  into  the  ischio-rectal  fossa.  Every 
attempt,  however,  should  be  made,  with  the  aid  of  a  good  light  and 
forcible  dilatation  of  the  sphincter,  to  lay  open  every  sinus  with  bistoury 
or  scissors,  extra  care  being  taken,  the  higher  the  incision  has  to  be 
carried,  to  arrest  all  bleeding  with  sterilised  silk  ligatures. 

While  the  sinuses  are  being  followed  up,  any  old  gristly  tissue  must  be 
completely  removed,  all  pyogenic  or  granulation  tissue  entirely  scraped 
out,  and  every  ill-nourished  flap  and  tag  of  undermined  skin  cut  away. 


760  OPERATIONS  ON  THE  ABDOMEN. 

If  any  troublesome  piles  co-exist  they  should  be  tied  and  cut  away  at 
the  same  time  (p.  761). 

Asa  dressing  I  prefer  a  little  twisted  salicylic  wool  dusted  with  iodo- 
form, as  I  find  this  adapts  itself  more  easily  to  the  different  wounds. 
Less  and  less  should  be  reapplied  daily  as  granulations  become 
established.  After  the  first  week  little  more  is  needed  than  daily 
cleansing  of  the  wound  with  a  dossil  of  cotton  wool  on  a  Playfair's 
probe.  If  the  edges  of  the  wound  close  too  soon  they  should  be 
separated  with  a  probe  from  time  to  time,  or  any  redundancy  may  be 
painted  with  cocaine  and  snipped  away.* 

Finally,  no  operation  better  exemplifies  the  truth  of  Mr.  Curling's 
saying  that  the  surgeon  should  be  his  own  dresser. 

Immediate  Union  of  Fistulse. — Mr.  Beeves  recommended  this 
treatment  some  years  ago  (Brit.  Med.  Journ.,  vol.  i.  1887,  p.  917).  It 
certainly  has  the  advantage  of  often  shortening  the  treatment  greatly, f 
and  preventing  loss  of  sphincter  power,  but  at  the  risk  of  two  dangers  : 
(1)  Sepsis.  (2)  The  part  within  the  bowel  is  sometimes  difficult  to 
suture  satisfactorily,  and  may  persist  as  a  sinus  later.  The  method 
may  be  tried  in  simple  cases  which  do  not  extend  far  into  the  bowel. 

Operation. — The  anus  having  been  well  dilated,  the  fistula  is  laid 
open,  thoroughly  scraped  out.  Any  skin  or  mucous  membrane  which  is 
unhealthy  or  which  will  get  between  the  edges  of  the  wound  must  be 
snipped  away,  the  bleeding  stopped,  the  wound  well  irrigated  with  lot. 
by  dr.  perch.  (1  in  4,000)  and  well  dried  out.  It  is  then  united  in  its 
whole  extent  by  sutures  of  salmon-gut  or  sterilised  silk.  The  sutures 
must  underrun  the  wound,  so  that  the  depth  of  the  latter  may  be 
efficiently  closed.  These  are  left  in  for  a  week  or  ten  days.  During 
this  time  the  bowels,  which  have  been  previously  (daily)  thoroughly 
emptied,  must  not  act.  A  glycerine  or  oil  enema  must  prevent  any 
passage  of  scybala  and  straining  at  the  time  of  the  first  relief. 

HEMORRHOIDS. 

Indications. 

1.  Continuance  of  haemorrhage  or  discharge,  and  persistent  liability 
to  descent  of  piles  in  spite  of  judicious  treatment.  Prolapse  of  the 
haemorrhoids  may  interfere  with  sitting,  walking,  and  riding. 

2.  Repeated  attacks  of  strangulation  and  thrombosis  of  the  prolapsed 
piles. 

3.  Severe  pain  from  associated  fissure  of  the  anus,  or  prolapse  of 
the  rectal  mucosa. 

4.  Absence  of  albuminuria,  diabetes,  and  hepatic  (probably  cardiac) 
disease. 

5.  Amenability  on  the  part  of  the  patient. 

In  Mr.  Cripps's  words  {loc.  supra  cit.,  p.  99),  "the  smallness  of  the 
risk  should  not  lull  the  surgeon  into  a  sense  of  absolute  security,  and 
he  should  spare  no  effort  in  ascertaining  the  general  constitutional  con- 
dition of  his  patients.  .   .   .   The  amount  of  risk,  Blight  as  it  is,  should 

*  Another  excellent  dressing,  later  on,  is  tr.  benz.  co.  or  dilute  nitric  acid  lotion 
10  minims  to  i  oz.     The  latter  needs  changing  every  four  hours. 

t  It  is  right  to  add  that  the  tediousness  of  the  after-treatment   is  often  due  to  the 

patient  refusing  to  lie  up,  or  to  inefficient  attention  on  the  part  of  the  surgeon  himself. 


HEMORRHOIDS. 


761 


Fig.  299. 


be  clearly  laid  before  the  patient  or  his  friends.  If  a  man  is  to  have 
some  grave  operation  performed,  such  as  the  removal  of  a  cancer  or  1 1 1 « - 
amputation  of  a  limb,  both  he  and  his  friends  are  well  aware  of  tin 
risk  involved,  and  are  accordingly  prepared.  It  is,  therefore,  in  the 
smaller  operations,  regarded  by  the  surgeon  and  public  as  free  from 
danger,  that  a  fatality,  when  it  does  occur,  becomes  so  tragic  from 
being  unexpected." 

Operations. 

Ligature  and  Excision. — Cautery. — Excision  and  Suture. — White- 
head's Operation. 

i.  Ligature. — I  have  placed  this  first,  because,  if  properly  used,  it  is 
a  very  easy,  rapid,  and  good  method.  Here,  as  elsewhere,  that  surgeon 
will  have  the  best  results  who  has  thoroughly  familiarised  himself  with 
the  details  of  one  operation.  The  following  appears  to  me  to  be  a  fair 
way  of  putting  the  merits  of  ligature  and  the  other  operations  : — 

i.  In  my  opinion  the  ligature  is  more  generally  suited  to  all  cases. 
Again,  it  can  be  more  easily  applied 
to  piles  high  up  than  can  the 
cautery.  2.  No  special  instruments 
are  needed.  3.  A  ligature  applied 
is  done  once  for  all ;  the  cautery 
may  have  to  be  reapplied  more  than 
once  if  bleeding  follows  when  the 
clamp  is  unscrewed.  4.  The  risk 
of  bleeding  is  less,  and  hence  this 
method  is  especially  advantageous 
in  anaemic  patients,  and  in  those 
for  whom  it  might  be  difficult  to 
immediately  obtain  surgical  aid 
(Allingham).  5.  The  ligature  is 
free    from    the    objections    to    the 

cautery  in  private  practice — viz.,  the  smell,  and,  unless  a  Paquelin's 
cautery  is  at  hand,  the  cumbersome  apparatus  otherwise  rarely  used. 

Operation. — The  preparatory  treatment  is  that  given  at  p.  759. 
The  patient  being  on  his  left  side,  or  in  the  lithotomy  position,  the 
anus  should  always  be  dilated.  This  may  be  done  by  introducing,  and 
then  separating  laterally,  the  two  thumbs  (Fig.  299),  the  pressure  being 
steadily  maintained  so  as  not  to  rupture  the  mucous  membrane.  After 
a  few  minutes  a  sensation  of  yielding  rather  than  of  tearing  is  per- 
ceived. Another  method  is  to  introduce  a  large  bi-  or  multi-valve 
vaginal  speculum,  and  to  withdraw  this  expanded.*  When  the 
sphincters  are  thoroughly  dilated  and  the  rectum  is  cleansed,  the  piles 
which  lie  lowest  according  to  the  patient's  position  1  are  drawn  down 
with  a  vulsellum  or  tenaculum-forceps,  and  the  surgeon  with  blunt- 
pointed  scissors,  curved  on  the  flat,  cuts  a  groove  around  the  lower 
two-thirds  of  the  pile,  which  is  then  separated  for  this  distance  from 


Forcible  dilatation  of  the  sphincters. 
(Esmarch  and  Kowalzig.) 


*  Eversion  of  the  rectal  mucous  membrane  by  the  finger  in  the  vagina  will  often  be 
most  helpful  in  bringing  piles  within  reach. 

t  This  prevents  the  other  hasmorrhoids  being  obscured  with  blood.  Mr.  Allingham 
advises  that  the  smallest  piles  should  be  taken  first,  as  there  is  a  danger  of  these  being 
overlooked  and  thus  leading  to  a  recurrence  of  the  disorder. 


762  OPERATIONS   ON   THE   ABDOMEN. 

the  sub-mucous  and  muscular  coats  by  blunt  dissection.  In  the  lower 
piles  this  groove  should  commence  in  the  sulcus,  which  marks  the 
junction  of  skin  and  mucous  membrane  close  to  the  anus.  The  object 
of  this  deep  groove  is  twofold  :  it  forms  a  bed  in  which  the  ligature 
can  be  sunk  tightly,  and,  above  all,  it  leaves  a  very  small  pedicle  of 
tissues  to  be  strangled.  The  groove,  moreover,  can  be  cut  without 
risk  of  hemorrhage,  as,  however  large  the  pile,  its  vessels  enter 
it  from  above,  running  into  its  upper  part  just  beneath  the  mucous 
membrane.  The  surgeon  then  ties  round  each  pile,  which  is  now 
still  further  dragged  down,  a  ligature  of  sterilised  silk,  the  strength  of 
which  he  has  previously  tested.  Sinking  this  into  the  groove,  he 
tightens  it  up  so  as  to  embed  his  ligatures  firmly,  without  cutting 
through  the  pedicle.  About  two-thirds  of  the  pile  are  then  cut  away, 
enough  being  always  left  to  ensure  a  safe  hold  for  the  ligature.  In 
Allingham's  Diseases  of  the  Rectum  (p.  146),  the  following  most  important 
practical  point  is  insisted  on.  When  the  piles  are  separated  from  the 
bowel  preparatory  to  applying  the  ligature,  it  is  essential  that  the  base 
to  be  ligatured  should  be  as  narrow  as  is  consistent  with  safe  securing 
of  its  blood-supply.  For  if  many  piles  have  to  be  tied,  and  their  bases 
are  left  large  and  broad,  when  tied  up  they  draw  the  mucous  membrane 
together,  and  cause  great  narrowing  of  the  rectum.  In  such  a  case  it  is 
almost  impossible  to  introduce  the  finger,  without  force,  beyond  the 
parts  tied.  In  other  words,  islets  of  untied  mucous  membrane,  as  wide 
as  possible,  should  always  be  left  between  the  tied  piles.  This  will 
secure  less  pain,  easier  action  of  the  bowels,  and  less  risk  of  contraction. 
After  every  internal  pile  has  been  carefully  treated  in  this  way,  the 
external  ones  are  partly  clipped  away,  care  being  taken  not  to  encroach 
upon  the  junction  of  skin  and  mucous  membrane,  and  not  to  remove 
subcutaneous  tissue  for  fear  of  subsequent  contraction.  If  any  bleeding 
points  still  persist,  they  should  now  be  tied.  The  ligatures  are  all  cut 
short,  and,  lastly,  the  stumps  of  the  piles,  after  thorough  irrigation  with 
lot.  hydr.  perch.  (1 — 4,000)  and  rubbing  in  of  iodoform  powder,  are 
returned.  A  morphia  suppository  is  then  introduced,  strips  of  iodoform 
gauze  wrung  out  of  carbolic  acid  lotion  applied,  and  firm  pressure  made 
with  a  T-bandage  and  the  aid  of  a  pad  of  salicylic  wool.  To  hasten 
healing  and  prevent  contraction,  I  generally  close  the  longitudinal 
wound  left  after  the  excision  of  each  pile  by  suturing  it  in  a  transverse 
direction  with  a  continuous  catgut  suture.  The  ligature  upon  the 
stump  of  the  hemorrhoid  is  thus  brought  down  to  the  anal  margin. 
When  many  haemorrhoids  have  to  be  removed  this  simple  plan  prevents 
any  narrowing  of  the  orifice. 

ii.  Clamp  and  Cautery. — This  method  has  been  perfected  by  Mr.  H. 
Smith.*  The  preparatory  treatment  and  position  of  the  patient  are 
those  already  given.  The  piles  having  been  sufficiently  protruded,  and 
the  anus  forcibly  dilated,  they  are  drawn  well  down,  one  by  one,  with 
vulsellum  forceps,  and  enclosed  within  the  blades  of  the  clamp,  which 
is  screwed  tightly  up.  With  scissors  curved  on  the  flat  the  pile  is  then 
so  cut  away  as  to  leave  a  sufficient  stump.     This  is  then  thoroughly 


*  Mr.  II.  Smith  {8yd.  of  Sttrg.,  vol.  ii.  p.  840)  had  almost  entirely  discarded  the  use 
of  BcissoTB,  removing  the  clamped  piles  with  heated  cauteries  instead.  Three  of  these  are 
figured. 


H.lvMOlMMlOlhS. 


7(>:> 


Fig.  300. 


iot  of  Pile 

_  First  loop 
securing;  vessels 
they  enter 


Wound 


seared  down  with  a  Paquelin's  cautery,  carefully  kept  at  a  dull 
red  heat.  If  the  iron  slicks  at  any  moment,  owing  to  its  cooling 
down,  it  should  not  be  pulled  away,  but  loosened  by  heating  it  a  little. 
The  clamp-screw  is  then  slightly  relaxed,  and  if  any  bleeding  takes 
place  it  is  at  once  tightened  up,  and  the  cautery  reapplied.  Every 
care  must  be  taken  to  burn  down  the  stump  thoroughly  at  the  first 
attempt,  for  if  this  fail,  and  oozing  take  place,  it  is  not  easy  to  stop  the 
bleeding,  from  the  tendency  of  the  stump  to  slip  through  the  slackened 
clamp.  The  piles  having  been  successively  dealt  with  in  this  way,  the 
stumps  are  smeared  with  iodoform  ointment  and  pushed  well  up  with  a 
finger  coated  with  the  same. 

This  method  is  thought  by  some  to  secure  more  rapid  healing  with 
less  pain  than  the  ligature.  This,  however  true  of  the  old  methods, 
does  not  hold  good  when  the  piles  are 
freely  detached  and  the  ligature  tied 
with  the  precautions  already  given. 
The  clamp  is  less  easily  manipulated 
in  the  rectum.  It  is  a  special  instru- 
ment not  always  at  hand,  and  the  smell 
entailed  by  the  cautery  is  most  un- 
pleasant. The  surgeon  who  uses  it 
must  be  extremely  careful  to  keep  his 
seared  surfaces  as  small  as  possible, 
and  by  no  means  to  entrench  upon 
the  skin.  It  is  well  known  how 
slowly,  how  painfully,  and  with  what 
a  tendency  to  contraction  bums  heal. 
The  cautery  is  a  troublesome  instru- 
ment to  carry  about,  and  not  infre- 
quently gets  out  of  working  order 
just  when  it  is  most  wanted,  and  for 
no  very  obvious  reason.  I  greatly 
prefer  to  use  the  more  exact,  simple, 
and  comparatively  painless  excision 
and  suture  method.  The  cautery 
ensures  asepsis  at  the  time  of  the 
operation,  and  hence  it  was  a  comparatively  safe  method  before  the 
days  of  aseptic  operations,  but  the  slough  must  separate  by  ulceration, 
which  makes  the  convalescence  of  the  patient  more  painful  and  uncertain 
with  this  than  any  other  method  used  at  the  present  day. 

iii.  Excision  and  Crushing.  Injection  with  chemicals — and  applica- 
tion of  acids  are  no  longer  necessary,  and  have  rightly  given  way  to 
more  accurate  and  more  radical  methods. 

iv.  The  Operations  of  Robert  Jones  and  Thelwall  Thomas. — Very 
similar  operations  were  independently  devised  and  described  by  these 
two  surgeons.  Mr.  Robert  Jones  published  the  following  account  in 
1893  (Prov.  Med.  Journ.,  1893,  p.  400)  : — 

"  The  hemorrhoid  is  placed  within  the  clamp  (Smith's  by  preference) 
and  cut  off,  leaving  about  an  eighth  of  an  inch  of  pedicle.  This  cut 
edge  is  sewed  with  a  catgut  suture,  the  clamp  removed,  and  the  opera- 
tion is  complete.  The  best  plan  is  to  take  a  piece  of  catgut  about 
eighteen  inches  long,  with  a  needle  at  each  end.     One  needle  is  passed 


Raw  surface 
and  edee  of 
severed  pile 


The  clamp  and  suture  method. 
(After  Robert  Jones.) 


764 


OPERATIONS  ON  THE  ABDOMEN. 


through  the  upper  end  of  the  pedicle,  and  a  first  knot  is  tied  ;  then  the 
needles  are  passed  from  left  to  right  and  right  to  left,  and  each  time 
they  cross  the  pedicle  they  are  tied.  The  diagrams  help  to  illustrate 
this  (Fig.  300).  Except  in  the  case  of  friable  granular  hemorrhoids, 
I  shall  not  use  the  cautery  again ;  and  I  am  inclined  to  believe  that 
stitching  the  pedicle  is  more  in  accord  with  one's  surgical  instinct  than 
burning  it,  which  of  necessity  means  the  subsequent  separation  of  a 
a  slough." 

Mr.  Jones  now  uses  narrow-bladed  special  clamp  forceps,  one  of  the 
blades  of  which  is  spiked  to  prevent  the  instrument  slipping. 


Fig.  301. 


The  pile  is  clamped. 
(After  Mitchell,  Brit. 

M11I.  .Ilium.) 


The  catgul  suture  is  begun  and  tied  just 
above  the  upper  end  of  the  stump,  thus 
securing  the  main  artery.     (After  Mitchell.) 


Mr.  Thelwall  Thomas  {Brit.  Med.  Journ.,  Nov.  26,  1898)  gave  the 
following  description  of  the  operation,  which  he  had  then  performed 
for  several  years. 

Operation. — The  sphincter  having  been  stretched,  "  a  large  pile  is 
seized  by  artery  forceps,  and  its  base  clamped,  the  clamp  being  always 
put  on  in  the  long  axis  of  the  bowel.  I  have  most  frequently  used 
Smith's  clamp,  but  a  dressing  forceps  witli  a  catch  will  do  quite  as 
well.*  The  bulk  of  the  pile  is  cut  away,  leaving  a  small  stump  stand- 
ing off  the  clamp.     The  treatment  of  this  is  the  essential  feature  of  the 


*  Later  Mr.  Thomas  says  that  he  has  found  Doyen's  broad  ligament  clamp  (small  size) 
superior  to  all  others.     These  are  apt  to  slip,  however. 


II.KMOIMIIIOIDS. 


765 


operation.  A  piece  of  catgut,  not  too  line,  about  a  foot  in  Length,  with 
a  domestic  needle  at  each  end,  is  used  for  a  suture.  Commencing  at 
the  top  end  of  the  stump,  one  needle  is  passed  through,  and  the  catgut 
follows  until  there  is  one  half  the  length  of  the  suture  on  each  side, 
with  its  own  needle  attached.  A  reef  knot  is  tied  on  the  stump,  and 
the  needle  which  is  on  the  right  side  is  brought  over  to  the  left  and 
passed  through  the  stump  lower  down  and  back  again  to  the  right. 
The  needle  which  is  on  the  left  is  taken  over  to  the  right  and  passed 
through  the  stump  back  to  the  left  immediately  adjoining  the  previous  one. 
A  reef  knot  is  again  made,  and  so  on  to  the  end  of  the  stump,  making 


Fig.  303. 


Fig.  304. 


A  continuous  suture  is  rapidly  applied 
round  the  clamp  with  a  curved  needle. 
(After  Mitchell.) 


The  clamp  is  removed,  the 
suture  tightened  and  knotted. 
(After  Mitchell.) 


five  or  six  crossings  to  the  inch.  This  method  of  suture  brings  the 
cut  edges  of  the  mucous  membrane  tightly  together,  and  its  advantage 
over  a  simple  continuous  suture  is  apparent,  each  cross  and  knot 
making  each  segment  independent  of  the  next.  The  clamp  is  slackened, 
and  occasionally,  though  rarely,  it  may  be  necessary  to  tie  a  small 
vessel  at  the  top  end  of  the  stump,  particularly  if  a  cross- acting  clamp 
is  used.  All  the  internal  piles  are  thus  treated."  The  great  advantages 
claimed  for  the  operation  are  (1)  that  primary  union  is  obtained,  and 
so  convalescence  is  more  rapid  ;  (2)  that  reactionary  and  secondary 
haemorrhage  is  prevented. 

Mr.    Thomas    has    performed    45    operations    in    this    way,    with 
extremely  satisfactory  results.     The  bowels  were  opened  on  the  fifth 


OPERATIONS    ON    THE    ABDOMEN. 


day,  and  full  diet  was  given  <»n  the  eighth  day.  No  pain  was  com- 
plained of,  and  none  had  any  hemorrhage  or  inflammation.  The 
average  stay  in  hospital  of  the  45  cases  was  8*8  days.* 

Mr.  A.  B.  Mitchell,  of  Belfast  {Brit.  Med.  Journ.,  Feb.  28,  1903),  also 
uses  a  continuous  catgut  suture,  bul  he  only  knots  it  twice,  just  beyond 
the  extremities  of  the  wound.  The  first  turn  secures  the  main  artery 
before  it  enters  the  stump.  The  tail  thread  is  left  long,  and  the 
continuous  suture  is  rapidly  passed  round  the  clamp,  so  that  th<-  thread 
gets  a  wider  grip  and  is  more  haemostatic.  The  damp  is  withdrawn 
when  the  suture  has  been  placed,  and  traction  is  made  upon  both  ends 

Fig.  305. 


separation 
Whitehead'-  operation.     A  tube  of  mucous  membrane  is  isolated. 

of  the  thread,  so  that  accurate  apposition  may  be  obtained  without 
puckering  of  the  wound.  The  lower  knot  is  then  tied,  and  the  upper 
and  lower  tail  ends  are  cut  off  (Figs.  301  to  304). 

Dr.  L.  S.  Pilcher,  of  New  York  (Ann.  of  Surg.,  1906,  vol.  xliv.  p.  275), 
describes  and  figures  an  operation  almost  identical  with  that  of  Mitchell, 
except  that  he  does  not  apply  the  clamp  forceps  until  he  has  severed 
the  redundant  perianal  skin  below  each  pile  and  has  separated  the 
lower  part  of  the  latter  from  the  sphincter.  He  removes  more  of  the 
skin  than  most  surgeons  do.  There  is  no  great  advantage  in  doing 
this. 

The  excision  and  suture  method  with  the  aid  of  clamps  is  the  most 


*  This  is  certainly  too  short.     The  patient  should  be  kept  recumbent  fur  a  fortnight. 


HAEMORRHOIDS.  767 

suitable  one  for  most  cases  of  piles  ;  but  it  is  not  applicable  to  the  very 
worst,  for  which  Whitehead's  operation  is  to  be  preferred.  The 
operation  is  a  very  sate  and  comparatively  easy  one,  and  most  surgeons, 
especially  those  without  much  experience,  will  get  far  better  results 

from  it  than  from  the  more  severe  operation  of  Mr.  Whitehead. 
When  it  is  used  for  cases  of  moderate  degree  of  severity  (the  majority) 
the  results  are  excellent,  and  recurrence,  although  possible,  is  quite 
rare.  On  the  other  hand,  if  it  is  attempted  for  extensive  disease 
encircling  the  lower  part  of  the  hovvel,  the  removal  is  hound  to  he 
either  incomplete  or  so  extensive  as  to  narrow  the  orifiee  when  the 
sutures  are  tied,  lleeurrence  is  therefore  likely  to  follow  in  such  cases, 
although  the  removal  of  many  strips  of  mucosa  tends  to  hrace  up  the 
remainder.  It  is,  therefore,  better  to  perform  Whitehead's  operation 
for  had  cases  in  order  to  be  certain  of  a  permanent  success. 

v.  "Whitehead's  Operation  of  Excision  of  the  whole  "  Pile- 
bearing  "  Area.* — This  extensive  operation  is  intended  to  bring  about 
a  radical  cure,  its  object  being  not  only  to  remove  any  existing  piles,  but 
also  all  the  mucous  membrane  in  the  lowest  part  of  the  rectum,  which 
is  the  seat  of  piles,  owing  to  the  tendency  of  its  veins  to  become  dilated. 
Though  Mr.  Whitehead  has  performed  this  operation  in  300 
cases  without  a  fatal  result  or  any  drawback,  I  cannot  but  consider  it 
needlessly  extensive  and  severe,  especially  in  patients  of  middle  life, 
and  in  a  part  which  cannot  always  be  kept  sweet.  The  operation  by 
ligature,  or  by  clamp  and  cautery,  carefully  performed,  gives  most 
excellent  results,  and,  in  answer  to  Mr.  Whitehead's  argument  that  as 
long  as  this  diseased  area  is  left  to  reproduce  piles  over  and  over  again 
no  permanent  cure  can  be  expected,  I  may  say  that  I  have  always 
found  that,  after  one  of  the  above  operations  has  been  properly  carried 
out,  the  patient  can  easily  prevent  any  recurrence  by  attention  to 
common-sense  details  in  daily  life.  Finally,  I  know  of  one  case,  in  a 
young,  healthy  patient,  fatal  from  blood-poisoning. 

The  following  criticism  (Allingham,  Diseases  oj  the  Rectum,  p.  139) 
appears  to  me  soundly  based :  "Mr.  Whitehead  terms  his  operation  simple. 
Simple  it  may  be,  but  difficult  to  perform,  for  with  the  anus  rugose 
and  elastic  as  it  is,  even  after  dilatation  of  the  sphincters,  it  is  not 
at  all  easy  to  separate  the  mucous  membrane  from  the  skin.  The 
time  required  for  the  operation  is  an  objection  ;  this  process  takes 
on  an  average  at  least  thirty  minutes,  where  a  skilled  surgeon  can 
operate  with  the  ligature  in  less  than  five  minutes.  The  haemorrhage 
by  this  method  far  exceeds  the  amount  lost  when  the  ligature  is  used, 
and  this  is  of  great  importance  in  those  patients  who  have  already 
lost  much  blood  from  their  piles.  .  .  .  Two  or  three  days  after  the 
operation  the  parts  not  infrequently  become  swollen,  and  the  mucous 
membrane  then  tears  through  the  ligatures  and  retracts  away  from 
the  skin.  This  leaves  a  large  granulating  surface  which  may  occupy 
the  entire  circumference  of  the  bowel,  and  cause  troublesome 
contraction." 

Stricture  of  the  rectum  has  occasionally  followed  Whitehead's  opera- 
tion, even  when  it  has  been  performed  by  the  ablest  surgeons.  Severe 
haemorrhage  has  also  occurred  when  the  stitches  have  given  way  and 

*  Brit.  Med.  Journ.,  Feb.  26,  1887. 


768 


OPERATIONS    ON    THE    ABDOMEN. 


tlif  rectal  mucous  membrane  1ms  retracted.  Both  these  catastrophes 
should  be  rare  if  the  suturing  be  done  with  great  care,  l»ut  even  the 
best  work  docs  not  always  prevent  the  Btitches  tearing  out  in  mal- 
nourished and  anemic  patit-ut-.    It  is  fairly  common  for  Borne  temporary 

loss  of  anal  sensation  and  control  to  follow  Whitehead's  operation. 

Careless  operators  or  those  without  a  knowledge  of  anatomy  have 
even  damaged  the  sphincter  ani  in  separating  the  mucous  membrane. 
I  fear  that  a  good  many  had  and  imperfect  results  have  not  heen 
published. 

Despite  these  occasional  accidents,  the  operation  is  a  good  one  when 


Fig.  306. 


Line  of  section 


Whitehead's  operation.  The  pile-bearing  tube  is  drawn  down  with  pressure- 
forceps  and  gradually  cut  away.  After  each  snick  with  the  Bcissors  a  retaining 
stitch  is  inserted  (A).  P.  Bhows  the  operation  completed,  the  ends  >>f  the  silk 
sutures  being  left  long  and  held  in  forceps  until  the  circle  is  completed,  and  any 

■ndary  sutures  inserted  between  the  primary  ones,  if  necessary. 

skilfully  performed  for  suitahle  cases  ;  but  it  is  certainly  not  one  to  be 
undertaken  lightly  by  surgeons  of  little  experience.  It  is  especially 
indicated  for  extensive  and  confluent  hemorrhoidal  disease  with  laxity 
of  the  anus  and  some  prolapse  of  the  mucosa  and  chronic 
inflammation.  Such  cases  are  not  suitable  for  less  severe  and  easier 
methods.  Debilitated  and  very  anaemic  patients  are  not  favourable 
subjects  for  it. 

Operation. — An  aperient  is  given  two  nights  before  the  operation,  and 
another  one  early  on  the  evening  before  the  operation,  so  that  the 
bowels  may  he  well  cleared  out  hefore  the  time  fixed  for  the  operation. 
If  this  plan  is  adopted  an  enema  is  not  required  in  the  majority  of 
cases,  hut  if  one  is  given  it  must  be  well  administered,  and  thoroughly 
evacuated  hefore  the  time  of  the  operation.     There   is  nothing  more 


HAEMORRHOIDS.  769 

annoying  and  dangerous  than  an  unsatisfactory  enema  which  causes  the 
bowels  to  act  during  the  operation. 

The  sphincters  having  been  thoroughly  dilated,  and  the  rectum  well 
cleansed,  a  temporary  plug  of  gauze  is  inserted  above  the  field  of  opera- 
tion to  prevent  any  possible  contamination  with  faeces.  A  ligature  is 
attached  to  the  gauze,  so  that  the  latter  may  be  easily  withdrawn  at  the 
end  of  the  operation.  The  hemorrhoidal  area  of  mucous  membrane  is 
made  to  prolapse,  and  the  prominent  edge  is  seized  with  four  long  haemo- 
static forceps,  placed  at  equal  distances  from  each  other  round  the 
circle.  Traction  is  made  with  the  forceps,  while  the  mucous  membrane 
is  divided  with  blunt-pointed  scissors  a  little  above  the  white  line,*  where 
the  skin  and  mucosa  meet.  The  mucous  membrane  is  then  dissected 
up  with  forceps  and  scissors,  from  off  the  external  and  in  part  the 
internal  sphincter,  till  the  whole  of  the  pile-producing  area  of  mucous 
membrane  can  be  pulled  down  and  drawn  outside  the  anus.  It  is  then 
cut  awa}r,  bit  by  bit, t  transversely  at  its  still  attached  upper  border, 
each  portion  when  divided  being  at  once  attached  to  the  cut  skin  with 
sterilised  silk  sutures.  In  this  way  the  diseased  area  is  removed  as  a 
complete  ring  of  mucous  membrane. 

It  is  of  vital  importance  to  use  plenty  of  sutures  both  for  controlling 
haemorrhage,  and  also  for  securing  firm  and  accurate  apposition.  Each 
suture  must  also  take  an  ample  bite  of  the  rectal  mucosa,  so  that  it  may 
not  tear  out  prematurely,  and  for  the  same  reason  the  threads  must 
not  be  too  fine. 

Bleeding  is  at  once  controlled  by  finger  pressure,  until  another 
suture  is  introduced  to  arrest  it.  It  is  not  necessary  to  ligature  any 
vessels.  Before  completing  the  operation  the  entire  circular  wound  is 
examined,  and  a  stitch  is  inserted  here  and  there  between  the  primary 
sutures  wherever  the  apposition  is  not  perfect  or  any  bleeding  occurs. 
This  examination  is  facilitated  by  traction  upon  each  primary  suture  in 
turn.  The  ends  are  then  cut  short,  and  the  temporary  plug  is  with- 
drawn. A  morphia  suppository  (gr.  3-  or  ^)  is  introduced  into  the  rectum. 
The  centre  of  a  large  piece  of  antiseptic  gauze  is  now  pushed  well  into 
the  rectum,  and  the  saccular  part  of  it  within  the  bowel  is  filled  with 
strips  of  gauze.  Gentle  traction  is  then  made  upon  the  enveloping 
layer,  to  bring  the  pear-shaped  plug  down  towards  the  sphincter.  The 
plug  serves  to  prevent  faeces  coming  down  to  the  suture  line.  To  keep 
the  rectum  at  rest,  no  solid  food  is  given  for  four  days;  hot  drinks 
and  milk  are  also  avoided,  for  the  same  reason.  On  the  fourth  day 
the  rectal  plug  is  removed  under  nitrous  oxide  anaesthesia,  and  an 
ounce  of  castor  oil  is  given  to  secure  a  free  and  fluid  evacuation. 
Allingham's  pill  also  acts  well  (Pil.  Hydrarg.  gr.  ii.,  Pil.  Colocynth 
et  Hyos.  ad  gr.  viii.).  When  the  bowels  have  been  opened,  the  diet 
is  rapidly  increased  to  full.  A  daily  evacuation  of  the  rectum  is 
essential,  otherwise  hard  scybala  soon  form  and  give  rise  to  much 
trouble  and  pain.  The  sutures  are  allowed  to  come  away  spontane- 
ously.  The  patient  is  kept  in  bed  for  a  week  or  nine  days,  and  is 
allowed  to  walk  out  at  the  end  of  a  fortnight.  The  anus  is  sprayed 
with  boracic  lotion  several  times  dairy,  and  is  thus  kept  quite  clean. 

*  The  li  white  line"  of  Mr.  Hilton  (Rest  and  Pain,  p.  289,  Figs.  51  and  52). 

f  So  as  to  diminish  the  haemorrhage,  which  would  otherwise  be  free  at  this  stage. 

s. — vol.  11.  49 


770  OPERATIONS   ON    THE    ABDOMEN. 

The  stream  of  warm  lotion  is  less  painful  than  even  the  gentlest 
swabbing. 

Causes  of  Failure  and  Tremble  after  Operations  for  Haemorrhoids. 
— i.  Hemorrhage. —  This  will  be  extremely  rare  if  the  precautions  which 
have  been  mentioned  under  each  operation  are  carefully  observed,  hut 

it  is  most  likely  to  follow  Whitehead's  operation,  owing  to  the  tearing 
out  of  stitches.  It  used  to  be  not  uncommon  after  the  (damp  and 
cautery.  It  is  very  rare  indeed  after  the  ligature  and  suture  methods. 
The  conditions  under  which  this  complication  may  occur  are  cases  of 
long-standing  piles  or  prolapsus  in  weakly  subjects,  cases  where  the 
tissues  are  very  friable,  where  the  patient  insists  on  getting  out  of  bed 
to  pass  water,  or  where  he  strains  very  much  at  the  first  action  of  the 
bowels.  If  the  surgeon  be  called  upon  to  meet  it,  the  best  means  is 
to  catch  the  vessels  with  Spencer  Wells's  forceps,  and  tie  them  with 
silk.  Failing  this,  the  centre  of  a  large  piece  of  antiseptic  gauze  is 
pushed  well  into  the  rectum,  and  the  saccular  part  of  it  within  the 
bowel  is  then  filled  with  gauze  strips  until  a  pear-shaped  plug 
is  formed.  Traction  upon  the  sides  of  the  sac  of  gauze  brings 
the  plug  down  against  the  sphincter  or  anal  constriction,  and 
effectually  controls  the  haemorrhage.  The  strips  of  gauze  are 
easily  removed.  Styptics  such  as  2000  °f  adrenalin  chloride  may  be 
applied  on  the  gauze.  The  plug  should  he  left  in  as  long  as  possible, 
the  patient  being  kept  under  the  influence  of  morphia  if  necessary. 

2.  Tedious  Ulceration. — This  is  often  due  to  the  patients  getting  up 
too  soon  or  the  use  of  the  clamp  and  cautery  or  the  ligature  method 
without  any  sutures  for  approximation  of  the  mucous  edges.  The 
patients  should  remain  in  bed  a  week  or  ten  days,  and  then  he  content 
to  pass  another  week  or  ten  days  upon  the  sofa. 

3.  Septic  Troubles. — These  may  follow  from  want  of  care  in  perform- 
ing the  operation,  especially  in  cleansing  the  rectum  very  thoroughly. 

4.  Contraction. — This  is  usually  stated  to  he  only  likely  to  occur 
when  in  cutting  away  piles,  especially  external  ones,  the  junction  of 
skin  and  mucous  membrane  is  trenched  upon.  But  the  fact  is  that 
where  many  piles  have  had  to  be  removed,  where  islands  of  mucous 
membrane  (p.  762)  have  not  been  left  between  them,  the  ulcerated 
surfaces  thus  tending  to  coalesce,  contraction  of  the  surface  as  it  cica- 
trises is  very  likely  indeed  to  lead  to  some  narrowing  of  the  lumen  of 
the  gut.  This  must  always  he  prevented  by  the  early  passage  of  the 
finger  of  the  surgeon  in  charge,  tins  being  repeated  daily  if  any  ten- 
dency to  contraction  is  found.  Where  a  stricture,  generally  about  one 
inch  and  a  half  from  the  anus,  has  been  allowed  to  form,  the  patient's 
condition  is  a  most  vexatious  one,  though  it  will  always  yield  to  the 
use  of  bougies,  aided,  if  need  be,  by  nicking  of  the  contraction. 

A  serious  stricture  is  most  likely  to  follow  Whitehead's  operation, 
from  retraction  of  the  rectal  mucosa  due  to  the  stitches  tearing  out. 
This  may  he  due  to  the  use  of  too  few  or  too  fine  threads,  or  to  the 
insufficiency  of  the  bite  taken  by  each  suture. 

5.  Loss  of  anal  sensation.  6.  Loss  of  perfect  control.  These  most 
often  follow  Whitehead's  operation. 

7.  Abscess.  8.  Fistulas.  9.  Bubo.  10.  Pelvic  suppuration.  These 
four  are  given  by  Mr.  Allingham  (loc.  supra  cit.,  p.  163)  as  Bequelffi  in  un- 
healthy patients,  especially  if  the  healing  has  been  accompanied  by  pro- 


fissure— r  i. ci:i:.  77, 

longed  suppuration.     The  antisrptir  surgery  of  the  presenl  day  Khould 
almosl  prevent  this. 

FISSURE.*— ULCER. 

The  operative  treatment  of  these  is  so  simple  and  so  eminently 
successful,  that  it  should  he  resorted  to  early. 

A.  Operation  by  Incision. —  The  preparatory  treatment  and  the 
position  of  the  patient  are  the  same  as  those  alreadv  given.  The 
division  of  the  ulcer  may  be  performed  in  one  of  two  ways :  (a)  from 
without,  (b)  from  within,  the  rectum. 

(a)  From  without. — Here  the  ulcer,  being  fully  exposed  with  a 
speculum — and  the  one  which  bears  Mr.  Hilton's  name,  with  a  movable 
valve,  will  be  found  the  best— a  small  sharp-pointed  bistoury  is  inserted 
a  little  beneath  the  base  of  the  ulcer,  and  its  point  made  to  protrude  in 
the  bowel  above  it ;  the  parts  are  then  divided  from  without  inwards 
through  the  centre  of  the  ulcer. 

(b)  From  within. — Here,  the  ulcer  being  also  exposed  either  by 
stretching  the  parts  with  two  fingers  or  with  a  speculum,  a  straight 
blunt-pointed  bistoury  is  drawn  across  the  whole  of  the  sore  through 
its  centre,  going  deep  enough  to  divide  about  a  third  of  the  fibres  of  the 
external  sphincter.  Mr.  Curling  (Diseases  of  the  Rectum,  p.  12)  has 
drawn  attention  to  an  important  point  here,  and  that  is,  that  the  fibres 
of  the  muscle  at  the  extremity  of  the  ulcer  near  the  verge  of  the  anus 
should  be  divided  rather  more  freely  than  those  above,  so  as  to  avoid 
any  ridge  or  shelf  on  which  the  faeces  would  lodge. 

There  is  usually  no  haamorrhage  to  speak  of,  and  the  whole  opera- 
tion is  so  simple  that  it  may  be  performed  after  an  injection  of  cocaine, 
or  with  nitrous  oxide  gas,  unless  anything  else — e.g.,  attention  to  piles 
— is  required.  I  prefer,  however,  to  operate  with  ether  or  the  A.C.E. 
mixture. 

Of  the  two  methods,  I  generally  make  use  of  the  first,  following 
Mr.  Hilton.  I  consider  it  the  more  certain,  and  have  never  known  of 
am  thing  like  incontinence  in  the  nine  cases  in  which  I  have  used  it. 
The  second  is  rather  the  slighter  operation,  and  also  gives  good  results. 

The  position  of  these  usually  club-shaped  ulcers  is  posterior.  If 
one  is  met  with  anteriorly  in  a  woman,  it  would  be  wiser  to  try  the 
application  of  acids,  or  the  actual  cautery.     See  footnote,  p.  758. 

The  surgeon  must  be  careful,  when  examining  into  the  amount 
of  repair  a  week  or  two  later,  not  to  do  any  damage  if  a  speculum 
is  employed. 

B.  Operation  by  Dilatation  of  the  Sphincter. — This  is  not  only 
rough,  but  uncertain,  and  should  not  be  employed. 

C.  Operation  by  Excision  and  Suture. — To  hasten  healing,  and 
make  it  more  certain,  the  whole  ulcer,  whose  base  and  margins  are 
often  firm  from  long-continued  chronic  inflammation,  is  excised  down  to 
the  muscle  fibres,  leaving  healthy  tissues,  which  are  sewn  carefully 
with  a  continuous  catgut  suture.    Each   stitch   must  run  deep   to  the 

*  This  condition,  often  called  a  fissure,  nearly  always  amounts  to  an  ulcer  when  it  is 
carefully  examined  and  the  parts  unfolded.  It  is  often  formed  by  the  tearing  down  of 
one  of  the  pouches  placed  at  the  junction  of  the  anus  and  rectum.  The  strip  of  mucous 
membrane  which  is  torn  down  to  the  anal  margin  is  often  called  the  sentinel  pile  (Ball). 

49—2 


772         OPERATIONS  ON  THE  ABDOMEN. 

apex  of  the  V-shaped  wound,  so  that  accurate  apposition  of  the  depth, 
as  well  as  of  the  mucous  edges,  is  obtained.  If  only  the  mucous  edges 
are  joined  a  fistula  may  result  and  time  be  lost  instead  of  saved  by 
adopting  excision  instead  of  incision.     Any  sentinel  pile  is  also  excised. 

PROLAPSUS. 

Indications. — Failure  of  previous  treatment.  Large  size  and  long 
duration  of  the  prolapsus.  Altered  condition  of  the  mucous  membrane 
— viz.,  thickening  or  ulceration,  the  latter  giving  rise  to  haemorrhage. 
Incontinence  of  faeces,  especially  when  fluid,  or  of  flatus.  It  is  very 
rare  for  any  operation  to  be  required  in  children,  for  care  in  dieting, 
enforced  rest  in  the  horizontal  position,  and  proper  attention  to  the 
bowels  nearly  always  suffice.  Threadworms,  rectal  polypi,  phimosis, 
or  vesical  stone  must  be  sought  for  and  treated  if  necessary. 

Operations. 

Acid. — Cautery. — Excision. — Sub-mucous  Injection  of  Paraffin. 

1.  Acid. — Of  these  I  prefer  the  acid  nitrate  of  mercury.  This 
method  is  especially  applicable  to  the  obstinate  cases  of  prolapsus  in 
children,  where  the  bowel  is  constantly  down.  Though,  if  the 
application  is  made  properly,  only  a  sensation  of  burning  is  complained 
of,  an  anaesthetic  should  always  be  given.  The  patient  being  in  the 
lithotomy  position,  or  on  one  side,  the  prolapsus  is  carefully  dried  of 
all  mucus,  and  the  surgeon  rubs  in  the  acid  with  the  aid  of  a  glass 
rod  or  pointed  pieces  of  wood,  the  adjacent  skin  being  protected  with 
vaseline. 

Care  must  be  taken  not  to  rub  in  the  acid  too  long  or.too  vigorou>ly, 
for  if  the  inflammatory  process  set  up  affects  deeply  the  sub-mucous 
tissue,  a  most  troublesome  stricture  may  readily  result. 

It  is  well  to  warn  the  patients  that  a  second  application  may  be 
required  in  severe  cases. 

The  after-treatment  is  that  given  below. 

2.  Cautery. — In  severer  cases,  or  where  the  acid  has  failed,  the 
following  will  be  found  efficient.  The  position  of  the  patient  is  as  for 
pile  operations,  but  it  is  best  to  apply  the  cautery  to  the  bowel  in  situ, 
though  this  may  be  used  when  the  bowel  is  prolapsed. 

Thus,  the  patient  being  in  lithotomy  position,  and  a  duckbill- 
speculum  introduced  and  held  in  contact  with  the  anterior  wall  of  the 
rectum,  the  blade  of  a  thermo-cautery  is  drawn  edgeways  along  the 
lower  three  or  four  inches  of  the  opposite  surface  of  the  gut.  The 
speculum  being  shifted,  the  anterior  and  lateral  aspects  are  similarly 
treated  in  severe  cases. 

Care  must  be  taken  not  to  go  through  the  mucous  membrane,  or 
septic  mischief  and  sloughing  may  be  setup  in  the  cellular  tissue  beneath, 

3.  Excision. — In  severe  cases  in  adults,  when  other  methods  have 
failed,  this  method  should  be  resorted  to,  but  even  with  the  improve- 
ments of  the  present  day  there  must  always  be  a  difficulty  in  keeping 
wounds  here  aseptic.  If  the  precautions  mentioned  at  pp.  768,  769 
are  observed,  the  risk  of  infection  from  the  faces  is  greatly  diminished, 
but  not  entirely  abolished.  Either  portions  of  mucous  membrane 
only,  or,  in  very  severe  and  intractable  cases,  the  whole  prolapse,  may 
be  removed. 


PROLAPSUS.  773 

i.  Excision  of  Mucous  Membrane. 

The  patient  being  in  Lithotomy  position,  the  prolapsus  reduced,  and 
the  parts  exposed  by  a  duckbill-speculum,  two  <>r  more  elliptical  pieces 
of  mucous  membrane  are  removed  by  pinching  them  up  with  vul- 
sellum-forceps  and  cutting  them  away  with  a  very  sharp  scalpel  or 
scissors.  Any  bleeding  vessels  are  then  tied  with  chromic  gut,  and 
the  edges  of  the  wound  united  by  catgut  sutures.  Iodoform  is  then 
carefully  dusted  on,  and  the  parts  smeared  with  an  ointment  of  the  same. 

The  insertion  of  sutures  has  the  advantage  of  preventing  haemor- 
rhage, and  hastening  the  cure.  In  some  cases  the  prolapsed  mucins 
membrane  is  excised  much  as  in  Whitehead's  operation  for 
haemorrhoids. 

ii.   Complete  Eemoval  of  the  Prolapse. 

Although  a  more  certain  cure,  this  method  is  much  more  severe 
than  those  already  described,  and  owing  to  the  risk  of  the  operation, 
should  be  reserved  for  cases  in  which  other  methods  of  treatment 
have  failed,  the  prolapse  has  become  irreducible,  or  when  gangrene 
threatens. 

The  operation  essentially  consists  of  amputation  of  the  prolapsed 
bowel,  with  suture  of  the  divided  edges  at  the  margin  of  the  anus. 

It  must  be  remembered,  however,  that  a  pouch  of  peritonaeum  may 
be  present  in  front  between  the  layers  of  the  prolapsed  bowel,  and 
that,  in  certain  cases,  a  herniated  loop  of  intestine  may  lie  within  this 
pouch.  Owing  to  the  vascularity  of  the  parts,  considerable  haemor- 
rhage may  occur,  and,  with  a  view  to  controlling  this,  several  operators 
have  advised  constriction  of  the  base  of  the  prolapse,  either  by  means 
of  specially  devised  clamps,  or  by  an  elastic  ligature,  applied  above 
transfixing  pins,  before  commencing  its  removal.  The  objection  to 
this  is,  however,  the  possibility  of  damage  to  a  knuckle  of  small 
intestine  lying  in  a  prolapsed  peritoneal  pouch.  Moreover,  the 
haemorrhage  may  be  satisfactorily  dealt  with  by  dividing  only  small 
portions  of  tissue  at  a  time  and  applying  catgut  ligatures  to  the  vessels 
in  each  portion  as  they  are  divided. 

The  details  of  the  operation  have  been  varied  by  many  surgeons,  one 
of  the  best  methods  being  undoubtedly  that  of  Mikulicz,  which  is 
described  as  follows  by  Cumston,  of  Boston  (Ann.  of  Surg.,  March, 
1900),  in  a  paper  containing  much  valuable  information  : 

"  Mikulicz  first  cuts  through  the  outer  intestinal  tube  in  its  anterior 
circumference  by  cutting  the  tissues  layer  after  layer,  catching  up 
each  bleeding  vessel  as  it  appears,  and  ligating  it  with  fine  catgut.  As 
soon  as  the  peritonaea!  pouch  has  been  opened,  its  interior  is  examined 
for  the  presence  of  small  intestine.  The  peritoneal  cavity  is  then 
closed  by  a  running  suture.  The  anterior  aspect  of  the  internal 
intestinal  tube  is  cut  through,  little  by  little,  until  it  is  opened,  and 
then  both  intestinal  tubes  are  united  by  deep  silk  sutures  along  the 
entire  line  of  the  incision. 

"  The  posterior  circumference  of  the  prolapse  is  treated  in  absolutely 
the  same  way,  both  intestinal  ends  being  united  by  means  of  silk 
sutures,  and  thus  the  resection  is  completed." 

4.  In  some  cases,  when  the  anus  is  patulous  or  the  sphincter  paralysed 
or  damaged,  some  form  of  plastic  operation  may  be  performed,  with 
the  object  of  narrowing  the  orifice  and,  if  possible,  of  restoring  the 


774  OPERATIONS   ON    THE    ABDOMEN. 

function  of  a  divided  sphincter  also.  Thus  Mayo  Robson  (Practitioner, 
February,  1903)  makes  a  semilunar  incision  parallel  with  the  anterior 
margin  of  the  anus.  The  wound  is  deepened  for  about  half  an  inch  and 
then  sutured,  so  that  it  runs  antero-posteriorly.  This  narrows  the 
anal  orifice  very  considerably,  and  tightens  the  sphincter.  The 
incision  may  he  so  placed  that  a  divided  sphincter  may  be  reconstructed. 
The  wound  is  entirely  external  to  the  bowel,  and  in  this  respect  this 
method  is  better  than  excision  of  wedges  from  the  anal  margin. 

5.  In  some  cases,  with  paralysed  or  lost  sphincter;  sub-mucous 
injection  of  paraffin  maybe  found  to  he  of  value  as  in  Mr.  Stephen 
Paget'scase  (Brit.  Med.  Jov/rn.,  February  14, 1903)  of  prolapse  following 
perineal  excision  of  the  rectum. 

Mr.  Paget  (Lancet,  1903,  vol.  L,  p.  1354)  thus  expresses  his  views 
upon  this  subject : — 

"  I  have  had  only  three  cases,  hut  the  results  were  so  good  that  the 
method  certainly  deserves  consideration.  My  patients  were  all  over 
60  years  old.  One  had  prolapse  of  the  bowel  after  excision  of  the  rectum 
for  cancer,  one  had  prolapse  of  the  bowel  of  twenty- two  years'  duration, 
and  one  had  suffered  for  twenty-eight  years  from  prolapse  of  the  uterus. 
I  need  not  say  what  an  amount  of  misery  these  three  old  people 
represent;  and,  to  my  amazement,  they  have  all  of  them  been  cured. 
It  is  too  soon  to  be  sure  that  they  will  not  need  another  injection  later ; 
but  for  the  present  there  they  are,  wholly  free  from  what  had  seemed 
incurable  troubles.  The  paraffin,  in  these  cases,  must  be  injected 
immediately  under  the  mucous  membrane  of  the  prolapse,  so  as  to 
raise  and  to  thicken  and  to  stiffen  it  and  to  narrow  the  passage  through 
which  the  prolapse  comes  down.  With  a  prolapse  of  the  bowel  I  think 
it  is  a  good  plan  to  take  a  fold  of  the  prolapse  between  one's  finger  and 
thumb,  and  to  endeavour  to  make  two  or  three  well-defined  round 
masses  or  hummocks  of  paraffin  which  shall  form  a  sort  of  valve  or 
partial  stricture  just  inside  the  anus.  In  a  bad  case  you  may  have  to 
inject  the  paraffin  at  diverse  levels  and  for  some  distance  above  the 
anus.  .  .  .  The  paraffin  must  be  kept  away  from  the  bladder  and  ureter, 
and  injected  mostly  under  the  posterior  and  lateral  folds  of  the  everted 
mucous  membrane." 

Mr.  Burgess  (Lancet,  1904,  vol.  ii.,  p.  759)  has  used  this  method  in 
18  cases  of  prolapse  of  the  rectum,  and  in  one  of  these  there  was  severe 
incontinence.     He  thus  describes  his  method  of  injecting  the  paraffin  : — 

"  The  paraffin  I  use  has  a  melting  point  of  in°,  ami  can  be  obtained 
sterilised  in  small  bottles.  It  is  kept  melted  by  placing  the  bottle  in 
a  bath  of  water  at  a  temperature  of  about  120°  F.  The  syringe  has  its 
barrel  covered  with  rubber  to  retain  the  heat  longer,  but  I  use  no  special 
means  to  keep  the  needle  hot.  The  syringe  also  is  placid  in  the  hot 
water  bath  for  a  few  minutes,  is  then  filled  with  the  melted  paraffin,  and 
replaced  in  the  bath  until  the  moment  it  is  required  to  be  used. 
The  syringe  and  paraffin  can  he  obtained  from  Mr.  Frank  Rogers,  of 
327,  Oxford  Street,  London,  W. 

"  The  following  is  the  technique  of  the  operation  which  I  now  perform. 
The  patient  is  anaesthetised  and  placed  in  the  lithotomy  position,  and 
the  prolapse  is  drawn  outwards  to  the  fullest  possible  extent.  I  next 
seize  the  apex  of  the  prolapse  with  artery  forceps  at  three  points 
equidistant  along  its  circumference,  so  selected  that  two  forceps  will  be 


PROLAPSUS. 


775 


placed  anteriorly  and  the  third  in  the  posterior  median  line.  By 
gentle  traction  <>n  these  forceps  the  assistant  then  raises  the  mucous 
membrane   into  three  ridges,   forming  an   equilateral   triangle.     The 

needle  of  the  syringe  is  inserted  in  turn  into  the  middle  of  each  side  of 
this  triangle,  from  two  to  three  cnhic  centimetres  of  paraffin  being 
introduced  on  each  occasion.  As  this  solidifies  it  will  he  found  that 
the  mucous  membrane  has  become  bulged  inwards,  encroaching  on  the 

lumen  of  the  bowel  and  converting  it  into  a  more  or  less  triradiate  slit. 
The  forceps  are  removed,  the  apex  of  the  prolapse  is  reduced,  and  the 
mucous  membrane  is  again  seized  with  forceps  about  one  and  a  half 
inches  from  the  original  apex,  the  forceps  heing  again  placed  equidis- 
tantly,  hut  this  time  two  are  placed  posteriorly  and  the  third  in  the 
anterior  median  line.  The  mucous  membrane  is  again  raised  into 
ridges  by  gentle  traction  on  the  forceps,  and  the  needle  is  inserted 
midway  along  each  ridge  as  before,  with  the  result  that  the  lumen  of 
the  howel  is  again  converted  into  a  triradiate  slit,  the  radii,  however, 
corresponding  to  the  intervals  between  the  radii  of  the  tier  above. 
This  portion  of  the  prolapse  is  now  reduced,  and  the  forceps  are 
reapplied,  this  time  two  being  anterior  and  one  posterior,  and  the 
process  is  repeated  until  the  anus  is  reached.  As  a  rule  three  tiers  are 
sufficient,  but  in  a  very  long  prolapse  more  may  safely  be  introduced. 
In  order  that  any  straining  on  the  part  of  the  patient  may  not  cause 
the  prolapse  to  redescend  before  the  paraffin  has  firmly  set  I  insert 
a  stout  silkworm  gut  suture  through  the  buttocks  on  either  side  and  tie 
it  firmly  over  a  pad  of  gauze  placed  over  the  anal  orifice.  This  suture 
is  removed  at  the  end  of  twenty-four  hours.  No  special  after-treatment  is 
required.  The  patient  is  kept  in  bed  for  four  or  five  days.  The  bowels 
have  usually  been  allowed  to  act  spontaneously. 

"  Results. — Of  the  18  cases  the  ages  ranged  from  3  to  48  years 
and  the  size  of  the  prolapse  from  one  and  a  half  to  five  inches  in  length. 
In  all  of  them  previously  to  the  operation  the  prolapse  descended 
with  almost  every  action  of  the  bowels  and  remained  down  until 
replaced.  Two  were  associated  with  excoriation  and  ulceration  of  the 
mucous  membrane.  Two  had  been  previously  treated  by  the  method 
of  linear  cauterisation  without  success,  and  two  had  recurred  even  after 
the  excision  of  the  lower  part  of  the  rectum.  The  result  of  the  opera- 
tion has  been  extremely  satisfactory  in  all  the  cases,  not  a  single 
instance  of  redescent  of  the  prolapse  having  occurred.  One  patient 
left  the  hospital  at  the  end  of  a  fortnight,  hut  the  remainder  have  all 
been  under  observation  for  at  least  two  months,  and  several  for  a  much 
longer  period.  I  have  examined  the  rectum  digitally  at  periods  of 
from  one  day  to  six  months  after  the  operation,  and  the  paraffin  masses 
can  readily  be  distinguished,  feeling  like  nodules  of  cartilage  or  dense 
fibrous  tissue.  They  do  not  appear  to  alter  this  character  within  the 
period  specified,  at  any  rate  to  any  appreciable  extent. 

"  The  action  of  the  paraffin  must,  in  the  first  instance,  be  a  purely 
mechanical  one,  since  the  good  results  follow  immediately  upon  its 
setting  and  cannot  therefore  depend  upon  any  vital  phenomena. 
During  the  descent  of  a  rectal  prolapse  it  may  be  observed  that  the 
process  is  a  progressive  eversion  of  the  rectal  mucosa,  beginning  at  the 
muco-cutaneous  junction  and  extending  upwards.  For  this  to  occur 
there  must  be  a  certain  degree  of  flexibility  of  the  rectal  wall,  which  is, 


776         OPERATIONS  ON  THE  ABDOMEN. 

of  course,  materially  impaired  when  it  is  infiltrated  with  paraffin, 
Moreover,  the  presence  of  the  hitter  very  considerably  narrows  the 
space  through  which  the  prolapse  lias  previously  descended,  and  in  fact,  if 
the  technique  is  carried  out  according  to  the  method  I  have  described,  the 
lumen  of  the  howel  is  converted  into  two  or  more  triradiate  slits  so  super- 
imposed that  the  radii  do  not  correspond.  This  valvular  arrangement 
offers,  I  believe,  a  very  efficient  obstacle  to  the  redescent  of  the  prolapse." 

Sepsis  and  embolism  have  followed  the  injection  of  paraffin  ;  but  the 
danger  of  these  accidents  is  not  very  great  if  proper  precautions  be  taken. 

Comparing  this  with  other  methods  of  healing  rectal  prolapse, 
Mr.  Burgess  claims  the  following  advantages: — (i)  "It  is  a  simpler 
procedure,  excepting,  perhaps,  linear  cauterisation,  and  can  be  more 
rapidly  performed  ;  (2)  it  entails  practically  no  risk  to  life  ;  (3)  no 
prolonged  after-treatment  is  required,  merely  keeping  the  patient  in 
bed  for  a  few  days  ;  (4)  the  benefit  obtained  is  apparent  immediately 
the  paraffin  has  set,  and  does  not  depend  upon  any  subsequent  vital 
phenomena,  nor  does  it  make  any  demand  upon  the  reparative  powers 
of  the  patient ;  (5)  it  offers  a  much  greater  probability  of  a  permanent 
cure  ;  and  even  should  it  fail  the  patient's  condition  is  no  worse  than 
before,  and  the  procedure  may  be  repeated  subsequently." 

It  is  uncertain  whether  this  treatment  will  find  a  permanent  place  in 
surgery  of  prolapse  of  the  rectum,  for  the  recorded  cases  had  not  been 
observed  for  a  sufficient  length  of  time  at  the  date  of  publication 
to  justify  us  in  drawing  reliable  conclusions  from  them.  Mr.  Stephen 
Paget's  cases  had  only  been  observed  for  a  few  months  and,  in  one  of 
them  Mayo  Robson's  plastic  operation  wras  also  performed  at  the  same 
time.  Mr.  Burgess's  18  cases  had  all  been  treated  within  fifteen 
months  of  the  publication  of  his  paper. 

I  cannot  agree  that  the  treatment  is  very  simple,  nor  has  it  been 
proved  that  the  results  are  more  permanent,  although  the  published 
results  are  good  as  far  as  they  go.  Some  of  the  patients  treated  in  this 
way  might  have  got  well  with  conservative  treatment,  for  at  least  some  of 
them  were  children,  who  rarely  require  any  operation  for  prolapse;  and 
it  must  be  a  rare  thing  for  one  surgeon  to  see  18  cases  of  prolapse 
requiring  operation  within  fifteen  months.  It  is  more  likely  that  this 
method  will  be  found  useful  when  plastic  operations  are  unsuitable  or 
have  failed,  and  when  the  sphincter  is  absent  or  paralysed.  Whether 
the  paraffin  will  or  will  not  sooner  or  later  give  rise  to  any  septic 
troubles  when  retained  in  the  rectal  wall  remains  to  be  seen. 

After-treatment. — After  any  operation  for  prolapsus  the  patient 
must  rest  for  three  weeks  on  the  sofa  to  allow  of  firm  consolidation  and 
cicatrisation  taking  place.  Light  diet  alone  should  be  allowed  at  first, 
and  the  bowels  should  at  first  be  allowed  to  act  only  every  three  days, 
and,  if  possible,  while  the  patient  is  on  his  side. 

EXCISION  OF  THE  RECTUM.* 
Partial  excision  would  be  usually  a  more  correct  term  in  the  majority 
of  cases,  but  as  by  the  sacral  route,  and  by  the  combined  methods,  the 
rectum  has  been  removed  up  to  the  sigmoid  flexure,  I  retain  this 
heading.  Under  it  the  following  operations  will  be  considered  :  (i.) 
Excision    from    the    perinaeum.      (ii.)  Zraske's  operation    and    its 

*  The  rectum  is  here  regarded  a-  starting  at  the  left  sacro-iliac  synchondrosis. 


KXCISION    OK    TIIK    RECTUM. 


777 


modifications.  (iii.)  Excision  by  the  vagina.  (iv.)  Excision  by- 
abdominal  section.  (v.)  Excision  by  the  combined  methods, 
especially  the  (a)   abdomino-purimeal  and  (h)  abdomino-anal. 

Indications.  Suitable  Cases. — r.  Malignant  disease  of  anus — e.g.t 
papillomata  or  a  neglected  fistula,  or  condylomata  becoming  epithelio- 
matous.  2.  Rarely  non-malignant  stricture  and  ulceration  may  be 
treated  in  this  way  instead  of  by  dilatation,  but  only  in  cases  where 
extensive  ulceration  exists  with  multiple  points  of  stenosis,  and  the  use 
of  the  bougie  is  found  to  be  ineffectual.  3.  Malignant  disease  of  the 
rectum.  Of  the  points  which  have  to  be  now  considered,  the  extent  of 
the  disease  is  the  most  important.  A  growth  that  is  limited  to  the 
rectum,  at  whatever  part  it  may  be  situated,  and  however  high  it  may 
extend  along  the  course  of  the  bowel,  may  be  removed  by  one  of  the 
methods  about  to  be  described.  Extension  beyond  the  rectum  to  sur- 
rounding parts,  as  shown  by  fixity  of  the  growth  to  the  sacrum  on  the 
one  hand,  or  to  the  bladder,  vagina,  or  uterus  on  the  other,  constitutes 
a  contra-indication  to  any  attempt  at  a  radical  operation  as  a  rule  ;  but 


FlG.    3O7.  FOR     BELLOWS 


|-i  i_  1'-j#^5^H1 -11H Ai-^gr^t:i:i:i:t:~" ^v^nr :i :i~i :~-{»^>t:":tiz :trrr^^^^t:z:i"/:«?^[fe«:^nf'~?:~^^^^t^:?'^^'tizi(c?ti:~~i : r:«: i_[^i : 


The  sigmoidoscope.  The  obturator  is  not  shown  in  the 
figure.  The  margin  of  the  end  of  the  tube  is  blunt,  so  that, 
once  the  instrument  has  been  introduced  well  into  the 
rectum,  the  obturator  can  be  withdrawn  and  the  tube 
advanced  along  the  inflated  rectum  with  the  invaluable 
aid  of  sight,  as  advocated  by  Mr.  Mummery. 

the  degree  of  adhesion  may  be  most  difficult  to  estimate,  and  in  doubt- 
ful cases  the  patient  may  himself  choose  to  undergo  an  operation 
which  may  perhaps  be  attended  with  unusual  risk  as  long  as  there 
remains  a  fair  prospect  of  obtaining  relief  of  symptoms  and  prolonga- 
tion of  life,  although  the  chances  of  a  permanent  cure  may  seem  to  be  poor. 

The  sigmoidoscope  is  of  decided  value  in  enabling  us  to  diagnose 
growths  of  the  upper  part  of  the  rectum  and  of  the  lower  part  of  the 
sigmoid  colon  at  an  earlier  stage  than  hitherto.  It  also  enables  us  to 
estimate  the  extent  and  mobility  of  growths  which  are  too  high  for 
complete  examination  by  means  of  the  finger. 

The  administration  of  ether  or  A.C.E.  may  help  here  as  well  as  in 
deciding  the  extent  of  the  disease.  The  parts  where  it  is  most  difficult 
and  important  to  estimate  the  mobility  are  the  neighbourhood  of  the 
prostate,  urethra,  and  the  neck  of  the  uterus.  Mr.  Cripps  thinks  that 
though  the  bowel  in  contact  with  the  prostate  may  be  diseased,  it  is 
a  long  while  before  the  prostate  itself  becomes  infected.  In  women,  on 
the  contrary,  when  the  disease  is  on  the  anterior  part  of  the  bowel,  the 
vagina  and  uterus  quickly  become  implicated.  The  recto-vaginal  septum, 


OPERATIONS    <>\    THE    ABDOMEN. 

if  involved  in  its  lower  part,  may  be  cul  away,  but  the  patient  will  be 
liable  to  find  feces  getting  into  the  vagina,  especially  when  the  bowels 
are  loose.  The  condition  of  the  glands,  sacral,  iliac,  and  inguinal,  will, 
of  course,  he  examined,  and  the  possibility  of  deposits  in  the  liver 
remembered.  Glandular  infiltration  is  said  by  several  to  occur  late  in 
rectal  carcinoma.  This,  at  first  sight  a  point  which  may  favour  opera- 
tion, is  counterbalanced  by  the  well-known  fact  that  rectal  carcinoma  is 
frequently  insidious,  and  that  thus,  by  the  time  it  has  pronounced  it> 
existence,  it  is  already  in  an  advanced  stage.  In  doubtful  cases  an 
exploratory  laparotomy  is  indicated,  and  is  invaluable. 

Finally,  the  age  of  the  patient,  this  being  not  judged  of  by  years  alone, 
the  condition  of  the  kidneys  and  other  viscera,  whether  the  general 
condition  and  reparative  powers  are  sufficiently  good  to  meet  the  calls 
of  what  may  be  a  very  severe  operation,  must  all  be  taken  into  careful 
consideration. 

Much  information  bearing  on  the  value  of  excision  of  the  rectum  will 
come  out  if  we  institute  a  comparison  between  excision  of  the 
rectum  and  colotomy.  The  chief  points  railing  for  attention  are — 
(i.)  The  mortality  of  the  operation,  (ii.)  The  duration  of  life  after  it. 
(iii.)  The  amount  of  comfort  given  by  it. 

(i.)  The  Mortality  of  the  Operation. — In  making  a  comparison  <>n 
thi^  bead  between  colotomy  ami  excision  of  the  rectum,  one  important 
point  must  always  be  remembered — i.e.,  that  the  latter  operation  is 
never  performed  under  those  unfavourable  conditions  of  obstruction 
which,  owing  to  the  operation  being  often  deferred  till  too  late,  render 
the  mortality  of  colotomy  such  a  high  one.  Turning  to  the  mortality  of 
excision  by  itself,  without  comparison  with  any  other  operation,  we  find 
that  McCosh,  in  1892  (New  York  Med.  Journ.,  Sept.  3),  collected  439 
cases,  with  84  deaths,  a  mortality  of  ig'i  per  cent.  Later  Kraske  (Ann. 
of  Surg.,  vol.  ii.  1897,  P-  3^°)  gives  a  mortality  of  9*8  per  cent.,  or 
5  deaths  in  51  cases  operated  upon  during  the  years  1890 — 1897,  and 
Paul  (Lancet,  vol.  ii.  1897,  p.  78)  publishes  a  series  of  28  cases,  with 
4  deaths,  i.e.,  a  mortality  of  14*2  per  cent.  Tuttle  found  the  mortality 
to  lie  20  per  cent,  in  a  collection  of  1,578  resections,  which  were  per- 
formed by  various  methods.  HartweU  (Ann.  of  Surg.,  1905,  vol.  xlii., 
p.  399;  analysed  the  results  of  46  radical  operations  by  17  New  York 
surgeons,  and  found  the  mortality  to  be  26  per  cent. 

In  this,  as  in  every  other  comparatively  novel  and  important  opera- 
tion, a  very  large  number  of  unsuccessful  cases  will  remain  unpublished, 
whilst  nearly  every  successful  case  is  reported  at  once.  The  real  death- 
rate,  therefore,  when  the  facility  with  which  shock,  haemorrhage,  cellu- 
litis, peritonitis,  may  occur  in  a  part  which  cannot  be  kept  absolutely 
aseptic,  and  in  patients  no  longer  young  and  the  subjects  of  rectal 
cancer,  is  fairly  estimated,  lies  probably  between  15  and  20  per  cent. 
Nor,  when  we  consider  how  limited  man's  capacity  for  bearing  grave 
operations  remains,  however  much  we  have  advanced  in  surgery,  is  it 
at  all  probable  that  the  death-rate  will  fall  much  below  2d  per  cent., 
if  all  cas.s  operated  on  are  honestly  reported.  When  we  consider  the 
mortality  of  inguinal  colotomy  for  rectal  cancer,  excluding  the  cases 
where  colotomy  is  performed  under  the  most  unfavourable  circnmstan 
of  obstruction,  in  other  words  "  the  too  late  cases,"  the  mortality  will  be 
distinctly  less,  varying  from  under  5  to  under  10,  accordingly  as  the 


EXCISION   OF   THE    RECTUM.  779 

operation  is  performed  by  operators  of  especial  experience  or  otherw  Lse. 
Here,  too,  the  value  of  statistics  is  greatly  impaired  by  the  tendency  to 

publish  only  successes.  But  there  can  he  no  doubt  whatever  that 
colotomy  in  cases  uncomplicated  by  obstruction  is  most  distinctly  a 
safer  operation  than  excision  of  the  rectum  from  the  perinsBum,  and,  a 
fortiori,  than  the  severer  methods. 

(ii.)  Dv/ration  of IAfe. — With  regard  to  this  point,  I  think  a  larger 
number  of  cases  will  show  that  if  the  surgeon  decides  to  advise,  and  the 
patient  is  willing  to  run  the  risk  of,  the  more  serious  operation,  the 
prolongation  of  life  will  be  greater  here  than  after  colotomy,  if  the  cases 
are  wisely  selected.  I  think  that  the  above  is  borne  out  by  the  results 
of  the  statistics  which  we  have.  It  is  rare  for  patients  after  colotomy 
for  carcinoma  to  survive  more  than  one  year  and  a  half.  Making  due 
allowance  for  the  advanced  date  at  which  cases  of  rectal  cancer  too  often 
come  under  treatment,  for  the  fact  that  excision  will  usually  be  per- 
formed in  selected  cases,  and  that  thus  colotomy  will  be  reserved  for 
those  less  favourable,  I  think  the  published  cases  of  excision  show  a 
greater  prolongation  of  life. 

Volkmann  (Sammluwj  Klin.  Vortrdrje,  May  13,  1878)  claimed  three 
complete  cures  and  several  cases  of  very  late  recurrence,  viz.,  one  after 
6  years,  one  after  5,  and  one  after  3.  One  case  died  of  carcinoma  of 
the  liver  8  years  after  operation  without  local  recurrence,  and  one  case 
remained  well  11  years  after  the  removal  of  a  large  mass  reaching  high 
up  ;  in  this  case  recurrence  occurred  twice  in  the  scar,  and  was  removed. 
Czerny's  experience  is  also  very  good.  Two  of  his  cases  had  survived 
the  operation  over  4  years,  one  3  years  and  4  months  ;  three  others  were 
well  after  intervals  of  at  least  2  years  (Henck,  Arch.  f.  Klin.  Chir., 
Bd.  xxix.  Hft.  3).  Mr.  Ball  (Diseases  of  the  Rectum  and  Anus,  2nd  ed. 
p.  364)  has  had  one  patient  alive  and  well  9  years  and  another  6  years 
after  operation.  Mr.  Cripps  (loc.  supra  cit.)  has  had  one  case  free  from 
recurrence  12  years,  two  6  years,  one  5  years,  two  4  years,  one  3  years, 
after  operation.  More  recently  Kraske  (loc.  supra  cit.),  in  the  series 
of  51  cases  above  referred  to,  states  that  16  patients  died  from  inter- 
current disease,  without  signs  of  recurrence  or  metastasis,  at  times 
varying  from  1^  to  5  years  after  the  operation,  and  15  patients  were 
alive  and  free  from  recurrence  three-quarters  of  a  year  to  8^  years  after 
the  operation.  Keen  (Ther.  Gaz.,  April,  1897)  gives  the  results  of  12 
cases  which  survived  the  operation ;  4  had  passed  the  4-year  limit, 
and  2  others  had  nearly  reached  it,  without  recurrence.  Hartwell 
(loc.  supra  cit.)  states  that  5  patients  (11  per  cent.)  out  of  44  were 
alive  and  free  of  recurrence  over  3  years  after  the  operation.  Ten 
others  were  free  of  recurrence,  but  in  only  2  of  these  had  the 
operation  been  performed  more  than  a  year  before  the  analysis  was 
made. 

(iii.)  Amount  of  Comfort  Afforded. — After  this  operation,  as  after 
excision  of  the  larynx,  a  distinction  must  be  drawn  between  mere 
survival  and  what  deserves  the  name  of  recovery.  The  amount  of 
comfort  enjoyed  by  the  patient  will  depend  on — (1)  the  amount  of 
contraction  that  takes  place  ;  (2)  how  far  he  has  control  over  his 
motions.  The  patient  should  always  be  warned  about  these  sequela?. 
If  he  does  not  keep  under  observation,  and  contraction  follows,  I 
consider  his   case  will   compare   most  unfavourably  with  that  after  a 


78o  OPERATIONS  ON  THE  ABDOMKN. 

well-performed  colotomy,  and  may  even  be  as  bad  as  that  of  a  patient 
with  advanced  rectal  cancer,  (i)  Where  the  whole  circumference  of 
the  bowel  has  been  removed,  and  a  raw  surface  left,  it  is  obvious  that 
there  must  be  a  great  risk  of  contraction  in  the  scar  tissue  which 
replaces  the  mucous  membrane.  This  contraction  forms  a  most  serious 
difficulty  in  the  after-treatment,  and  is  liable  to  lead  to  most  unsatis- 
factory results.  The  more  the  connective  tissue  around  the  bowel  is 
interfered  with,  the  more  profuse  the  suppuration,  and  the  longer  the 
healing,  the  more  marked  will  the  contraction  be.  Colotomy  has  been 
required  for  it,  as  occurred  in  a  case  under  my  care,  where  excision  of 
the  rectum  had  been  performed  elsewhere.  The  above  risk  may  be 
obviated,  no  doubt,  by  drawing  down  the  bowel  and  suturing  it  to  the 
skin  ;  but  this  step  (p.  788)  is  not  always  feasible,  especially  in  men, 
and  if  sutures  are  inserted  they  cut  through  quickly  (vide  infra).  The 
severed  end  of  the  bowel  is  drawn  considerably  downwards  during  the 
process  of  healing.  This  renders  it  easier  for  the  patients  to  pass  a 
bougie  from  time  to  time,  the  need  of  which  must  be  firmly  impressed 
upon  them.  Another  means  of  securing  the  patency  of  the  bowel  is  by 
wearing  a  vulcanite  tube,  as  recommended  by  Mr.  Allingham.  These 
are  three  or  four  inches  long,  with  one  end  conical,  and  with  the 
other  ending  in  a  broadish  flange  to  prevent  it  slipping  into  the 
bowel,  and  also  to  enable  it  to  be  stitched  to  a  bandage,  which 
keeps  it  in  place.  Patients  begin  to  wear  it  about  a  fortnight  after 
the  operation,  and,  save  for  taking  it  out  when  the  bowels  act,  retain 
it  constantly  for  some  months,  some  having  to  wear  it  for  the  rest  of 
their  lives. 

(2)  As  to  the  power  of  retaining  fseces,  incontinence  is  nearly  always 
present  at  first,  but  control  is  usually  regained  after  a  time,  save  where 
the  motions  are  loose.  Mr.  Cripps  (loc.  supra  cit.)  states  that  incon- 
tinence was  present  in  only  seven  out  of  36  cases  which  he  collected. 
Torsion,  after  the  advice  of  Gersuny  (vide  infra),  as  a  preventive 
when  the  entire  circumference  of  the  bowel  and  the  sphincters  have  been 
removed,  has  proved  satisfactory  in  some  cases  (p.  800). 

Operation. 

The  preliminary  treatment  is  most  important.  The  patient  should 
be  kept  in  bed  for  several  days  before  the  operation,  and  the  strength 
and  general  condition  improved  as  much  as  possibleby  the  administration 
of  plenty  of  Light,  easily  digested,  and  nitrogenous  food,  which  leaves 
but  little  residue.  The  rectum  and  large  intestine  should  also  be 
thoroughly  emptied  by  means  of  mild  purgatives  and  daily  enemata. 
Although  purgation  is  the  only  satisfactory  way  of  bringing  the  colon 
and  rectum  into  a  state  of  comparative  cleanliness,  it  must  not  be  over- 
done, so  as  to  weaken  the  patient ;  and  no  laxative  should  be  given  for 
at  least  twenty-four  hours  before  the  operation,  but,  on  the  contrary, 
peristalsis  is  to  be  inhibited  by  the  administration  of  opium.  The 
rectum  and  colon  are  thoroughly  emptied  by  means  of  enemata  the  last 
of  which  is  given  about  three  hours  before  the  time  fixed  for  the  operation. 
When  the  patient  is  under  the  anaesthetic,  the  bowel  is  washed  out 
with  an  antiseptic  solution.  If  the  growth  causes  marked  obstruction 
to  the  passage  of  faeces  or  to  the  efficient  administration  of  enemata, 
lavage  of  the  bowel,  by  means  of  a  long  rectal  tube  passed  through  the 
stricture,  should  be  made  use  of.     h\  order  to  promote  rapid  healing 


EXCISION   OF   THE    RECTUM.  781 

and  prevent  suppuration  as  much  as  possible,  every  efforl  should  be 
made  to  render  the  bowel  as  little  septic  as  possible.  To  this  end 
intestinal  antiseptics,  such  as  resorcin,  salol,  &c,  may  be  administered 
by  the  mouth,  and  weak  antiseptic  solutions  used  for  lavage  and  for 
the  enemata.  Commercial  peroxide  of  hydrogen  £,  or  perchloride 
of  mercury  -%jfejj  may  be  used.  Where  a  rapid,  soft  growth,  quickly 
ulcerating,  has  given  rise  to  a  foul  discharge,  Dr.  E.  H.  Taylor  (Ann. 
of  Surg.,  vol.  i.  1897,  p.  385)  recommends  curetting  as  a  preliminary 
measure  in  order  to  bring  about  a  sweeter  condition  of  the  growth  and 
surrounding  parts.  He  makes  use  of  a  flushing  spoon  for  this  purpose, 
and  finds  that  the  hemorrhage  is  "trivial,  and  soon  ceases."  On  the 
other  hand,  Kraske  considers  that  this  should  be  done  only  exceptionally, 
as  it  is  not  without  danger.  The  perinaBum  and  pubis  are  shaved  and 
cleansed,  and  a  suitable  compress  is  applied  on  the  evening  before  the 
operation. 

Question  of  Colotomy  before  Excision  oj  the  Rectum. — Theoretically 
this  preliminary  step  would  seem  very  advisable,  as  diverting  the  fasces, 
and  thus  a  source  of  decomposition,  and  as  doing  away  with  the  need 
of  the  use  of  bougies  to  prevent  contraction  (Haslam,  St.  Thomas's 
Hosp.  Rep.,  vol.,  xviii.  p.  151);  but  the  opinions  of  authorities  differ. 
Kraske  only  makes  use  of  it  when  the  growth  is  causing  obstruction, 
and  so  prevents  efficient  emptying  of  the  bowel  before  operation.  He 
then  makes  the  artificial  anus  in  the  transverse  colon,  as  being  less 
likely  to  interfere  with  the  subsequent  operation  and  more  easy  to  close 
later.  On  the  other  hand,  M.  Qu6nu,  quoted  by  Taylor  (loc.  supra  cit.), 
always  performs  a  preliminary  inguinal  colotomy,  usually  about  twelve 
days  before  the  main  operation.  Keen  (Journ.  Amer.  Med.  Assoc,  1898) 
also  is  in  favour  of  a  colotomy,  and,  moreover,  makes  the  artificial 
anus  a  permanent  one  by  closing  the  upper  end  of  the  divided  rectum 
after  removal  of  the  growth. 

Hartwell  (loc.  cit.)  also  advocates  a  preliminary  complete  colotomy 
in  all  cases,  maintaining  that  a  controllable  anus  is  a  very  rare  thing 
after  a  satisfactory  removal  of  the  rectum  for  growth ;  in  only  two  out 
of  46  cases  was  good  function  re-established.  The  risks  of  sepsis 
are  lessened,  and  the  probability  of  wide  and  complete  removal  of  the 
growth  is  increased,  when  a  permanent  colotomy  is  adopted.  He  also 
believes  that  the  combined  mortalities  of  complete  preliminary  colotomy 
and  resection  would  be  lower  than  that  of  resection  without  preliminary 
artificial  anus.  The  chief  objections  to  a  preliminary  colotomy  are 
that  it  causes  loss  of  valuable  time  without  a  compensating  advantage, 
since,  with  careful  preliminary  evacuation  of  the  bowel,  the  operation 
and  the  after-course  are  quite  satisfactory  without  it ;  that  it  saps  the 
patient's  strength  and  so  diminishes  his  power  of  standing  the  more 
severe  operation  ;  and  that,  by  fixing  the  bowel  above,  it  may  interfere 
with  its  mobility,  thus  nreventing  it  from  being  efficiently  pulled  down 
at  a  second  operation.  Moreover,  a  third  or  even  a  fourth  operation 
may  be  required  to  close  the  artificial  anus  after  the  new  rectum  has 
soundly  healed.  Finally,  as  remarked  by  Mr.  Ball,  the  advantages  of 
retaining  a  fsecal  outlet  in  theperinseum  are  great,  so  long,  of  course,  as 
this  is  not  contracted. 

It  would  seem,  therefore,  that  the  wisest  course  lies  in  reserving 
colotoury  for  (i.)  those    cases   in    which   there  is   either   declared   or 


78: 


OPERATIONS   ON    THE    A  I'.DuM  |-;\. 


threatened  obstruction,  preventing  the  proper  evacuation  of  the  bowel 
before  the  growth  is  excised  ;   (ii.)  cases  in  which  it  is  fairly  certain 

that  it  will  never  be  possible  to  secure  a  controllable  anus  in  the  natural 
position.  An  inguinal  artificial  anus  is  preferable  and  more  under  the 
control  of  the  patienl  than  a  sacral  one,  and  it  is  far  better  than  a  long 
fibrous  stricture,  or  the  ulcerating  track,  devoid  of  any  control,  which  so 
often  follows  an  unsatisfactory  perinseal  excision.  I  have  seen  patients 
whose  lives  have  been  very  miserable  under  these  conditions,  and  who 
have  been  greatly  relieved  by  a  secondary  colotomy. 


CHOICE    OF    OPERATION. 

The  most  suitable  operation  in  a  given  case  will  vary  according  to 
the  position  and  extent  of  the  growth.  For  an  early  growth  situated 
in  the  lowest  two  inches  of  the  rectum  the  operation  by  a  perinseal 
incision  will  usually  suffice,  and  should  be  chosen  on  account  of  its  low 
mortality.      See  table. 

Tuttle  collected  1,578  cases  of  extirpation  of  the  rectum  and  sigmoid 
(pelvic  colon)  : — 


Method. 

Number 

of  CaS68. 

Dea*.li>. 

Mortality. 

Sacral   ... 
Perinseal 
Abdominal 
Combined 

nal 

Anal 

913 
569 

49 
22 

23 
2 

211 

76 

18 

9 

3 

2 

23-1  per  cent. 
l3'5   ii       » 
367   ••       - 
4°'9   ,1       •, 

I4'3      »            H 

IOO      ., 

Total 

1,578 

3i9 

202     .. 

In  many  cases,  however,  it  is  impossible  to  preserve  functional 
sphincters  by  this  operation,  which  is  also  accompanied  by  more 
haemorrhage  than  either  the  sacral  or  the  abdominal  operation.  When 
it  is  not  possible  to  bring  the  bowel  to  the  anus,  and  to  re-establi>h 
control,  it  is  probably  better  to  perform  either  preliminary  or  secondary 
colotomy.  In  the  female,  especially  when  the  growth  is  adherent 
to  the  vagina,  the  vaginal  method  may  be  chosen,  and  it  has  a  low 
mortality. 

When  the  growth  does  not  extend  higher  than  the  middle  of  the 
sacrum,  and  docs  not  involve  the  rectum  as  low  as  the  sphincters,  the 
sacral  route  is  to  be  preferred.  This  is  especially  true  if  there  is  any 
adhesion  to  the  sacrum  or  coccyx.  Bone  flap  operations  have  recently 
come  into  greater  favour  again,  and  the  risk  of  necrosis  is  not  consider- 
able if  the  bones  are  not  wired  together,  and  only  the  soft  parts  are 
sutured,  when  good  union  generally  follows  with  firm  re-establishment 
oi  tin;  pelvic  floor  and  attachments  of  the  pelvic  diaphragm.     In  some 


EXCISION    OF   THE    RECTUM. 

cases,  when  the  bowelabove  the  growth  cannot  be  liberated  sufficiently, 
the  abdomen  maybe  opened  for  this  purpose,  through  the  lower  part  of 
the  left  rectus  muscle.  In  one  case  I  avoided  this  necessity  by  seeking 
and  drawing  down  a  mobile  sigmoid  loop  from  the  sacral  wound.     The 

middle  of  the  loop  was  easily  brought  to  the  anus  without  any  tension. 
When  this  fact  was  recognised,  there  was  no  need  to  preserve  the 
blood  supply  of  the  upper  part  of  the  rectum,  which,  together  with 
the  lower  part  of  sigmoid,  was  easily  removed  through  the  sacral 
wound. 

The  haemorrhage,  which  used  to  be  the  terror  of  this  operation,  is 
largely  avoided  by  securing  the  vessels  at  the  upper  end  of  the  incision 
and  then  dissecting  the  bowel  from  its  anterior  connections  from  above 
downwards,  instead  of  in  the  reverse  direction.  The  dangers  of  infec- 
tion of  the  peritonaeum  are  minimised  by  taking  care  not  to  open  the 
bowel  before  it  is  withdrawn  from  the  wound.  Every  effort  should  be 
made  to  bring  healthy  and  vascular  intestine  down  to  the  lower 
segment,  or,  if  possible,  to  the  anus,  without  tension.  Failing  this, 
a  sacral  anus  may  be  made,  the  bowel  being  drawn  out  through  the 
piriformis  and  gluteus  maximus  as  well  as  twisted  after  Gersuny's 
method. 

When  the  growth  is  entirely  above  the  peritonaeal  reflection,  and  the 
finger  cannot  reach  beyond  the  growth,  an  abdominal  exploration  should 
be  recommended.  This  enables  the  surgeon  to  examine  for  secondary 
growth  and  enlarged  glands,  and  to  determine  the  extent  and  mobility  of 
the  tumour.  He  can  then  choose  his  subsequent  procedures.  When 
secondary  growths  exist  it  may  be  wise  to  close  the  abdomen  without 
even  performing  colotomy.  When  the  growth  is  irremovable  a  per- 
manent artificial  anus  can  be  at  once  performed.  In  other  cases  with 
accumulation  of  faeces,  especially  of  scybala,  a  temporary  artificial 
anus  may  be  made,  to  be  followed  later  by  resection  by  the  sacral, 
abdominal,  or  one  of  the  combined  methods. 

When  the  growth  occupies  the  upper  part  of  the  rectum  or  the  pelvic 
colon  one  of  the  abdominal  or  combined  methods  should  be  selected, 
and  it  is  to  be  hoped  that  recent  improvements  in  technique  may 
reduce  the  high  mortality  which  has  attended  these  operations,  until 
quite  recently.  The  methods  described  by  Sir  Charles  Ball  and  Miss 
Aldrich  Blake  have  much  to  recommend  them,  but  they  are  not  capable 
always  of  application.  Under  these  circumstances  the  surgeon  must 
make  an  artificial  anus,  so  that  he  may  not  be  tempted  to  remove  too  little 
of  the  rectum  on  the  one  hand,  or  to  join  parts  which  are  ill-nourished 
or  under  too  great  tension  on  the  other.  Whenever  possible  it  is  wise 
to  bring  the  upper  segment  to  the  anal  margin,  or  at  least  below  the 
pelvic  diaphragm.  Sepsis,  which  is  the  chief  cause  of  failure  here,  is 
thus  prevented  to  a  great  extent.  With  the  same  object  always  in 
view,  the  surgeon  should  refrain  from  dividing  the  intestine  until  the 
peritonaeum  has  been  closed  by  suture  or  packing,  and  until  the  bowel 
has  been  drawn  out  of  the  wound  if  possible.  Failing  this,  the  division 
must  be  made  between  clamps  or  ligatures,  and  the  ends  sterilised 
and  covered. 

I.  Perinseal  Excision. — When  the  disease  involves  the  anal  canal 
or  the  very  lower  part  of  the  rectum  Allingham's  method  may  still  be 
used  (Figs.  308,  309),  but  when  the  growth  is  a  little  higher  and  the 


7«4 


nl'KI!  ATIONS    ON    TIIK    ABDOMEN. 


external  sphincter  can   be  saved  it  is  better  to  adopt  the  following 
adaptation  of  Quenu's*  method: — 

The  patient  is  anaesthetised  and  placed  in  the  lithotomy  position 
with   the   pelvis   slightly   raised.      The   rectum   is   cleansed,  dried,  and 

Fig.  308. 


Perinatal  excision  of  rectum.  The  patient  is  placed  in  lithotomy  position,  and 
the  surgeon  makes  an  oval  incision  into  both  ischiorectal  fossre  around  the  bowel, 
then  prolongs  this  oval  incision  backwards  so  as  to  reach  the  coccyx.    (Allingham.) 

loosely  packed  with  gauze  so  that  its  wall  may  be  easily  recognised  and 
avoided  during  the  later  stages  of  the  operation.  The  vagina  is  also 
washed  out  and  the  bladder  emptied.     An  incision  is  made  close  to 


Fig.  309. 


(Allingham.) 

and  around  the  anus,  and  the  mucous  membrane  of  the  anal  canal  is 
dissected  up  for  about  half  an  inch,  where  it  is  firmly  tied  by  means 
of  a  strong  silk  ligature,  and  the  end   of  the  stump  is  sterilised  with 

*  Quenu,  Rev.  de  Gynecol.,  September,  1898;   Tuttle,  Diseases  of  the  Rectum  and 

Colon,  1903. 


EXCISION    OF   THE    RECTUM. 


785 


the  cautery.  The  ends  of  the  elliptical  incision  are  then  continued 
backwards  as  far  as  the  tip  of  the  coccyx  and  forwards  into  the 
perineum  nearly  as  far  as  the  scrotum.  The  fibres  of  the  external 
sphincter  arc  separated  and  divided  exactly  in  the  middle  line  anteriorly 
and  posteriorly,  and  drawn  aside  with  the  skin  (Fig.  310). 

The  posterior  wound  is  deepened  and  the  rectum  is  freed  upon  its 
posterior  and  lateral  aspects,  the  levator  ani  being  divided  close  to  the 
rectum  (Fig.  311).  The  anterior  fibres  are  divided  last  after  being 
isolated  by  passing  the  finger  forwards  and  upwards  close  to  rectum 
(Fig.  311).  By  blunt  dissection  the  rectum  is  then  freed  from  the 
sacrum,  and  from  the  loose  pelvic  cellular  tissues  upon  its  lateral  aspect. 


Fig.  310. — Perineal  Extirpation  of  the  Rectum  (Qm'nu's  method. 
i?,  rectum  ;  E,  external  sphincter  ;  C,  coccyx  ;  1\  transversus  perinaji  muscles  ;  A,  bulbous 

urethra.     (Tattle.) 

The  separation  of  the  bowel  in  front  varies  with  the  sex  of  the 
patient.  In  a  male,  a  full-sized  metal  sound  having  been  passed  into 
the  bladder  and  kept  well  hooked  up  under  the  pubes,  the  surgeon 
carefully  dissects,  partly  with  his  ringer  and  partly  with  scissors, 
between  the  bowel  and  urethra  and  prostate.  These  parts  are  natur- 
ally adherent,  and  this  dissection  must  be  carefully  conducted,  as  any 
opening  into  the  bladder  or  urethra  or  injury  of  the  ureters  is  a 
serious  matter.  As  it  is  freed  the  bowel  is  drawn  backwards  and 
downwards  so  as  to  afford  a  good  view  of  the  depth  of  the  wound 
(Fig.  312);  disarticulation  of  the  coccyx,  which  is  then  folded 
backwards,   facilitates  this  procedure. 

In  the  case  of  a  woman  the  surgeon's  left  index,  or  the  finger  of  an 
assistant  in  the  vagina,  will  give  the  best  warning  of  his  knife  or 

s. — vol.  11.  50 


786  OPERATIONS   ON   THE    A.BDOMEN. 

scissors  (the  latter,  long  and  blunt-pointed,  are  preferable)  getting  too 

near  the  vaginal  mucous  membrane.  If  this  be  encroached  upon,  it 
must  he  removed  without  hesitation,  and  the  opening  thus  made  closed 
towards  the  end  of  the  operation  (p.  802). 

On  continuing  the  dissection  upwards  the  peritonaeal  pouch  in  front 
of  the  rectum  is  displayed.  In  some  cases,  when  the  growth  does  not 
extend  beyond  this  pouch,  it  is  possible  to  avoid  opening  the  peri- 
tonaeum by  displacing  the  peritonaeum  upwards  by  blunt  dissection. 
In  the  majority  of  cases,  however,  it  is  best  to  open  the  peritonaeum  at 
its  lowest  point  (Fig.  313),  and  then  to  continue  the  incision  to  either 
side  close  to  the  rectum  until  the  meso-rectum  is  reached.     This  is 


Fig.  311. — I'kuin.kal  Extirpation  -loosening  Rbctum  from  Anterior 

Perineal  Ehapiik. 

L,  levator  ani  ;  J>,  rectum  ;  M,  rhaphe.     (Tattle.) 

divided  close  to  the  sacrum  so  that  it  can  be  drawn  downwards  with 
the  bowel.  This  avoids  the  risk  of  dividing  the  superior  hemorrhoidal 
artery  at  this  stage  in  the  depth  of  the  wound,  and  also  enables  the 
surgeon  to  remove  the  glands  within  the  meso-rectum. 

The  small  intestines  are  packed  away  with  gauze,  which  also  serves  to 
collect  any  blood  which  tends  to  gravitate  towards  the  abdomen  when 
the  pelvis  is  elevated.  The  rectum  is  separated  freely  enough  to 
allow  the  growth  to  be  drawn  well  out  of  the  wound,  and  the  bowel  at 
least  an  inch  above  the  disease  to  be  brought  down  and  sutured  without 
tension  to  the  anal  skin.  The  superior  haemorrhoidal  artery  is  tied 
and  divided.  The  parietal  peritonaeum  is  then  sutured  to  the  serous 
covering  of  the  rectum,  with  the  double  object  of  closing  the  peritonaeal 
cavity   as  far   as  possible  and    lessening  the   tendency  to  retraction. 


EXCISION    OF   THE    RECTUM. 


7*7 


Fig.  312. — Perineal  Extirpation. 
/.'.  rectum  :  L.  levator  ani ;  G,  neoplasm  ;  P,  peritonseal  pouch ;  S,  seminal  vesicles  and 

prostate.     (Tuttle.) 


Fig.  313. — Perineal  Extirpation — the  Peritoneal  Pouch  laid  open. 

(Tuttle.) 

50—2 


788 


OPERATIONS  ON  THE  ABDOMEN. 


Next  the  edges  of  the  levator  ani  are  sewn  together  and  to  the  side  of 
the  rectum  ;  this  serves  to  reconstitute  the  pelvic  floor,  to  limit  retrac- 
tion and  do  away  with  the  dead  space,  which  otherwise  tends  to  fill 
with  hlood  or  serum  and  to  get  infected. 

The  howel  is  drawn  down  and  clumped  well  above  the  growth  with 
long  curved  intestinal  forceps,  the  handles  of  which  are  below  or 
behind.  These  prevent  any  leakage,  retraction,  or  haemorrhage  during 
the  next  stage.  The  rectum  is  cut  across  one-third  of  an  inch  below 
the  forceps  and  at  least  one  inch  above  the  disease.  The  margin  is 
then  accurately  joined  to  the  anal  skin,  with  numerous  interrupted  silk 
sutures,  which  pierce  all  the  coats  of  the  rectum  and  secure  a  good  hold. 


Fig.  314. — Perineal  Extirpation. 
P,  lateral  peritonaeal  folds  ;    I  .  glandular  enlargement  between  folds  of  nicso-rectura. 

(Tuttle.) 

The  anterior  and  posterior  wounds  are  closed  near  the  rectum  by 
sutures  which  pass  deeply  and  bring  the  divided  ends  of  the  external 
sphincter  together.  The  wound  is  drained,  and  a  tube  is  passed  into 
the  rectum  (Fig.  315). 

Mr.  Cripps  considers  that  any  attempt  to  bring  down  the  cut  edges 
of  the  rectum,  and  to  stitch  them  in  situ  around  the  anus,  is  perfectly 
useless,  as  the  sutures  are  certain  to  cut  their  way  out,  and  harmful, 
as  likely  to  prevent  the  escape  of  discharges.  As  this  entails  the  very 
serious' risk  of  septicaemia,  the  advantage  which  suturing  the  bowel 
would  give,  if  it  were  safe,  of  preventing  subsequent  contraction 
(p.  779)  has  been  put  aside. 

On  the  other  hand,  Volkmann,  Czerny  (loc.  supra  cit.)  and  others 
have  recommended  the  use   of  sutures  so  as  to  hasten   healing  and 


EXCISION   OF   THE    RECTUM.  789, 

obviate  the  tendency  to  Rtricture.  It'  they  are  employed,  they  must 
be  passed  as  advised  by  Ball,  not  only  through  skin  and  bowel,  but 
also  deeply  through  the  Burrounding  pelvic  structures  us  well; 
drainage-tubes  should  also  be  inserted  here  and  there  between  the 
sutures.  Superficial  sutures  are  then  put  in  as  well,  so  as  to  further 
diminish  the  strain.  If  these  precautions  are  taken,  if  no  faecal  con- 
tamination of  the  wound  has  occurred,  if  antiseptic  precautions  have 
been  taken  throughout,  and  if  the  wound  has  been  rendered  thoroughly 
dry  and  bloodless,  the  employment  of  sutures  is  recommended  in 
appropriate  cases. 

Mr.   Bidwell  {Brit.   Med.  Journ.,   Oct.    21,   1899)  recommends   the 
following  plan  to  enable  the  edges  of  the  wound  to  be  brought  together. 


iFic  315. — Perix.eal  Extirpation  Completed. 
U,  tampon  and  drainage-tube  in  anus.     (Tuttle.) 

Two  transverse  incisions  about  two  inches  long  are  made  on  each  side 
of  the  perinaeal  incision.  The  flaps  of  skin  so  formed  are  then  dis- 
sected up  and  attached  to  the  cut  edge  of  the  rectum  by  means  of 
silkworm  gut  sutures.  As  a  rule,  this  can  be  carried  out  without 
undue  tension,  but  should  there  be  any,  a  longitudinal  incision  in  the 
posterior  surface  of  the  rectum  will  enable  the  union  to  be  effected. 

If  the  growth  reaches  the  skin  of  the  anus  the  inguinal  lymphatic 
glands  must  be  carefully  examined,  and,  if  found  enlarged,  they  must 
be  removed  either  at  once  or  at  a  second  operation.  If  the  bowel 
cannot  be  sutured  in  the  position  of  the  anus,  Taylor  (loc.  supra  cit.) 
recommends  that  "  it  be  drawn  backwards  in  the  middle  line  between 
the  levatores  ani  and  a  subcoccygeal  anus  formed.  The  wound  in 
front  is  then  closed  by  deep  sutures.     As  Mr.  Ball  points  out,  they 


790  OPERATIONS  ON  THE  ABDOMEN. 

have  the  great  advantage  of  not  leaving  recesses  about  the  rectum  in 

which  serum  might  collect  and  decompose.  These  deep  sutures  should, 
of  course,  include  the  levatores  ani ;  our  object  being  to  reconstruct  a 
sphincteric  apparatus." 

Question  of  partial  removal. — If  any  of  the  mucous  membrane, 
even  a  mere  strip,  can  be  safely  left,  the  amount  of  subsequent  con- 
traction will  be  less ;  but  here,  as  in  all  other  operations  for  malignant 
disease,  every  consideration  must  give  way  to  the  chief  object,  that  of 
extirpating  the  growth. 

Partial  operations  should  be  reserved  only  for  cases  where  the  disease 
is  very  localised  in  amount,  and  admits  of  extirpation,  together  with 
a  very  wide  margin  of  bowel.  Where  the  disease  implicates  one-half 
of  the  bowel,  even  if  apparently  not  disseminated  in  the  mucous  mem- 
brane, the  whole  circumference  should  be  removed.  Mr.  Allingham 
thus  condemns  partial  operations  :  "  The  partial  removal  of  the  cir- 
cumference of  the  bowel  is,  in  my  opinion,  most  unsatisfactory.  In 
all  the  cases  in  which  I  have  removed  only  part  of  the  wall  there  has 
been  either  a  return  of  the  disease  in  the  rectum,  or  in  the  glands  in 
the  groin,  or  in  some  internal  organ,  mostly  the  liver." 

If  the  surgeon  decide  on  a  partial  operation,  he  must  be  prepared 
for  some  increased  difficulty,  owing  to  the  diminished  room  for  working, 
and  meeting  tlie  haemorrhage.  Perhaps  only  one  semilunar  incision 
around  the  anus  will  be  required. 

In  rare  cases  a  growth  which  forms  the  presenting  part  of  an  intus- 
susception, or  a  growth  limited  to  one  aspect  of  the  rectum,  may  be 
capable  of  withdrawal  through  the  dilated  anus.  In  such  cases,  which 
are  early  ones  with  unusual  mobility  and  freedom  from  invasion  of 
neighbouring  tissues,  the  intussuscepted  mass  can  be  safely  resected, 
and  the  remaining  healthy  ends  joined  together  after  Maunsell's 
method  (vide  p.  364),  but  the  lymphatic  glands  cannot  be  removed. 

(ii.)  Kraske's  Operation  and  its  Modifications  (Fig.  319). — Kraske, 
of  Freiburg  (Arch.  f.  Klin.  Chir.,  Bd.  xxxiii.  S.  563),  introduced  this 
route  as  best  adapted  for  those  cases  which,  in  Volkmann's  words,  are 
situated  too  high  for  the  perimcal  route  and  are  too  low  and  too  fixed 
to  admit  of  removal  by  abdominal  section.  It  will  be  understood  by 
all  that  this  is  an  operation  of  great  severity,  and  only  justifiable  when, 
as  compared  with  colotomy,  the  risks  on  the  one  hand,  and  the  advan- 
tage on  the  other,  of  attempting  a  radical  cure,  and,  at  all  events, 
affording  a  greater  prolongation  of  life  (p.  778),  have  been  fairly  put 
lx  lore  the  patient  or  the  friends.  Again,  it  is  only  a  surgeon  who  has 
had  large  operating  experience  who  should  undertake,  and  only  patients 
who  have  sufficient  reparative  power  who  should  be  submitted  to,  any 
of  these  operations  of  excision  of  the  rectum,  more  particularly  to  this 
and  the  ones  that  follow.  For  at  least  four  days  before  the  operation 
the  patient  should  be  prepared  by  aperients  and  enemata  and  a  wisely 
restricted  fluid  diet.*  The  parts  having  been  previously  shaved  and 
cleansed,  the  latter  process  is  repeated  when  the  patient  is  passing 
under  the  anaesthetic,   and  the  bowel  cleansed  as  high  up  as  possible 

*  Dr.  ('.  I'..  Kelsej  (New  York  Med.  .fount.,  vol.  ii.  1895,  p.  457)  advises  thai  a  dose 
of  morphine  and  bismuth  should  be  given  on  the  evening  before,  and  repeated  a  few  hours 
before  the  operation.  The  paper  is  an  excellent  one.  full  of  practical  hints  from  which 
I  have  borrowed  largely. 


EXCISION    <)F   THE    RECTUM. 


7'<i 


by  irrigation  with  lot,  hydr.  perch,  (i  in  5000),  and  with  swabs  of 

iodoform  gauze  on  long  forceps.  A  tampon  of  iodoform  gauze  may  be 
left  iii  the  rectum  for  Localising  purposes,  but  too  large  a  mass  obscures 
palpation  id' the  diseased  part  from  the  incision.  Every  can;  must  be 
taken    not    to    open    the    bowel  during    its   liberation.       The    patient 

Fig.  316. 


From  a  dissection  made  by  J//1.  E.  II  Taylor. 

The  black  clots  over  the  sacrum  indicate  the  levels  of  the  first,  second,  third, 

and  fourth  posterior  sacral  foramina. 

1.  Gluteus  maximus  muscle.  6.  Pyriformis  muscle. 

2.  Sciatic  artery.  7-  Lesser  sacro-sciatic  ligament. 

3.  Great  sacro-sciatic  ligament.  8.  Coccygeus  muscle. 

4.  Levator  ani.  9-  Internal  pudic  artery  and  pudic  nerve. 

5.  Sphincter  ani  externus.  10.  Obturator  internus  muscle. 

may  be  on  bis  right  side  as  recommended  by  Kraske,  or  on  his 
face,  or,  again,  in  the  lithotomy  position,  according  to  the  conveni- 
ence of  the  operator.  If  the  thighs  are  kept  well  flexed,  and  a  sand 
pillow  is  placed  under  the  lumbar  spine,  it  will  be  found  that  the 
lithotomy  position  is  very  suitable,  the  intestines  in  this  position  fall- 
ing away  from  the  recto-vesical  pouch,  the  separation  of  the  peritoneum 


792 


OPERATIONS   ON   THE    ABDOMEN. 


being  thus  facilitated,  and  moreover,  the  light  coming  from  above,  the 
deep  wound  will  be  well  illuminated,  and  the  whole  of  its  extent  well 
under  the  eye  of  the  operator.  Whatever  be  the  position,  the  pelvis 
should  be  elevated,  so  as  to  diminish  haemorrhage.     An  incision  is  then 


Fig.  317. 


From  a  dissection  made  by  Mr.  /'.  II.  Taylor, 

The  black  dots  over  the  sacrum  indicate  the  levels  of  the  first,  second,  and  third 

posterior  sacral  foramina. 

Glutens  lnaximus  muscle. 

Levator  ani. 

Sphincter  ani  externus. 

Sacral  canal. 

Lateral  sacral  artery. 

Rectum. 

Middle  haemorrhoids]  artery. 

made  in  the  middle  line  from  the  posterior  edge  of  the  anus  to  the 
centre  of  the  sacrum,  the  knife  being  carried  down  to  the  bone  at  once. 
A  flap  on  the  left  side  is  then  turned  outwards,  including  a  part  of  the 
gluteus  maximus,  and  exposing  the  side  of  the  sacrum  and  the  sacro- 
sciatic  ligaments.     These  last  must  be  divided  and  detached  from  both 


I. 

Lateral  sacral  artery. 

7 

2. 

Middle  sacral  artery. 

8 

3- 

Superior  hemorrhoidal  artery  (left 

9 

main  division). 

10 

4- 

The  pelvic  peritonaeum. 

11 

5- 

Lesser  sacro-sciatic  ligament. 

12 

6. 

Pelvic  fascia. 

13- 

EXCISION    OF   TIIK    RECTUM. 


793 


sides  of  the  coccyx  and  the  left  side  of  the  Bacrura,  together  with  the 
coccygeus,  part  of  the  left  pyriformis  and,  if  the  anal  region  is  to  be 
removed,  the  sphincter  and  levator  ani.     With  a  periosteal  elevator 


Fig.  318. 


From  a  dissection  made  by  Mr.  E.  II.  Taylor. 

The  black  dots  over  the  sacrum  indicate  the  levels  of  the  first,  second,  and  third 

posterior  sacral  foramina. 


1 .  The  sacral  canal. 

2.  The  pelvic  peritonaeum. 

3.  The  rectum. 

4.  The  ureter. 

5.  Middle  haemorrhoidal  artery. 

6.  Tas  deferens. 

7.  Seminal  vesicle. 

8.  Pelvic   fascia,  clothing  the   upper 

surface  of  the  levator  ani. 


9.  Cut  surface  of  the  ano-coccygeal 
raphe. 

10.  The  pelvic  peritonaeum. 

11.  The  bladder. 

12.  Superior      hasmorrhoidal      artery 

(right  division). 

13.  Pelvic  fascia  (recto-vesical  layer). 

14.  Cut  surface  of  the  ano-coccygeal 

raphe. 


passed  under  the  sacrum  the  soft  parts  are  now  detached  from  the 
hollow  of  this  bone,  including  the  sacra  media  vessels  and  a  venous 
plexus,  thus  avoiding  troublesome  bleeding.  The  surgeon  must  now 
decide  how  much  bone  requires  removal.  Reference  to  the  lines  ot 
bone-section  indicated  in  Fig.  319  will  show  the  extent  to  which  bone 


794 


nl'KKATIOXS    ON    Till".     VP.DOMKN. 


is  removed  in  Kraske's  original  operation,  and  in  some  of  the  chief 
modifications  of  this.  No  hard-and-fast  lines  can,  however,  be  laid 
down,  since  the  amount  of  room  required,  and  therefore  the  amount 
of  bone  which  must  be  removed,  must  depend  entirely  upon  the  extent 
of  the  growth  and  the  size  of  the  outlet  of  the  pelvis.  Kraske  (loc. 
supra  cit.  p.  499)  does  not  now  recommend  removal  of  any  bone 
beyond  the  coccyx  except  when  this  is  necessary  in  order  to  get  sufficient 
room.  Senn  (Philad.  Med.  Journ.,  Sept.  30,  1899)  has  come  to  the 
conclusion  that  resection  of  the  sacrum  is  not  only  needless,  but 
absolutely  harmful,  and  maintains  that  removal  of  the  coccyx  only  will 
always  be  sufficient.  The  coccyx  should  therefore  be  removed  in  the 
first  instance ;  if  then  the  amount  of  space  obtained  is  found  to  be 
insufficient,  resection  of  the  sacrum  must  be  resorted  to.  Taylor 
(loc.  supra  cit.)  advocates  temporary  sacral  resection,  as  first  practised 
by  Heinecke,  and  later  by  Eehn  find  Rydygier,  chiefly  on  the  ground 
that  this  prevents  the  loss  of  posterior  support  of  the  levatores  ani 

which  results  from  permanent  re- 
section. The  chief  objections  to 
this  plan  arc,  that  it  does  not  give 
so  much  room,  that  the  bone-flaps 
are  liable  to  necrosis,*  and  that  the 
formation  of  a  sacral  anus  is  not 
possible.  In  suitable  cases,  how- 
ever, such  as  the  successful  one 
which  Taylor  describes,  the  method 
has  much  to  recommend  it,  but,  as 
a  general  rule,  it  will  be  found  that 
sacral  resection  as  carried  out  by 
Kraske  will  be  as  efficient  as  the 
more  complicated  methods,  and, 
moreover,  is  more  rapid  in  perform- 
ance and  more  suitable  for  the 
formation  of  a  sacral  anus  should 
this  be  necessai-y.  The  soft  parts 
being  vigorously  retracted  the  sur- 
geon cuts  through  the  left  side  of 
the  sacrum  along  a  curved  line  (Fig. 
319)  commencing  on  the  left  edge,  at  the  level  of  the  third  posterior  sacral 
foramen,  and  runninginwards  and  downwards  through  the  fourth  foramen 
to  the  left  corner  of  the  sacrum.  By  cutting  along  this  line  the  anterior 
division  of  the  third  sacral  nerve  will  not  be  divided  nor  the  sacral  canal 
opened.  The  bleeding  up  to  this  time,  which  is  largely  venous,  is  best  met 
by  firm  sponge  or  finger  pressure  ;  much  time  will  be  lost  in  attempting 
to  seize  the  bleeding  points  in  the  usual  way.  As  soon  as  the  bone  is  out, 
the  vessels  may  be  closed  by  forci-pressure  or,  where  needful,  by  under- 
running.  The  haemorrhage  comes  chiefly  from  the  lateral  and  middle 
sacral,  the  hamiorrhoidal  arteries,  the  bone  itself,  and  a  venous  plexus 
on  both  aspects  of  the  sacrum.     The  pelvis   is,    in   this   way,   freely 


u.  The  incision,  through  the  sacrum,  of 
Kraske's  (p.  792).  a,  a'.  That  of  Barden- 
haner,  wIki  takes  away  the  whole  Lower  pari 
of  the  bone  as  far  as  the  third  sacral  fora- 
mina, b.  Incision  of  v.  Volkmann  and  Rose 
which  passes  through  the  bone  at  a  higher 
level  still.     (Esmarch  and  Kowalzig.) 


*  If  the  bones  are  not  wired,  but  apposition  obtained  by  moans  of  catgut  sutures  in 
the  soft  parts,  necrosis  does  not  occur.  Tuttlc  {loo.  fit.)  has  not  noticed  any  want  of 
union  or  necrosis  in  any  of  his  20  cases  (jvide  Figs.  320  to  325). 


KM'ISION    OF    T 111:    IlKCTHM. 


795 


opened,  and  from  six  to  eight  inches  of  the  bowel  may  be  removed. 
The  tissues,  down  to  and  including  the  levatores  ani,  are  now 
divided  along  the  median  raphe  behind,  and  the  separation  of  bowel 
commenced.  If  the  growth  does  not  reach  to  within  an  inch  of  the 
external  sphincter,  this,  together  with  the  anus,  is  left  intact ;  if,  on 
the  other  hand,  there  is  any  suspicion  that  the  external  sphincter  and 
anal  region  may  be  involved  by  the  growth,  these  must  be  removed. 
Unless  matted  by  extension  of  the  disease,  the  bowel  will  readily  be 
shelled  out  of  its  bed,  posteriorly  and  laterally.  In  Dr.  Kelsey's  words 
(/oc.  supra  cit.),  "  the  finger  cannot  be  passed  completely  under  and 
around  the  gut  on  account  of  its  size  at  this  point,  nor  can  it  be  drawn 


Fict.  320. — Second  Step  in  Bone-flap  Operation. 

i?,  rectum  ;  N,  neoplasm  ;  LS,  lateral  rectal  ligaments  ;  S,  sacrum.     (Tuttle.) 

down  at  all  on  account  of  the  firm  attachments  of  the  peritonaeum  and 
the  meso-rectum.  Any  forcible  attempt  to  drag  it  down  at  this  stage 
is  attended  by  great  risk  of  rupture  and  consequent  soiling  of  the  wound, 
and  all  that  should  be  attempted  is  gentle  isolation  on  each  side  by 
separating  it  from  its  loose  attachments  with  the  finger,  and  discover- 
ing by  touch  the  extent  of  the  disease  to  be  removed,  which  can  gene- 
rally be  easily  done  by  palpating  the  tube  as  it  lies  in  the  wound." 
On  continuing  the  blunt  dissection  at  the  upper  end  of  the  w^ound  the 
peritonseal  reflection  will  be  reached  on  the  anterior  wall ;  if  this  is 
found  to  lie  well  above  the  upper  extremity  of  the  growth  it  may  be 
possible  to  separate  it  upwards  with  the  finger  to  the  desired  extent, 
and  thus  avoid  opening  the  peritonseal  sac  altogether.  Should  it  be 
found,    however,    that   the   growth   extends   above   the   level   of  the 


796 


OPERATIONS    ON    THK    A150OMKN. 


peritoneal  reflection,  it  will  not  be  possible  to  separate  the  peritoneum, 

mid  the  fold  should  then  he  opened  freely  at  once.  This  step  is 
necessary  in  the  large  majority  of  cases,  and  it  is  hotter  to  take  it  early 
in  the  operation,  for  once  the  peritoneal  attachments  are  divided,  il  is 
far  easier  to  bring  the  rectum  down,  and  also  to  avoid  injuring  the 
ureters.  The  serous  membrane  is  incised  close  to  the  rectum  <>n  the 
front  and  sides  of  the  latter,  hut  higher  up  and  further  hack  the  nieso- 
rectum  is  severed  close  to  the  sacrum,  so  that  the  hemorrhoidal  artery 
may  he  avoided  and  the  lymphatic  glands  removed  with  the  growth.  The 
rectum  and  the  presacral  cellular  tissues  are  carefully  separated  from 
the  concavity  of  the  sacrum  to  the  desired  extent,  gentle  traction  being 


Fig.  321. — Third  Step  in  Bone-flap  Operation. 
P,  opening  in  the  peritonaaum  ;  V,  seminal  vesicle  and  bladder  ;  A.  neoplasm  :  //.rectum. 

(Tuttlc.) 

made  on  the  bowel  while  this  is  being  done.  When  the  bowel  at  least 
an  inch  above  the  growth  can  be  brought  down  to  the  healthy  segment 
an  inch  below  the  disease,  or  better  still  to  the  anal  margin,  the 
peritoneal  cavity  is  cleansed  and  closed  with  sutures,  some  of  which  arc 
passed  through  the  serous  covering  of  the  rectum  well  above  the  disease. 
A  gauze  pack  may  be  used  instead  of  sutures,  which  are  difficult  to 
insert,  and  packing  isjust  as  safe.  After  this  important  step  has  been 
taken  the  bowel  about  an  inch  and  a  half  above  the  growth  is  divided 
between  two  clamps,  and  the  ends  sterilised  with  pure  carbolic  acid. 
The  superior  hemorrhoidal  artery  is  tied.  The  growth  and  the  lower 
portion  of  the  rectum  are  then  drawn  downwards  and  separated  by 
blunt  dissection  from  the  bladder  and  prostate  or  from  the  vagina. 
This  dissection  is  far  simpler  and  safer  when  conducted   from  above 


EXCISION    OF   THK    UKCTUM. 


7(J7 


Fig.  322. — Fourth  Step  in  Bone-flap  Operation. 
7?,  rectum  ;  <S7,  sigmoid  ;  E,  site  of  recto- vesical  cul-de-sac  ;  P,  peritoneal  cavity'closed. 

(Tuttle.) 


Fig.  323. — Fifth  Step  in  Bone-flap  Operation. 
The  growth  has  been  resected,  and  the  ends  of  the  intestine  have  been  sutured  together. 

(Tuttle.) 


79« 


OPERATIONS    ON    T11K    AUDoMKN. 


downwards  instead  of  in  the  reverse  direction  ;  moreover,  it  is  accom- 
panied with  much  less  hemorrhage  (Tattle).  A  sound  in  the  urethra 
and  bladder  in  the  male,  and  an  assistant's  finger  in  the  vagina  in  the 
female  act  as  useful  guides  in  difficult  cases.  When  the  separation  has 
been  carried  well  below  the  growth,  the  bowel  is  clamped,  and  divided 
an  inch  below  the  disease.  As  soon  as  the  growth  is  removed  the 
upper  stump  must  be  wrapped  up  in  a  piece  of  iodoform  gauze  while 
the  wound  is  attended  to.  All  bleeding  must  be  arrested,  v< 
ligatured,  and  the  wound  wiped  over  with  pledgets  of  gauze  wrung  out 
of  hot  perchloride  or  formalin  lotion  (i  in  2000). 


r  w 


Fig.  324. — Sackal  Anus. 
Made  in  bone-flap  operation  when  it  was  impossible  to  establish  aperture  in  normal 

position.     (Tuttle.) 

Treatment  of  the  Ends  of- the  Bowel. — The  methods  advocated 
by  different  surgeons  as  regards  this  most  important  step  vary  very 
considerably,  and  at  the  present  time  it  cannot  be  said  that  the 
question  is  by  any  means  settled.  Kraske  (loc.  cit.,  p.  778)  after 
having  abandoned  it  for  some  time,  on  account  of  repeated  failu 
has  finally  returned  to  his  original  plan  of  immediate  direct  suture, 
finding  that  complete  or  almost  complete  union  can  be  obtained  if 
the  bowels  are  kept  constipated  for  eight  to  ten  days  after  the  operation. 
The  anterior  and  lateral  portions  are  united  by  two  tiers  of  Butures, 
one  passing  through  the  whole  thickness  of  the  bowel,  and  the  other 
through  mucous  membrane  only.  The  posterior  part  is  closed  by 
inverting  sutures  not  involving  the  mucous  surface.  Where  the  growth 
does  not  reach  very  low  down  this  method  may  be  carried  out,  but 
if  the  external  sphincter  has  to  be   sacrificed,  a   sacral   anus  may  be 


EXCISION    <>K    'NIK    KKCTCM. 


7'^ 


Formed  by  fixing  the  upper  divided  end  of  the  1  >< > \%_«- 1  to  the  posterior 
angle  of  the  wound  as  recommended  l>y  Hochenegg  {Brit.  .1/"/.  Jowrn., 

vol.  i.  1900,  p.  1031).  When  end  to  end  union  is  attempted  it  is  well 
to  pass  a  few  sutures  through  the  meso-rectum  and  the  skin  in  the 
neighbourhood  of  the  eoccvx  to  lessen  the  tendency  of  the  bowel  to 
retract.  Paul,  who  gives  a  series  of  twenty-eight  cases  with  tour  dent  lis 
{Lancet,  vol.  ii.  1897,  p.  78),  lias  abandoned  approximation  of  the 
divided  ends  if  more  than  three  inches  of  the  rectum  have  been  removed, 
and  uses  one  of  his  tubes  (Fig.  54)  in  the  following  manner,  as  described 
in  a  former  paper.  The  rectum  is  first  thoroughly  freed  by  opening  the 
peritonaea!  sac,'and  dividing  as  much  of  the  meso-rectum  as  is  necessary. 


Fig.  325. — Final  Step  in  Bone-flap  Operation. 
G,  gauze  draining  retro-rectal  space  ;  T,  tampon  and  drainage-tube  in  anus. 


(Tuttle.) 


"  When  plenty  of  the  bowel  has  been  drawn  down,  the  rent  in  the  peri- 
tonaeum may  be  loosely  closed  with  a  few  fine  sutures,  and  a  large  glass 
intestinal  drainage  tube,  plugged  with  wool,  is  inserted  into  the  bowel  and 
ligatured  above  the  growths.  If  the  intestine  is  loaded  with  fasces  the 
tube  had  better  be  introduced  below  the  stricture  and  forced  up,*  to 
the  detriment  of  the  specimen,  as  it  is  very  difficult  to  avoid  some 
escape  of  faeces  when  this  powerful  bowel  is  opened  under  high  pressure. 
The  tube  having  been  fastened  in,  the  diseased  part  is  cut  off  and  the 
stump  sutured  to  the  top  corner  of  the  wound  ;  the  higher  the  better, 


*  This  would  appear  to  me  to  run  some  risk  of  carrying  up  cancer  cells  on  the  upper 
edge  of  the  glass  tube,  and  perhaps  infecting  the  cut  edge  of  the  bowel  above,  when  the 
gut  is  severed  very  shortly  after. 


8oo 


OPKUATIONS   ON    TIIK    AHhOMEN. 


as  less  gut  needs  to  be  drawn  and  the  orifice  is  in  a  more  favourable 
position  for  the  truss*  (Brit.  Med.  .loam.,  1895,  vol.  i.  p.  520)."  This 
method  of  inserting  a  tube  has  the  advantages  of  being  simple  and 
rapidly  used  ;  it  also  prevents  contamination  of  the  wound  with  faeces, 
and  further,  any  large  vessels  in  the  intestinal  wall  are  closed  with  a 
single  ligature.  The  tube  becomes  loose  about  the  fourth  day.  The 
disadvantage  of  the  tube  is  that  its  presence  prevents  the  surgeon  from 
fashioning  a  smaller  artificial  anus.  But  this  is  a  minor  point.  How- 
ever well  the  anus  may  look  at  the  time,  artificial  support  is  almost 
certain  to  be  required  later  on,  when  part  of  the  sacrum  and  coccyx 
has  been  removed.  Hence,  to  prevent  prolapsus,  and  to  aid  in  giving 
a  patient  control,  such  a  truss-pad  as  that  of  Mr.  Paul's  will  be  found 
a  real  boon  (vide  Fig.  326). 

Gersuny  (Centr.f.  Chir.,  1893,  No.  6)  advocates  treating  the  upper 
end  of  the  rectum,  if  long  enough,  by  torsion,  and  then  fixation  of  the 
twisted  gut  to  the  skin  by  suture.  The  end  is  grasped  by  catch-forceps 
and  twisted  around  its  own  long  axis  until  considerable  resistance  is 

experienced  on  attempting  to  intro- 


Fio.  326. 


Paul's  truss  for  use  after  excision 
of  the  rectum. 


duce  the  finger  into  the  bowel.  He 
has  treated  two  cases  in  this  way 
successfully.  Mr.  Ball  (loc.  supra 
cit.)  has  also  used  it  in  one  case, 
and  recommends  it.  Dr.  Gerster,  of 
New  York,  has  published  two 
cases  in  which  he  adopted  this 
plan  successfully,  and  thinks  that 
the  method  deserves  preference 
and  extensive  trial  (Med.  Record, 
Feb.  10,  1894;  Ann.  of  Sun/., 
Oct.  1895,  p.  499). 

Witzelf  reports  (Centr.f.  Chir., 
1894,  No.  40)  six  successful  cases 
in  which  the  end  of  the  rectum 
was  treated  as  follows.  A  short  incision  having  been  made  a  little 
above  the  free  margin  of  the  glutasus  maximus,  this  muscle  is  perforated 
with  a  blunt  instrument,  and  the  rectal  stump  drawn  through,  the 
edges  of  the  gut  being  united  to  those  of  the  skin. 

Murphy's  button  has  also  been  used  to  unite  the  ends  of  the  bowel, 
a  successful  case  being  described  by  Taylor  (loc.  supra  cit.)  in  which 
"  the  button  was  removed  on  the  tenth  day  by  gentle  traction  through 
the  anus  and  the  bowels  were  made  to  act.  Some  fa3ces,  however,  came 
by  the  wound."  The  fistula  rapidly  contracted  and  was  completely 
closed  about  six  weeks  after  the  operation. 

Taylor  also  describes  a  successful  case  treated  by  the  method  of 
Moulonguet  of  Amiens.  "  He  removes  the  mucous  membrane  of  the 
lower  segment  down  to  the  anus,  taking  good  care  not  to  injure  the 
external  sphincter.     When  the  cancer  has  been  excised  he  draws  down 


*  I.e.,  the  rectal  pad  carried  by  the  truss  will  be  more  out  of  the  way,  especially  when 
the  patient  is  sitting  down.     Mr.  PauTs  truss  is  figured  in  the  above-mentioned  paper. 

t  Willems  and  Hydygier  had  recommended  a  similar  step  before,  from  experiments  on 
the  dead  body  {Centr.f.  Chir.,  1893,  No.  19  ;  1894.  No.  45). 


EXCISION    OF   THE    RECTUM.  8oi 

the  upper  cud  and  sutures  it,  to  the  Bphincteric  orifice.     Moulongnet 

remarks  that  with  this  method  there  is  less  chance  of  abscess  and 
fistula,  since  the  intestine  opens  on  to  the  exterior."  This  method  is 
to  be  strongly  recommended,  for  the  chances  of  infection  of  the  deeper 
parts  of  the  wound  and  dangerous  cellulitis  are  greatly  diminished  by  it. 

Keen  (Jouni.  Amer.  Med.  Assoc,  1898)  is  in  favour  of  total  closure 
of  the  lower  end  and  establishing  a  permanent  abdominal  anus,  lie 
performs  a  preliminary  inguinal  colotomy,  and  about  a  fortnight  later 
removes  the  rectum  by  Kraske's  method.  The  lower  end  of  the  bowel 
is,  however,  closed  entirely  by  means  of  sutures.  The  advantages 
claimed  are  that  neither  fasces  nor  mucus  escape  into  the  wound,  so 
that  primary  union  may  be  obtained ;  that,  since  there  is  no  escape  of 
fasces  or  mucus  after  recovery,  the  patient  need  not  wear  a  napkin  ;  and, 
thirdly,  that  prolapse  is  avoided. 

The  question  of  the  treatment  of  the  end  of  the  rectum  having  been 
decided,  the  gut  placed  in  the  position  which  it  is  to  occupy,  and  a 
source  of  contamination  thus  removed,  the  wound  must  be  attended 
to.  If  a  bone  flap  has  been  used  it  must  be  replaced  and  fixed  with 
catgut  sutures  which  include  only  the  soft  parts.  The  deep  recesses 
of  the  wound  are  then  most  thoroughly  cleansed  by  irrigation  with  lot. 
hydr.  perch.  (1  in  4,000),  iodoform,  or  glutol,  carefully  dusted  in,  and 
the  chief  cavities  of  the  wound  filled  with  packs  of  iodoform  gauze,  to 
check  oozing.  The  gauze  can  be  safely  removed  after  three  days.  The 
patient's  head  and  trunk  are  raised  so  that  drainage  may  be  facilitated. 
Drainage-tubes  must  be  inserted  at  points  where  there  is  obstinate 
oozing,  or  pockets  difficult  of  thorough  cleansing.*  A  large  rubber 
tube  is  passed  into  the  bowel  above  the  suture  line  to  allow  the  escape 
of  gas,  and  prevent  distension  of  the  bowel  and  strain  upon  the 
sutures. 

The  Management  of  Defsecation. — Here  there  is  a  divergence  of 
opinion.  The  majority  of  surgeons  have  endeavoured  to  retard  as  long 
as  possible  the  first  action  of  the  bowels.  This,  the  bowels  not  acting 
till  the  sixth  or  eighth  day,  is  facilitated  by  previously  emptying  them 
thoroughly  (p.  780).  Others  have  held  that  if  the  bowel  can  be  brought 
down  satisfactorily  under  the  cut  sacrum  or  into  the  perinreum,  and  the 
recesses  of  the  wound  kept  plugged,  an  early  action  of  the  bowels  will 
be  safe  and  the  formation  of  scybala  avoided.  Much  must  depend  on 
the  state  of  the  patient  as  to  flatulent  distension,  a  condition  which  is 
very  variable  in  different  individuals. 

(iii.)  Excision  of  the  Rectum  by  the  Vagina. — This  method  was 
introduced  by  Norton,!  and  advocated  by  Campenon  J  and  Behn.§ 
More  recently  it  has  been  successfully  used  and  recommended  for 
certain  cases  by  Murphy  and  others.     It  is  chiefly  indicated  when  the 

*  I  have  no  space  to  allude  to  the  many  modifications  of  Kraske's  operation,  para- 
sacral, osteo-plastic,  and  others.  As  in  many  other  operations,  these  modifications  do  not 
appear  to  me  to  be  improvements.  Moreover,  most  of  them,  owing  to  their  additional 
severity,  are  quite  unsuitcd  to  the  patients  who  come  to  us  with  rectal  cancer.  Many  of 
them  are  mentioned  in  a  helpful  article  by  Dr.  A.  G.  Gerstcr  (Ann.  of  Surg.,  October,  1895, 

P.  485)- 

t   Trans.  Chir.  Soc,  1890. 

\  France  Medicate,  1894. 

§   Cent./.  Chir.,  1895,  Xo.  10. 

S. VOL.  II.  51 


Su2 


OPERATIONS    ON    TIIK    ABDOMEN. 


vaginal  wall  or  uterus  is  adherent  to  the  growth.  The  following 
description  is  based  upon  Tuttle's  modification  of  Murphy's  method.* 

The  patient  is  carefully  prepared  in  the  usual  way,  and  placed  in 
the  lithotomy  position  with  the  pelvis  slightly  raised.  The  vagina  is 
dilated  with  broad  retractors.  Unless  the  growth  is  very  low  down,  the 
peritonaeum  must  be  opened,  and  this  step  greatly  facilitates  the 
liberation  of  the  growth  (vide,  Fig.  327). 

The    cervix    is    drawn    downwards    and    forwards    with    tenaculum 


Fig.  327. 


Jefabatioh  <>f  Rectum  fbom  Yagin'al  Walls 
(Murphy). 


forceps,  and  the  pouch  of  Douglas  opened  transversely  just  below  the 
cervical  reflection,  and  the  intestines  packed  away  with  gauze.  A 
vertical  incision  is  then  made  through  the  posterior  vaginal  wall  in  the 
middle  line,  extending  from  the  first  incision  to  the  anal  margin. 
The  mucous  membrane  of  the  anal  canal  is  isolated  as  in  Whitehead's 
operation  and  ligatured  to  prevent  any  leakage  during  the  later  steps 
of  the  operation.  The  posterior  vaginal  wall  is  dissected  off  the  rectum, 
great  care  being  taken  not  to  open  the  bowel.     This  accident  is  most 


*  Tuttle,  Diseases  of  the  Rectum  a  nd  Pelvic  Colon,  1903. 


EXCISION    OF   THE    RECTUM.  803 

easily  prevented  by  beginning  the  separation  above  at  the  peritoneal 

reflection.     If  any  of  the  vaginal  wall  is  involved,  it  must  be  sacrificed. 

When  the  anterior  surface  of  the  rectum  has  been  cleared,  the  lateral 
peritonasal  reflections  and  the  serous  coverings  of  the  meso-rectum  are 
divided  as  already  described  (p.  785).  Then  the  bowel  can  be  more 
easily  drawn  forwards  and  downwards,  while  the  posterior  surface 
together  with  the  lymphatic  glands  are  separated  from  the  sacrum  by 
blunt  dissection.  If  necessary,  this  dissection  may  be  carried  up  as  high 
as  the  promontory  of  the  sacrum,  in  order  to  bring  healthy  bowel  well 
above  the  growth,  to  the  anal  margin,  without  tension.  To  allow  this,  the 
superior  hamiorrhoidal  artery  has  to  be  tied  and  divided  a  little  below 
the  selected  line  of  section  of  the  bowel  above  the  tumour.  The  rectum 
is  then  drawn  down  and  the  peritonaeum  closed  by  sutures  or  gauze 
packing,  or  both.  When  this  essential  step  has  been  taken,  the  intestine 
is  divided  between  two  clamps  at  least  one  inch  above  the  upper  limit 
of  the  disease.  When  the  growth  has  been  removed,  all  bleeding 
vessels  are  secured,  and  the  upper  end  of  the  bowel  below  the  clamp 
forceps  is  sutured  to  the  anal  margin  with  numerous  catgut  or  silk  sutures. 

In  some  cases  it  may  be  possible  and  wise  to  preserve  some  of  the 
lower  segment  of  the  rectum,  and  to  join  the  upper  end  to  this,  but  the 
risk  of  leakage  and  infection  of  the  wound  is  greater  by  this  method, 
and  it  is  therefore  better  to  complete  the  operation  after  Moulonguet's 
method  as  described  above,  although  this  involves  freer  separation  of 
the  upper  part  of  the  bowel.  In  any  case  there  must  be  no  tension 
upon  the  sutures,  and  the  blood  supply  must  be  satisfactory,  or  slough- 
ing is  bound  to  ensue. 

The  vaginal  wall  and  the  perinseum,  including  the  external  sphincter 
ani,  are  carefully  sutured  with  catgut. 

An  incision  may  be  made  between  the  coccyx  and  the  anus,  and  a 
drainage  tube  introduced  through  the  pelvic  floor  into  the  hollow  of  the 
sacrum.  This  will  be  all  the  more  necessary  if  end  to  end  union  above 
the  levator  ani  has  been  adopted. 

The  results  of  the  vaginal  method  have  been  good.  Out  of  23 
cases  collected  by  Tuttle  only  three  died  as  the  result  of  the  operation 
(14/3  per  cent.).  The  method  is  most  suitable  for  growths  low  down  and 
adherent  to  the  vagina. 

(iv.)  Excision  of  Rectum  by  Laparotomy. — This  mode  of  attacking 
rectal  cancer  is  justifiable  where  the  growth  is  situated  very  high  up,  at 
the  junction  of  the  rectum  and  sigmoid  flexure,  too  high  for  the  employ- 
ment of  the  sacral  route  and  too  low  to  be  reached  b}'  the  far  safer 
resection  from  the  left  iliac  fossa  (p.  388). 

The  bowels  having  been  most  thoroughly  emptied,  the  bladder  is 
emptied  by  a  catheter,  and  the  abdomen  opened  by  a  vertical  incision 
passing  through  the  left  rectus  abdominis  and  brought  as  low  down  as 
possible.  The  small  intestines  are  then  packed  out  of  the  way,  and 
the  growth,  if  possible,  brought  well  up  into  view.  Trendelenburg's 
position  greatly  facilitates  this.  If  adhesions  interfere  with  safe 
manipulation  of  the  growth,  the  operation  should  be  abandoned.  If  it 
is  possible  to  proceed,  the  following  steps  are  open  to  the  surgeon  : 
(A)  To  resect  the  growth,  and  to  unite  the  ends  with  a  large-sized 
Kobson's  bobbin  (p.  374,  Fig.  121)  or  Murphy's  button  (p.  368).  If  the 
bowels  are  empty,  and  if  the  patient's  condition  calls  for  speedy  operating, 

5i—2 


804 


OPERATIONS    OX    TI1K    AliDO.MKN. 


this  position  is  one  most  favourable  to  the  button.  Every  possible 
care  must  be  taken  with  clamps  and  the  assiduous  use  of  gauze  sponges 
to  secure  that  no  infection  of  the  wound  takes  place.  Another  method, 
Maunsell's  (p.  364),  which  has  been  successfully  used  for  the  removal 
of  an  intussusception  (Hartley,  New  York  Med.  Journ.,  Oct.  22,  1892), 
is  also  applicable  to  carcinomata. 

(B)  Paul  suggests  {he.  supra  cit.)  that  in  cases  where  the  bowels  are 
not  emptied  the  safer  plan  would  be  "to  double  ligature,  and  divide 


Fig.  328. — Colokectobtohy  (Kelly)  ob  Invagination  ov 

COLOM    THBOCGH    A    SLIT    IN    THE    AbTBKIOB    WaLL    OF 

the  Rectum.     (Tuttle). 

the  bowel  above  the  growth,  taking  the  upper  end  out  through  a  small 
separate  wound  in  the  inguinal  region,  where  subsequently  a  tube  could 
be  inserted  and  an  artificial  anus  established.  Then  excise  the  diseased 
portion  of  the  rectum,  and  invaginate  and  close  the  lower  end."  In 
some  cases  it  may  be  possible  after  closing  the  lower  end  to  bring  the 
liberated  lower  part  of  the  sigmoid  through  a  vertical  incision  in  the 
anterior  wall  of  the  rectum,  after  Kelly's  method  (Fig.  328).  Retraction 
is  prevented  by  sutures  attached  to  the  open  end  of  the  sigmoid  and 
secured  to  forceps  placed  across  the  anus.  The  edges  of  the  vertical 
incision  in  the  anterior  wall  of  the  rectum  become  inverted,  and  wide 
serous  apposition  is  thus  secured.      Tuttle  found  that  narrowing  of 


EXCISION    OF   THE    RECTUM.  805 

the  aperture  occurred  in  one  of  his  three  cases ;  but  the  opening  was 
easily  enlarged  through  the  anus. 

(v.)  Excision  of  the  Rectum  by  the  Combined  Methods. — (A) 
The  Abdomino-perinaal  Method. — This  plan,  which  is  advocated  by 
M.  Quenu,  of  Paris,  is  thus  described  by  Allinghain  (Med.  Aim.,  1901, 
p.  464)  :  "  A  preliminary  sigmoidostomy  is  carried  out  some  days 
beforehand.  The  belly  is  opened  in  the  middle  line,  and  both  internal 
iliac  arteries  are  ligatured.  The  already  existing  sigmoid  anus  is 
liberated,  and  the  bowel  is  completely  cut  across  with  the  thermo- 
cautery. The  cut  ends  are  cleansed  and  enveloped  in  iodoform  gauze. 
The  upper  end  is  then  brought  out  in  the  left  iliac  region,  and 
constitutes  the  permanent  anus.  The  lower  end  is  freed  by  dividing 
the  meso-sigmoid  and  meso-rectum  along  the  entire  length  of  the 
hollow  of  the  sacrum.  It  is  then  packed  with  gauze  at  the  lower  part 
of  the  pelvis.  The  abdominal  wound  is  closed.  The  patient  is  then 
placed  in  the  lithotomy  position,  and  the  final  steps  of  the  operation 
are  carried  out  from  the  perinaeurn.  After  plugging  the  anal  canal, 
semilunar  incisions  are  made  on  either  side  of  the  anus,  the  levatores 
ani  are  divided,  the  anterior  wall  of  the  rectum  is  carefully  liberated, 
the  pouch  of  Douglas  is  opened,  the  remaining  connections  are  divided, 
and  the  diseased  segment  of  bowel,  along  with  the  gauze  stuffing  in  the 
pelvis,  is  brought  out  of  the  wound  and  removed.  In  two  cases  in 
which  the  author  carried  out  the  above  operation  successfully  '  there 
was  not  the  slightest  shock ' — a  fact  which  was  corroborated  by 
M.  Nelaton,  who  was  present." 

(B)  Abdomino-anal  Operation. — Maunsell  (Lancet,  Aug.  27,  1892, 
p.  473)  through  a  median  laparotomy  wound  freed  the  growth  and  the 
bowel  above  and  below  it.  He  placed  a  loop  of  tape  round  the 
rectum,  then  through  a  perforation  in  its  anterior  wall  and  out  at  the 
anus.  By  means  of  this  tape  the  rectum  was  intussuscepted  and  the 
growth  brought  well  outside  the  anus  and  removed,  the  bowel  above 
and  below  being  joined  up  by  direct  suture.  Traction  upon  the  tape 
is  apt  to  enlarge  the  perforation  in  the  rectal  wall  and  to  lead  to  leakage 
into  the  pelvis.  Therefore  Weir  (Journ.  Amer.  Med.  Assoc,  1901, 
vol.  ii.  p.  801)  modified  Maunsell's  method,  as  indicated  in  Figs.  329, 
330.  The  superior  hemorrhoidal  artery  is  tied  near  the  promontory  of 
the  sacrum  and  the  bowel  loosened,  tied  and  divided  between  the  two 
lower  tapes  placed  just  above  the  levator  ani  (vide  Fig.  329).  The 
growth  is  then  drawn  out  of  the  abdominal  wound  and  excised.  The 
lower  segment  of  bowel  is  everted  w7ith  forceps  passed  up  from  the  anus. 
The  healthy  bowel  is  then  drawn  out  through  the  everted  tube  and 
sutured  as  indicated  in  Fig.  330.  The  bowel  is  then  allowed  to 
retract,  and  a  tube  inserted  in  the  pelvis  through  a  wound  in  front  of 
the  coccyx,  and  another  large  tube  is  inserted  through  the  anus, 
reaching  above  the  suture  line,  so  that  the  latter  may  be  neither  strained 
by  distension  of  the  bowel,  nor  contaminated  with  fseces  before  union 
has  occurred.  The  abdominal  wound  is  closed.  The  chief  objections 
to  this  method  are  that  it  is  a  severe  procedure,  and  that  it  is  difficult 
to  separate  the  bowel  freely  enough  to  allow  the  evagination  described 
without  interfering  seriously  with  the  blood  supply.  Further,  the  rectum 
is  divided  from  within  and  deep  down  in  the  pelvis,  where  it  is  difficult 
to  avoid  contamination. 


8o6 


OPERATIONS    ON    TIIK    ABDOMEN. 


Sir  Charles  Ball  in  his  instructive  Erasmus  Wilson  lectures  (Brit. 
Med,  Joum.,  1903,  vol.  i.  p.  540)  advocated  the  more  frequent  adoption 
of  the  abdomino-anal  method.  An  incision  is  made  through  the  lower 
part  of  the  left  rectus,  the  Trendelenburg  position  adopted,  the  small 
intestine  protected  with  gauze,  and  the  sigmoid  loop  brought  out  and 
examined.  The  point  at  which  the  meso-sigmoid  is  longest  is  deter- 
mined.    The  average  length  at  this  point  is  about  six  inches  ;  and  unless 


Fio.  329. — Abdomino-anal  Extibpatiob  of  High  Rectal  Cancer 
— Enucleation  of  Diseased  Portion  thbough  Abdominal 
Route.     (Tut  tie). 


it  is  shorter  than  this,  the  middle  of  the  sigmoid  loop  can  be  brought 
down  to  the  anus  without  tension.  Under  these  circumstances  the 
whole  of  the  bowel  below  the  middle  of  the  sigmoid  loop  is  extirpated, 
and  the  most  mobile  part  of  the  sigmoid  is  brought  to  the  anus,  for 
it  is  more  difficult  to  mobilise  the  lower  end  of  the  loop  without 
seriously  interfering  with  its  blood  supply.  The  line  of  section  is 
therefore  chosen  without  any  regard  to  the  position  of  the  growth  in 
the  rectum,  and  this  has  the  additional  advantage  of  allowing  a  much 
freer  removal  of  the  meso-rectum  and  lymphatic  glands.  The  bowel 
is  divided  at  the  middle  of  the  sigmoid  loop  and  between  two  ligatures. 


EXCISION    OF    TIIK    RF/TUM. 


807 


The  ends  are  cleansed  and  covered  with  gauze,  which  is  tied  round  them 
to  prevent  soiling. 

The  meso-siginoid  is  severed  between  clamp  forceps,  and  the  edges 
sutured  or  treated  with  the  galvano-cautery.  The  superior  hemorrhoidal 
vessels  are  tied  and  divided  as  they  run  near  the  posterior,  border  of  the 
mesentery.  The  meso-rectum  is  divided  close  to  the  sacrum,  and 
lower  down  the  lateral  and  posterior  peritoneal  reflections  are  incised 
close  to  the  rectum.  The  middle  hemorrhoidal  vessels  are  secured  as 
they  run  under  cover  of  the  lateral  peritoneal  reflections.  By  blunt 
dissection  the  bowel  is  then  separated 
from  the  sacrum  and  coccyx  as  far 
as  the  pelvic  diaphragm.  Similarly 
the  anterior  surface  is  liberated  from 
the  bladder  and  prostate  or  vagina. 
This  separation  is  generally  easy  in 
the  cases  of  high  growth  to  which  this 
operation  is  suitable.  When  there  are 
adhesions  obliterating  Douglas'  pouch, 
however,  considerable  difficulty  may  be 
experienced  in  conducting  the  anterior 
separation  in  the  proper  plane,  and  in 
avoiding  injury  of  the  ureter  and  vagina. 
A  firm  ligature  is  placed  below  the 
disease  at  the  lower  end  of  the  isolated 
part  of  the  rectum  close  to  the  levator 
ani.  The  anus  is  then  irrigated  with 
an  antiseptic  solution  by  an  assistant, 
and  the  bowel  is  divided  below  the 
ligature  with  a  long-handled  and  curved 
pair  of  scissors.  The  growth  is  then 
free  and  is  removed. 

The  lower  end  of  the  rectum  is 
seized  with  forceps,  everted,  and  its 
mucous  membrane  dissected  off.  The 
sigmoid  is  then  drawn  down,  and  its 
end  is  uncovered  and  sutured  to  the 
skin  around  the  anus  after  the  abdo- 
minal wound  has  been  completely 
closed.  A  tube  is  passed  into  the 
bowel ;  and  another  one  may  be  passed  into  the  hollow  of  the  sacrum 
through  an  incision  made  in  the  skin  and  pelvic  floor  in  front  of  the 
coccyx. 

In  cases  of  growth  of  the  upper  part  of  the  rectum,  in  which  the 
meso-sigmoid  is  unusually  short,  Sir  Charles  Ball  does  not  attempt  to 
bring  the  bowel  down  to  the  anus,  but  prefers  to  avoid  the  risks  of 
tension  by  making  an  artificial  anus  in  the  groin. 

Miss  Aldrich  Blake  in  such  a  case  (Brit.  Med.  Journ.,  1903,  vol.  ii. 
p.  1586)  "straightened  out  the  lower  part  of  the  sigmoid  at  its  junction 
with  the  rectum  "  by  incising  the  peritoneum  to  the  left  of  the  sigmoid, 
and  close  to  the  parietes,  without  injuring  the  vessels.  A  few  careful  snips 
in  any  position  of  the  sigmoid  meso-colon  which  seemed  tight  freed  the 
flexure  sufficiently  to  allow  the  lower  part  of  the  sigmoid  to  be  brought 


Fig.  330. — Abdomino-anal  Extirpation'. 

Sigmoid  is  brought  down  through  everted 

rectum  and  sutured  after  method  of  Weir. 

(Tuttle). 


8o8 


OPERATIONS  ON  THE  ABDOMEN. 


dowD  to  the  tip  of  the  coccyx  without  tension.  The  rectum  had  been 
previously  separated  by  blunt  dissection  down  to  pelvic  diaphragm. 
The  rectum  and  its  mesentery,  containing  enlarged  lymphatic  glands, 
were  pushed  down  to  the  pelvis,  and  the  edges  of  the  U-shaped  incision 
in  the  pelvic  peritonaeum  were  sutured  together  so  as  to  re-establish  the 
pelvic  pouch  of  peritonaeum.  The  abdominal  wound  was  completely 
closed  by  three  layers  of  sutures.  An  incision  was  then  made  from  the 
coccyx  to  the  anus.  The  lower  end  of  the  bowel  was  liberated,  and  the 
rectum  drawn  out  and  divided  at  a  point  previously  chosen  and  marked 
by  a  silk  suture.  The  lower  end  of  the  sigmoid  was  then  sutured  to  the 
anal  mucous  membrane  about  three-quarters  of  an  inch  above  the  cuta- 
neous margin.  Xo  attempt  was  made  to  rejoin  the  posterior  extremities  of 
the  sphincter  ani,  but  the  posterior  wound  was  left  freely  open  for 

Fig.  331. 


Abdominoperineal  excision  of  the  rectum  (Aldrieh-P.lake).     A.  dependent  loop 
of  sigmoid  ;  B.  end  of  sigmoid.     The  growth  is  shown  lower  down. 

drainage.  The  patient  was  well  in  February,  1906,  but  with  imperfect 
control  over  the  anus,  but  "  she  has  never  had  the  sphincter  operated  on, 
as  the  bowels  act  so  regularly  that  she  did  not  consider  the  incon- 
venience sufficient  to  wish  for  further  operation." 

It  is  probably  better  to  avoid  dividing  the  posterior  commissure  of  the 
anus  and  external  sphincter,  and  to  bring  the  lower  end  of  the  bowel  if  well 
nourished,  as  indicated  by  free  bleeding  from  it,  to  the  actual  anal  margin. 
If  more  room  is  required,  and  the  sphincter  has  therefore  to  be  divided, 
it  can  be  joined  up  again,  and  the  posterior  end  of  the  wound  drained. 

After-treatment. — The  chief  points  here  are  to  keep  the  wound 
sweet  by  frequent  syringing  with  peroxide  of  hydrogen  1,  the 
careful  insufflation  of  iodoform,  and  the  keeping  all  pockets  dry.  The 
patient  is  kept  in  Fowler's  semi-sitting  attitude  if  possible  to  aid 
drainage.  The  catheter  will  probably  be  required,  and  a  mild 
aperient  may  be  given  about  the  sixth  day,  if  needed.      The  finger 


KXCISION    OF   TIIK    RECTUM. 


809 


should  be  occasionally  passed  with  the  utmost  gentleness,  and  alter  a 
week  or  ten  days  a  bougie  or  vulcanite  tube. 

Causes  of  Trouble  and  Failure  after  Excision  of  the  Rectum. — 
1.  Shock.  2.  Haemorrhage.*  This  will  rarely  be  difficult  to  deal 
with  at  the  time,  or  met  with  later,  if  the  surgeon  has  plenty  of 
Spencer  Wells's  forceps,  good  assistants,  and,  if  he  does  the  operation, 
methodically  takes  care  to  secure  the  vessels  high  up  and  to  work 
from  above  downwards  as  far  as  possible.  Gauze  packing  is  also  very 
valuable  in  arresting  both  primary  and  secondary  haemorrhage  in, 
these  cases.  3.  Suppuration,  cellulitis,  and  other  septic  troubles. 
4.  These,  which  cause  75  per  cent,  of  the  fatalities,  can  be  largely 

Fig.  332. 


Abdominoperineal  excision  of  the  rectum  (Aldrich-Blake).  The  greater  part 
of  the  rectum  has  been  freed  by  abdominal  section,  the  angle  of  union  of  the 
sigmoid  having  been  straightened  out  so  that  the  end  of  the  sigmoid  can  be 
brought  to  the  anal  canal.  The  unopened  bowel  containing  the  growth,  and  the 
meso-rectum  have  been  pushed  down  into  the  pelvis,  the  pelvic  peritoneum 
sutured,  and  the  abdomen  closed. 

prevented  by  carefully  carrying  out  the  preliminary  treatment,  and  by 
preventing  as  far  as  possible  any  leakage  from  within  the  bowel  into 
the  wound  during  and  after  the  operation.  5.  Gangrene  of  the 
stump  of  the  bowel  from  over-interference  with  its  blood  supply  or 
retraction  of  the  superior  haemorrhoidal  artery  (Morestin,  quoted  by 
A.  G.  Gerster,  loc.  supra  cit.,  Gaz.  des.  Hbp.,  1894,  p.  326).  To 
avoid  this  care  must  be  taken  to  preserve  the  blood  supply  of  the 
upper  segment,  and  to  see  that  its  cut  surface  bleeds  freely  before  it 
is   joined.     Moreover,  tension  is  to   be   avoided,  and  it  is  preferable 

*  Mr.  Cripps  has  shown  that,  as  most  of  the  bleeding  comes  from  vessels  situated  in 
the  walls  of  the  rectum,  dragging  down  the  bowel  with  a  firm  grasp  will  not  only  greatly 
facilitate  the  operation,  but  also  prevent  hemorrhage. 


8io 


OPERATIONS  ON  THE  ABDOMEN. 


not  to  join  tissues  which  are  upon  the  stretch.  6.  Exhaustion. 
7.  Recurrence.  Freer  excisions  are  required  to  lessen  the  frequency 
of  this.  8.  Sacral  fistula.  This  may  he  primary  from  defective  sutures 
of  the  bowel,  or  .secondary  from  the  formation  of  (9)  a  stricture  after 
resection.*  10.  If  the  fistula  does  not  close  it  must  be  submitted  to  a 
plastic  operation,  n.  Prolapsus.  This  may  date  to  the  operation, 
or  to  straining  afterwards  and  yielding  or  bursting  of  the  scar.     This 

Fig.  333- 


O^^L 


Abdominoperineal  excision  of  the  rectum  (Aldrich-Blake).  The  lower 
extremity  of  the  rectum  has  been  isolated  through  a  perineal  incision,  and  the 
growth  removed.  The  lower  end  of  the  sigmoid  has  been  sutured  to  the  anal 
canal  and  the  posterior  end  of  the  wound  drained  with  gauze. 

tendency  will  be  met  by  the  use  of  Mr.  Paul's  truss  or  one  like  it 
(p.  800).  When  it  occurs  in  the  perinseum  a  modified  Whitehead's 
operation  may  be  performed  for  its  removal. 


IMPERFORATE  ANUS.— ATRESIA  ANI.— IMPERFECTLY 
DEVELOPED  RECTUM  (Figs.  334 — 340). 

A  surgeon,  when  called  upon  to  explore  these  cases,  will  do  well  to 
bear  in  mind  the  following  natural  and  practical  classification,  because 
on  this  depends  his  treatment : — 

Two  Main  Varieties  :  A.  Cases  in  which  no  normal  anus  exists — 
Imperforate  Anus.  B.  Cases  in  which  a  normal  anus  exists,  but  the 
gut  is  obstructed  higher  up,  or  undeveloped — Imperforate  Rectum. 

A.  Imperforate  Anus.  I.  Anus  partially  closed — (a)  by  adhesions 
of  epithelial  surfaces,  as  occasionally  happens  in  the  labia  of  a  female 


*  A.  G.  Gerster  (loe.  supra  rit.')  holds  that  resection  has  been  invariably  followed  by 
a  stricture,  no  matter  what  form  of  approximation — suture,  Murphy's  button,  or  invagi- 
nation— is  used.  Frequent  digital  examination  is  indispensable.  The  stricture,  if  detected 
early,  will  yield  to  systematic  dilatation  with  a  bougie. 


[MPERFORATE    ANUS    AND    ItKCTU.M. 


Ml 


infant ;  (b)  by  a  membrane.  2.  Anus  completely  closed,  but  only  by 
a  membrane.  3.  Anus  completely  closed  by  a  membrane,  but  a  fistula 
exists — (a)  on  tlie  surface  of  the  body  (e.g.,  the  raphe  of  tbe  scrotum) ; 
(b)  into  tbe  vagina  (Fig.  335);  (c)  into  tbe  urethra  or  bladder  (Figs. 
336,  340).  4.  Anus  imperforate  and  tbe  rectum  deficient  as  well. 
B.  Anus  in  Natural  Position,  but  the  rectum  is  deficient*     (a)  Tbe 


Fig.  334.1 


Fig.  135- 


Anus  absent,  rectum  opening 
by  fistula,  close  to  urethra.  ( Rush- 
ton  Parker.) 


Anus  absent,  rectum  com- 
municating with  vagina.  (Rushton 
Parker.) 


Fig.  336. 


rectum  is  deficient  for  a  short  distance  only,  and  separated  from  tbe 
anus  by  a  cul-de-sac  (Fig.  338)  ;  (b)  tbe  rectum  is  deficient  for  a  long 
distance,  or  entirely  (Fig.  339). 

Treatment.     A. — Those  in  which  no  natural  anus  exists. 

1  and  2.  If  tbe  atresia  be  due  to  epithelial  adhesions,  or  to  a  more 
or  less  complete  membrane,  the  former  should  be  broken  down  and 
the  latter  snipped  away  with  scissors,  and  the 
opening  kept  patent  by  a  small  piece  of  oiled 
lint,  the  nurse's  little  finger  being  introduced 
twice  daily. 

3.  If  the  anus  be  imperforate  and  the  fistula 
open  (a)  on  the  surface  of  the  body,  (b)  into 
the  vagina,  or  (c)  urethra. 

(a)  A  probe  is  passed  from  the  skin-fistula 
(e.g.,  in  the  scrotum)  towards  the  proper  anal 
site  ;  it  is  then  cut  down  upon  and  the  opening 
established  in  the  proper  position. 

(b)  If  tbe  fistula  open  into  the  vagina,  the 
treatment  will  vary  somewhat  with  the  urgency 
of  the  case,  the  size  of  the  opening,  and  the 
age  of  tbe  child. 

Thus  if  the  opening  be  very  small,  and  the 
retention  urgent,  a  silver  director  should  be 
passed  through  the  vaginal  fistula  back  to  the 
proper  site  of  the  anus,  and  there  cut  down  upon 


Anus  ending  in  a  cul-desac, 

rectum  opening  into  urethra 
far  hack.  A  case  for  Littre's 
operation.  (Rushton  Parker.) 


If  the  bowel  is 


*  As  Mr.  Holmes  has  shown,  these  cases  are  important,  as  they  are  liable  to  be  over- 
looked till  considerable  distension  has  taken  place. 

}  This  and  the  next  six  figures  are  taken,  with  a  few  alterations,  from  an  article  by 
Mr    Rushton  Parker  (Liverpool  MeA.  Chron.,  July,  1883). 


;i2 


nl'KUATIONS    ON    THE    ABDOMKN. 


witliin   reach,  it  should  be   drawn   down   and    stitched   in  situ.     The 
orifice  should  be  kept  patent. 

In  such  a  case,  though  eld  anus  is  established  in  the  proper  position, 
it  is  very  doubtful  if  the  vaginal  fistula  will  close,  and  a  further  opera- 
tion will  probably  be  required  later  on.      Plastic  operations  should  not 


Fig.  337. 


Fig.  338. 


Anus  absent.  Rectum  could  be 
reached  by  dissection.  (Rushton 
Parker.) 


Anus  ending  in  cul-de-sac.  Rectum 
readily  reached  from  this.  (Rushton 
Parker.) 


be  tried  too  early,  on  account  of  the  softness  of  the  tissues  and  the 
liquid  condition  of  the  faeces. 

If,  owing  to  the  size  of  the  vaginal  fistula,  there  be  not  much 
retention,  and  especially  if  the  child  be  not  very  young,  the  following 
operation  may  be  performed,  after  the  method  of  Rizzoli,  quoted  by 


Fig.  339. 


Fig.  340. 


Anus  absent,  rectum  ending  high 
up.  A  case  for  Little's  operation. 
(Rushton  Parker.) 


Anus  and  rectum  deficient,  the 
bowel  ending  in  the  bladder.  (Bnsh- 
ton Parker.) 


Mr.  Holmes,  Syst.  of  Surg.,  vol.  iii.  p.  788.  An  incision  is  made 
from  the  vulva  to  the  coccyx  in  the  middle  line,  the  rectum  found  by 
most  careful  dissection,  separated  from  the  vagina,  and  then  brought 
d<»wn  and  fixed  in  its  natural  position.  To  aid  in  finding  the  rectum, 
a  probe  should  be  passed  from  the  fistula. 

After  the  rectum  has  been  brought  down  and  secured  the  incision 
between  the  anus  and  vulva  is  united  to  form  a  new  perinsenm. 


IMPERFORATE   ANUS   AND    RECTUM.  813 

(c)  Fistula  into  the  urethra  or  bladder.  Two  questions  here  arise  : 
How  high  up  is  the  communication?      How  much  of  the  bowtd   is 

deficient?  .       . 

If  the  periiifeum  seems  fairly  developed,  if  the  ischial  tuberosities  are 
not  in  close  contact,  if  any  bulging  can  be  detected  at  the  natural  site 
of  the  anus,  the  communication  is  probably  recto-urethral,  and  an 
attempt  may  reasonably  be  made  to  find  the  bowel  from  the  permseum. 
If  it  is  found,  and  can  be  brought  down,  an  attempt  may  be  made 
to  separate  it  from  the  adjacent  urethra,  but  usually  the  surgeon  will 
have  to  be  satisfied  with  a  free  opening,  and  with  keeping  this  patent, 
so  as  to  encourage  the  urethral  communication  to  close.  If  there  appear 
no  probability  of  the  bowel  being  within  reach,  or  if  this  cannot  be 
found,  Littre''s  operation  should  be  performed  (p.  128).  It  the  child 
survive,  the  bladder  must  be  kept  carefully  washed  out  if  any  faeces  still 
find  their  way  into  it.  Thus,  in  a  case  of  Mr.  Clutton's  {St.  Ihomas  s 
Hosp.  Rep.,  vol.  xi.  p.  84),  a  child  about  a  month  old  died,  sixteen  days 
after  Littre's  operation,  of  suppurating  kidneys,  due  to  the  oftensive 
purulent  urine.  TT  .  .  „ 

4.  Anus  absent  and  rectum  deficient  as  well.  Here  the  chief 
question  is  how  far  upwards  an  exploratory  operation  may  be  sately 

conducted.  ,  , 

External  evidence.  Genitals  far  back  and  close  to  the  coccyx,  and 
ischial  tuberosities  close  together,  point  to  absence  of  the  rectum 

In  most  cases  the  surgeon  begins  by  exploring.  The  child  being 
under  the  A.C.E.  mixture  and  in  lithotomy  position,  and  a  small  sand- 
bag placed  under  the  sacrum,  and  the  bladder  emptied  with  a  catheter, 
the  surgeon,  seated  at  a  comfortable  level,  makes  a  free  incision  from 
the  position  of  the  anus  back  to  the  coccyx.  Keeping  exactly  in  the 
middle  line,  and  opening  up  the  cellular  tissue  with  his  finger-tip,  aided 
by  a  scalpel  and  director,  the  surgeon  works  backwards  towards  the 
concavity  of  the  sacrum,  constantly  taking  note  with  his  finger-tip  ot 
the  depth  to  which  he  has  got,  while  an  assistant  aids  in  bringing  down 
the  bowel  by  supra-pubic  pressure.  ,_.      „ 

As  a  rule,  two  inches  are  a  sufficient  depth  in  a  new-born  child  It 
still  in  doubt  whether  to  proceed  or  no,  the  surgeon  may  make  a 
careful  puncture  with  a  morphia-syringe  backwards,  and  note  the 
condition  of  the  point.     No  puncture  with  a  trocar  is  justifiable  at  this 

B Points  to  bear  in  mincl—i.  The  rectum  may  end  at  the  brim  of  the 
pelvis  2.  If  it  end  lower  down,  it  may  be  floating  with  a  long  meso- 
rectum  3  Though  the  rectum  may  end  within  reach,  the  peritonaeum 
may,  and  not  infrequently  does,  extend  low  down  on  the  bowel.  4-  Even 
if  the  rectum  is  successfully  opened  high  up  without  opening  the  peri- 
tonaeum, fatal  cellulitis  may  be  set  up  by  the  escaping  faeces,  or  by  the 
attempts  to  keep  the  bowel  patent.  T'**>» 

If  the  above  exploratory  operation  fail,  inguinal  colotomy  or  Littre  s 
operation  should  be  resorted  to  (p.  128). 

B  Imperforate  Rectum.— The  treatment  here  will  be  an  exploratory 
perineal  operation,  followed,  in  case  of  failure,  by  Littre's  operation 
(p  128),  but  in  some  cases  the  colon  may  be  found  empty  or  represented 
only  by  a  fibrous  cord.  In  such  cases,  the  small  intestine  must  be 
drained  as  low  down  as  possible. 


CHAPTEK  XVI. 
RUPTURED    PERINJEUM    (Figs.  341,  342). 

The  following  account  is  taken  from  my  colleague  Dr.  Galabin  *  : 

A.  Operation  for  Partial  Rupture  (Fig.  341). — The  patient  is  placed 
in  lithotomy  position.  The  need  for  assistants  to  support  the  thighs 
is  avoided  if  a  "  Clover's  crutch  "  is  used. 

"  The  extent  of  surface  to  be  freshened  is  indicated,  to  some  extent, 
by  the  cicatrix  left  by  the  rupture.  It  is  well,  however,  to  go  a  little 
beyond  the  limits  of  this  in  all  directions,  especially  up  the  median 
line  of  the  vagina  and  towards  the  lower  halves  of  the  labia  majora, 
both  in  order  to  secure,  if  possible,  a  perineal  body  somewhat  larger 
and  deeper  than  the  original  one,  and  to  allow  some  margin,  in  case 
the  surfaces  do  not  unite  completely  up  to  the  edges.  To  put  the 
mucous  membrane  on  the  stretch,  an  assistant  at  each  side  places  one  or 
two  fingers  on  the  skin  of  the  thigh  and  draws  the  vulva  outwards 
(Fig.  341).  The  skin  just  beneath  a,  in  front  of  the  anus,  may  also  be 
seized  by  a  tenaculum  and  drawn  downwards.  If  still  the  mucous 
membrane  is  not  sufficiently  on  the  stretch,  from  laxity  of  the  vagina, 
the  posterior  vaginal  wall,  some  distance  above  b,  should  be  seized  by 
a  vulsellum  and  pushed  upwards.  Incisions  are  then  made  through 
the  mucous  membrane  from  b  to  a,  in  the  median  line  of  the  vagina, 
and  from  a  to  c  and  i>  through  the  junction  of  mucous  membrane  and 
skin.  These  should  not  be  extended  in  the  direction  of  c  and  d 
farther  than  the  lower  extremity  of  the  nymphae  at  the  utmost.  There 
are  then  two  triangular  flaps,  abc  and  abd.  These  are  to  be  dissected 
up  from  the  apex  a  towards  the  base  bc  and  bd,  the  corner  of  the 
mucous  membrane  at  a  being  seized  with  dissecting  forceps.  The 
dissection  should  not  be  deeper  than  necessary,  and  if  it  is  done  with 
the  knife  the  surfaces  are  more  ready  to  unite.  If,  however,  there  is 
much  tendency  to  bleed,  scissors  may  be  used.  The  apices  of  the  flaps 
are  then  out  off  with  scissors,  leaving  an  upturned  border  along  bc 
and  bd.  When  the  surfaces  are  drawn  together  these  borders  form  a 
slightly  elevated  ridge  towards  the  vagina,  and  if  there  is  any  failure  of 
union  just  along  the  edge  they  fall  over  and  cover  it. 

"  Silkworm-gut  sutures  are  then  placed  as  shown  in  the  figure  by 
means  of  Hagedorn's  needles  of  half-circle  curve.  Another  mode  is  to 
bury  the  sutures,  I,  2,  and  3,  in  the  tissues  throughout  their  whole 
course.  If,  however,  they  are  brought  out  in  the  centre  for  spaces 
alternately  short  and  long  (Fig.  341),  the  surfaces  are  more  easily 
brought  into  contact  at  all  levels  without  undue  tension.     In  passing 

*  Diseases  0/  Women,  1903,  p.  618.  Anyone  making  trial  of  this  method  will  agree 
with  me  as  to  its  simplicity  and  excellent  results. 


RIIITUKKD    PE1UN.KUM 


8i5 


sutures  4,  5,  6,  the  needle  should  be  brought  out  precisely  on  the 
margin  along  which  the  border  of  mucous  membrane  bd  is  turned  up 
from  the  vagina,  not  passing  through  the  mucous  membrane  itself,  and 
passed  in  again  on  the  corresponding  spot  on  the  margin  bc,  to  be 
brought  out  so  as  to  include  the  skin  of  the  perinseum.  The  sutures 
are  then  tied  in  the  order  of  the  numbers  1  to  6,  care  being  taken  that 
the  surfaces  are  brought  just  sufficiently  into  apposition,  and  that  no 
clots  of  blood  are  left  between  them.  The  bleeding,  if  any  continues, 
is  arrested  by  bringing  the  surfaces  together,  and  if  they  are  properly 
united  there  will  be  no  secondary  haemorrhage,  unless  the  sutures  begin 

Fig.  341. 


(Galabin.) 

to  cut  from  excessive  tension.     The  sutures  may  be  left  in  from  seven 
to  nine  days." 

Operation  for  Complete  Rupture  (Fig.  342). — A  sponge  tied  by  a 
tape  is  passed  into  the  bowel,  and  preliminary  steps  are  taken  as  above. 
"A  point  b  in  the  median  line  of  the  vagina,  a  sufficient  distance 
above  the  apex  of  the  rent  in  the  septum,  is  taken,  and  an  incision 
through  the  mucous  membrane  is  made  from  b  to  G  and  from  g  to  e  and  f 
along  the  edges  of  the  septum,  between  the  rectal  mucous  membrane 
and  the  cicatrix.  Incisions  are  also  made  through  the  skin  from  e  to 
c  and  f  to  d,  so  that  the  freshened  surface  may  extend  somewhat 
beyond  the  limits  of  the  cicatrix  left  by  the  rent,  c  and  d  not  to  be 
higher  than  the  lower  extremities  of  the  nymphae.  The  quadrilateral 
flap  egbc  is  then  seized  at  e  by  dissecting  forceps,  and  dissected  up 
with  the   knife  from  the  angle  e,  and  afterwards  from   the  angle  g, 


8i6 


OPERATIONS   ON    TIIK    ABDOMEN. 


towards  the  base  nc.     While  this  is  done,  the  parts  arc  kept  on  the 

stretch  by  an  assistant  drawing  down  the  skin  below  E  with  a 
tenaculum.  The  flap  is  then  cut  away  with  scissors,  except  an 
upturned  border,  which  is  left  along  uc.  The  Hap  FGBD  is  treated  in 
a  similar  manner.  If,  as  is  usual,  the  ends  of  the  sphincter  at  E  and  v 
have  retracted  from  the  margin  of  the  cicatrix,  it  is  well  to  cut  away 
with  the  scissors  a  narrow  strip  of  rectal  mucous  membrane,  generally 
somewhat  everted,  a  short  distance  from  E  and  p  towards  a,  so  as  to 
bring  the  freshened  surface  to  the  ends  of  the  sphincter. 

"  Sutures  are  then  applied  in  the  following  manner :    First,  rectal 


Fig.  342. 


' 


(Galabin.) 

sutures  of  chromic  gut,  either  two  or  three,  according  to  the  extent  of 
the  rent  in  the  septum,  are  applied.  These  are  destined  to  be  tied  in 
the  rectum,  and  left  to  be  absorbed,  the  ends  being  cut  short.  They 
are  best  applied  with  Hagedorn's  needle  holder  and  needle.  The 
needle  is  passed  in  a  little  distance  from  the  margin  of  the  rent,  and 
brought  out  almost  at  the  very  edge  of  the  rectal  mucous  membrane, 
on  the  line  gf.  The  needle  is  then  threaded  at  the  other  end  of  the 
suture,  and  that  is  drawn  through  in  the  same  way  from  without 
inwards,  emerging  on  the  margin  eg.  The  remaining  sutures  should  be 
of  stunt  iisliing-gut.  One  or  two  sutures  may  be  first  passed  com- 
pletely round  through  the  remnant  of  the  septum  by  means  of  a 
Hagedorn's  needle.  The  first  of  these  (3,  Fig.  342)  is  passed  in 
somewhat  behind  and  below  the  angle  f,  so  as  to  take  up,  if  possible, 


RUPTURED    PERINiEUM.  817 

or  at  least  go  quite  close  to,  the  end  of  the  divided  sphincter,  and  is 
brought  out  in  a  similar  position  near  e.  Thus,  when  tightened,  it 
brings  together  the  ends  of  the  sphincter,  drawing  it  into  a  circle  ;  but 
it  often  brings  into  apposition,  not  so  much  the  freshened  surfaces 
above  as  the  unfreshened  rectal  mucous  membrane.  This  serves  as  a 
barrier  to  keep  out  faecal  matter,  while  the  next  suture  (4,  Fig.  342) 
aids  the  rectal  sutures  in  uniting  the  freshened  surfaces.  The 
remaining  sutures  are  passed  as  shown  in  the  figure  (5 — 8,  Fig.  342) 
by  a  Hagedorn's  needle,  in  the  same  way  as  in  the  operation  for 
incomplete  rupture.  The  needle  is  passed  in  pretty  close  to  the  edge 
ce  or  fd,  and  is  brought  out  (except  in  the  case  of  suture  5,  Fig.  342) 
on  the  line  where  the  margin  cb  or  db  is  turned  up.  On  the  opposite 
side  it  is  passed  in  a  similar  way  from  within  outwards.  The  effect  is,  that 
when  the  sutures  are  tightened  the  margins  bc,  bd,  are  turned  up  into 
a  slight  ridge  towards  the  vagina,  and  afterwards  fall  over  and  cover 
any  portion  of  the  vaginal  border  which  does  not  unite  quite  up  to  the 
edge.  Suture  5  (Fig.  342)  may  either  be  buried  throughout,  or  brought 
out  for  a  very  short  space  near  the  median  line  bg. 

"  When  all  the  sutures  are  in  place,  the  sponge  is  withdrawn  from  the 
rectum,  and  the  rectal  sutures  are  tied  first.  Care  must  be  taken  to 
draw  up  the  whole  of  the  slack  in  the  centre,  and  bring  the  edges 
eg,  fg,  perfectly  together.  This  will  approximate  the  ends  of  the 
sphincter  to  a  great  extent,  and  the  approximation  is  completed  by 
tightening  suture  3.  The  remaining  sutures  are  then  tied  in  the  order 
of  the  numbers,  care  being  taken  to  allow  no  clots  of  blood  to  remain 
between,  and  to  tighten  them  just  enough  to  bring  the  surfaces  in  con- 
tact. The  ends  of  each  perinaeal  suture  should  be  tied  together,  and 
left  rather  long,  so  as  to  be  less  likely  to  prick  the  skin.  After  three  clear 
days  an  action  of  the  bowels  is  obtained  by  a  dose  of  an  ounce  of  castor 
oil.  Enemata  should  be  avoided  if  possible,  but  may  be  necessary  if  a 
collection  of  faeces  has  formed  in  the  rectum.  Special  care  must  be 
taken  that  no  collection  of  hard  fasces  takes  place  for  the  first  two 
or  three  days  after  removal  of  the  sutures. 

"  The  perinaeal  sutures  are  removed  in  seven  or  eight  days. 

"  In  some  cases,  by  the  primary  operation  after  labour,  only  superficial 
union  is  secured,  and  a  recto-vaginal  fistula  is  left  close  to  the  part 
united.  The  best  plan  is  then  to  cut  through  the  bridge  of  union  with 
scissors  at  the  time  of  the  operation,  and  then  proceed  as  in  the  case  of 
complete  rupture.  This  is  the  only  way  to  secure  a  firm  and  thick 
perinaeum,  and  is  less  likely  to  fail  than  an  operation  on  the  fistula 
alone." 


-vol.  11  52 


CHAPTER   XVII. 
OPERATIONS   ON  THE   OVARY. 

OVARIOTOMY. 

One  or  two  practical  points  will  be  alluded  to  before  tbe  operation 
is  described. 

Date  of  Operation. — An  ovarian  tumour  should  be  removed  as  soon 
as  possible  after  its  discoveiy.  For  by  delay  not  only  is  the  patient 
subjected  to  the  risk  of  accidents  in  connection  with  the  tumour  itself, 
but  her  general  health  is  likely  to  suffer  from  the  effects  of  pressure  on 
neighbouring  organs. 

Accidents  in  connection  with  Tumour. — The  accidents  to  which  an 
ovarian  tumour  is  liable  should  be  borne  in  mind.  They  are,  shortly, 
as  follows : — 

(i)  Inflammatory  Changes. — These,  whether  confined  to  the  perito- 
neal covering  or  dependent  upon  inflammatory  and  necrotic  changes 
in  the  cyst  itself,  will  lead  to  adhesions  between  the  tumour  and  the 
abdominal  wall  or  viscera.  When  recent  these  adhesions  may  readily 
be  separated,  but  when  old  and  fibrous  they  may  lead  to  serious 
difficulties  in  the  course  of  the  operation.  The  contents  of  the  cyst 
may  suppurate,  and,  fouling  the  peritoneeal  cavity,  lead  to  suppurative 
peritonitis. 

(2)  Torsion  oj  the  Pedicle. — When  slowly  produced,  the  interference 
with  the  blood-supply  to  the  tumour  will  set  up  necrosis  and  so  render 
the  cyst  wall  liable  to  rupture.  Acute  torsion  will  lead  to  bleeding, 
which  may  be  so  profuse  as  to  rupture  the  cyst  wall  and  endanger  the 
patient's  life.  Under  these  circumstances  an  immediate  operation  is 
called  for,  with  all  the  disadvantages  that  an  operation  of  urgency 
entails. 

(3)  Rupture  of  the  Cyst. — This  may,  as  has  been  mentioned,  follow 
necrotic  changes  in  the  cyst  or  torsion  of  the  pedicle.  It  may,  in 
addition,  depend  merely  upon  thinness  of  the  wall  or  upon  weakening 
due  to  the  extension  of  growth  from  the  interior  through  the  cyst-wall. 
As  a  result  the  contents  become  disseminated  through  the  peritoneal 
cavity,  setting  up  peritonitis  in  certain  cases,  or  leading  to  a  general 
infection  of  the  peritonaeum  with  secondary  growths  in  others. 

(4)  Malignancy. — We  have,  finally,  to  remember  this  important  prac- 
tical point,  that  it  is  difficult  at  an  early  stage  to  say  whether  we  are 
dealing  with  a  malignant  growth  or  not.  It  is  especially  in  children 
that  an  early  removal  is  demanded,  for  in  them  the  proportion  of 
malignant  tumours  is  much  higher  than  in  adults.     Mr.  Bland  Sutton 


OVARIOTOMY.  819 

found  21  oases  of  sarcoma  in  a  series  of  100  ovariotomies  per- 
formed in  girls  under  the  age  of  15  {Surgical  Disease*  of  the  Ovaries 
and  Fallopian  Tubes,  1896,  p.  178). 

General  Condition  of  the  Patient. — The  condition  of  the  viscera, 
kidney,  lungs,  &e.,  the  habits  of  the  patient,  her  digestive  powers, 
must  all  be  carefully  noted.  For  upon  a  consideration  of  these  points 
not  only  does  the  prognosis  to  some  extent  depend,  but  also  the  nature 
and  duration  of  the  treatment  to  be  adopted  preparatory  to  the  opera- 
tion. Age  need  not  be  regarded  as  a  bar  to  operation.  Mr.  Bland 
Sutton  has  collected  11  cases  of  ovariotomy  in  women  over  80,  all 
of  whom  recovered  (Bland  Sutton,  loc.  cit.,  p.  175).  The  presence  of 
albumen  in  the  urine  should  not  be  regarded  as  necessarily  a  contra- 
indication to  operation.  Small  amounts  often  clear  up  after  the  removal 
of  the  tumour.  If  chronic  nephritis  is  known  to  be  present,  the  opera- 
tion should  still  be  carried  out,  in  most  cases,  after  suitable  preliminary 
treatment. 

As  regards  difficulties  likely  to  be  met  with  in  the  course  of  the 
operation,  some  information  will  be  obtained  from  the  history  of 
the  patient  and  from  careful  examination.  Attacks  of  pain  will 
point  to  peritonitis  and  adhesions.  An  examination  of  the  tumour 
will  give  some  idea  of  its  mobility,  of  the  proportion  of  solid 
matter,  &c. 

The  amount  of  skill  of  the  surgeon,  though  a  delicate  matter,  must 
also  be  mentioned.  No  one  should  operate  on  these  cases  who  has 
not  had  good  opportunities  of  seeing  others  operate  frequently,  and  no 
one  should  undertake  a  case  whose  ovariotomies  are,  at  the  most,  likely 
to  be  but  two  or  three  in  his  lifetime. 

Preparation  of  the  Patient. — The  patient  should  be  kept  quiet  for 
two  or  three  days  before  the  operation  in  an  ordinary  uncomplicated 
case,  and  the  bowels  regulated.  The  diet  need  not  be  unduly  restricted 
or  altered  beyond  seeing  that  it  is  easily  digestible  and  nutritious. 
One  or  two  warm  baths  may  be  taken  for  a  day  or  two  before  the 
operation.  On  the  evening  preceding  the  operation  the  abdomen 
should  be  thoroughly  washed,  attention  being  paid  particularly  to  the 
navel.  It  is  better,  especially  in  a  delicate,  sensitive  patient,  to  defer 
the  shaving  of  the  pubes  until  she  is  under  the  anaesthetic.  A  compress 
of  1  in  2000  perchloride  of  mercury  should  then  be  applied.  A  purge 
should  be  given  overnight,  followed  by  an  enema  in  the  morning.  On 
the  day  of  operation  a  light  breakfast  should  be  taken,  and  some  beef- 
tea  or  soup  about  10,  if  the  operation  is  to  take  place  about  2  p.m. 
When  the  patient,  warmly  clad,  especially  as  to  her  extremities,  comes 
in  to  take  an  anaesthetic,  only  two  or  three  faces  that  are  familiar 
to  her  should  be  present ;  when  she  is  under  the  anaesthetic,  a  catheter 
should  be  passed,  if  the  bladder  has  not  been  emptied  beforehand. 

Preparation  of  Instruments,  &c. — The  room,  which  has  been 
thoroughly  cleansed,  and  not  rendered  too  comfortless  for  the  sake  of 
ventilation,  &c,  should  have  a  temperature  of  about  650.  A  good  light, 
and  one  likely  to  last,  should  be  secured.  The  table  should  be  suffi- 
ciently high  to  save  the  operator  stooping,  and  only  just  wide  enough 
to  hold  the  patient  comfortably.  It  will  be  found  an  advantage  to  have 
a  table  which  allows  of  the  patient  being  placed  in  the  Trendelenburg, 
or  raised  pelvic,  position,  if  necessary.     A  dozen  new  Turkey  sponges, 

52-2 


820  OPERATIONS   ON    THE    ABDOMEN. 

chosen  t"i  their  even  softness  of  texture,  should  have  been  carefully 
prepared,  and  four  flat  ones  (not  too  large)  should  also  be  provided. 
A  few  Bmall  Bponges,  ready  for  use  on  holders,  leave  no  excuse  for  the 
dividing  of  sponges  during  the  operation,  ;i  course  to  be  unhesitatingly 
condemned.  Instead  of  Bponges,  gauze  swabs  and  pads  are  more 
generally  employed  ;  these  must,  of  course,  be  provided  in  larger 
numbers,  as  they  cannot  he  cleansed  after  use  ;  they  must  be  carefully 
counted  before  and  after  the  operation. 

The  following  should  be  in  readiness  :  two  scalpels,  steel  director, 
twelve  pairs  of  Spencer  Wells's  forceps  at  least,  cyst  forceps,  Spencer 
Wells's  vulsellum-trocar  and  tubing  and  a  simple  curved  trocar  and 
canula,  blunt-pointed  scissors,  needles  (long  straight  ones  to  be 
threaded  with  silkworm  gut  for  closing  the  abdominal  wound,  and  fine 
ones,  both  straight  and  curved,  for  underrunning  any  bleeding  point 
or  introducing  tine  sutures  if  any  of  the  contents  of  the  abdomen  are 
unavoidably  injured),  two  aneurysm-needles,  pedicle  needle,  needle 
holder,  two  retractors,  Bponge  holders,  plenty  of  silk  and  chromic-gut 
ligatures  of  varying  sixes  (and  the  material  carefully  prepared,  including 
some  stout  enough  for  the  pedicle),  two  pairs  of  dissecting  forceps, 
dressing  forceps,  drainage  tubes  (both  glass  and  rubber),  abundance  of 
lysol  and  mercury  perchloride  lotion,  a  foot-pan  to  stand  under  the  table, 
two  others  to  wash  the  sponges  in,  and  a  laryngeal  mirror  or  electric 
lamp.  The  instruments  should  stand,  in  two  trays  or  pie-dishes,  on  a 
small  wheel-table  close  to  the  operator's  right  hand.  The  ligatures  and 
sutures  should  be  in  separate  porringers,  all  covered  with  carbolic  acid 
(i  in  40)  or  lysol. 

In  addition  to  the  anaesthetist  two  assistants  will  be  found  amply 
sufficient,  one  to  stand  opposite  the  operator  to  assist  in  securing  vessels, 
to  help  with  the  tumour,  &c.,  whilst  the  second  will  hand  instruments, 
thread  needles,  prepare  ligatures,  and  so  on.  One  nurse  will  be  required 
to  wash  sponges  if  these  are  used,  and  another  to  attend  to  the  nursing 
operations  generally. 

The  Operation. 

Incision  of  Abdominal  Wall. — An  incision  in  the  median  line, 
reaching  from  just  below  the  umbilicus  to  within  two  inches  of  the 
pubes,  is  made  through  skin  and  fat.  There  is  no  object  in  having  the 
incision  more  than  lour  inches  long  to  commence  with,  as  it  can  be 
lengthened  as  required  subsequently.  After  dividing  the  skin  and  fat, 
the  layer  of  fascia  which  forms  the  sheath  of  the  recti  muscles  comes 
into  view.  If  the  muscles  are  in  apposition,  one  or  both  of  them  will 
be  exposed  on  incising  the  fascia ;  the  interval  between  them  should 
be  sought  for,  and  the  two  muscles  separated  for  the  length  of  the 
incision.  If  the  linea  alba  is  missed,  and  a  difficulty  is  experienced  in 
finding  the  median  line,  a  director  or  the  handle  of  the  scalpel  should 
be  introduced  beneath  the  fascia  ;  the  director  will  be  arrested  on  the 
side  on  which  the  linea  alba  lies. 

If  the  recti  are  separated,  an  incision  through  the  fascia  in  the  median 
line  at  once  exposes  the  sub-peritonaea]  fat  and  peritonaeum.  Be: 
this  is  incised  Spencer  "Wells's  forceps  are  applied  to  every  bleeding 
point;  these  may  be  left  on  until  the  operation  is  concluded;  any 
bleeding  points  then  persisting  should  be  treated  by  torsion,  and  not 
by  ligatures,  as   these   latter   weaken   the    cicatrix.      The   peritoneum, 


OVARIOTOMY.  821 

readily  recognised,  when  healthy,  by  its  delicate  fasciculation  and  trans- 
lucency,  is  carefully  picked  up  by  a  pair  of  forceps  so  as  to  include 
nothing  else,  and  an  incision  is  made  in  it  horizontally  with  a  knife. 
As  soon  as  the  peritoneal  cavity  is  opened  the  intestines  fall  away  from 
the  abdominal  wall.  The  peritonaeum  is  then  slit  up  on  two  fingers 
for  the  length  of  the  incision;  the  fingers,  used  in  this  way  as  a  director, 
are  enabled  to  detect  the  height  to  which  the  bladder  conies  at  the  Lower 
part  of  the  wound,  and  so  determine  the  limit  to  which  the  peritoneal 
incision  may  safely  be  carried  below. 

Mr.  Doran  (.1////.  of  Surg.,  May,  1888)  thinks  a  mistake  is  often  made 
in  not  bringing  the  incision  near  enough  to  the  pubes,  which  may  cause 
much  trouble  when  the  pedicle  has  to  be  drawn  out,  and  greatly  impede 
a  thorough  exploration  of  the  pelvis. 

Care  should  be  taken  not  to  mistake  the  sub-peritonaea!  fat  for 
omentum,  as  this  may  lead  to  extensive  stripping  off  of  the  peritonaeum 
from  the  abdominal  wall,  an  accident  likely  to  be  followed  by  sloughing 
of  this  structure. 

In  an  easy  case  without  parietal  adhesions  the  pearly  glistening  cyst 
comes  into  view  as  soon  as  the  peritonaeum  is  incised  ;  but  if  the  peri- 
tonaeum is  thickened  and  adherent  to  the  cyst  there  may  be  the  greatest 
difficulty  in  deciding  when  this  is  reached,  and  the  incision  may  even 
be  carried  through  the  cyst  wall.  In  cases  of  difficulty  the  incision 
should  be  prolonged  upwards  to  the  left  of  the  umbilicus  until  a  spot 
free  from  adhesions  is  found. 

When  the  tumour  is  exposed  it  should  be  examined  carefully  by  eye 
and  hand.  Its  nature  should  be  noted,  whether  cystic  or  solid,  or 
partially  solid,  whether  a  dermoid  or  inflamed ;  the  presence  of  adhesions 
should  be  ascertained,  or  secondary  malignant  deposits,  rendering 
further  operation  inadvisable.  If  we  are  dealing  with  an  uncomplicated 
cystic  tumour  of  the  ovary,  the  first  proceeding  is  to  tap  it.  To 
separate  adhesions  before  tapping  is,  in  Mr.  Thornton's  words  (Diet  of 
Surg.,  vol.  ii.  p.  153),  "bad  practice,  because,  if  they  are  separated  wdiile 
the  parietes  and  cyst  wall  are  both  stretched  by  the  fluid,  all  the  little 
vessels  in  them  bleed,  and  very  serious  haemorrhage  may  occur  out  of 
sight  during  the  subsequent  emptying  of  the  cyst,  whereas,  if  the  cyst 
be  first  tapped,  the  contraction  of  both  parietes  and  cyst  wall  closes 
the  smaller  vessels." 

Emptying  the  Cyst. — The  abdominal  incision  should  be  packed  round 
to  prevent  fluid  running  back  into  the  abdominal  cavity.  The  cyst  is 
next  tapped  by  carefully  plunging  in  a  Spencer  Wells's  trocar,  then 
guarding  the  point  with  the  inner  tube,  and  as  soon  as  the  walls  of  the 
cyst  are  rendered  lax  enough  by  the  escape  of  the  contents  attaching 
the  clawrs  to  the  cyst  wall,  so  as  to  keep  this  on  the  trocar,  as  forward 
traction  is  made. 

Dr.  Baldy  (Syst.  oj  Gyncecol.,  1894)  points  out  that  the  puncture 
should  not  be  made  at  the  lower  angle  of  the  wound,  for  the  reason 
that  as  the  c}Tst  empties  it  retracts,  and  leaves  the  opening  situated 
below  the  wound,  increasing  the  difficulty  of  preventing  fluid  from 
entering  the  peritonaeal  cavity.  As  soon  as  the  trocar  is  inserted  into 
the  cyst,  the  assistant  should  place  a  hand  low  down  on  each  side  of  the 
abdomen,  and  press  steadily  and  firmly.  By  this  means  he  not  only 
forces  out  the  fluid  from  the  cyst,  but  keeps   the  abdominal  incision 


822  OPERATIONS   ON    THE   AI'.DOMKN. 

taut  over  the  tumour,  thus  preventing  the  contents  of  the  cyst  from 
running  into  the  peritonaea]  cavity.  As  the  cyst  empties  traction  is 
applied  to  it  by  means  of  the  claws  of  the  trocar  or  by  other  forceps, 

and  if  there  are  no  adhesions  it  is  readily  brought  out  of  the  wound. 

If  there  is  difficulty  in  delivering  the  tumour,  and  it  is  clear,  from 
the  bulk  of  the  cyst  remaining  after  tapping,  that  it  is  multilocular  or 

solid,  it  will  have  to  he  further  reduced  in  size  before  extraction.  If  it 
is  multilocular,  it  must  be  tapped  again  in  two  or  three  more  places  by 
removing  the  trocar  and  closing  the  puncture  with  cyst  forceps,  and 
then,  while  the  cyst  is  dragged  forward  and  steadied,  the  first  trocar  or 
a  smaller  one  is  thrust  in  at  other  spots  where  fluid  is  still  present. 
This  is  a  better  practice  than  thrusting  the  trocar  from  the  first 
puncture  into  other  parts  of  the  cyst  in  the  dark.  If  this  latter  method 
is  adopted,  the  hand  should  first  be  passed  into  the  abdomen  to  make 
sure  that  the  trocar  does  not  perforate  the  cyst  wall  and  injure  the 
viscera.  In  cases  in  which  the  tumour  is  composed  of  a  large  number 
of  small  cysts,  or  in  which  the  contents  are  so  viscid  that  they  will  not 
escape  through  the  trocar,  the  opening  should  be  enlarged  and  the 
hand  passed  into  the  cyst  to  break  down  the  numerous  septa  or  scoop 
out  the  viscid  contents. 

If  the  bulk  of  the  cyst  is  solid,  the  trocar  puncture  having  been 
enlarged  and  clamp  forceps  firmly  keeping  forward  the  edges,  the 
surgeon  first  introduces  two  or  three,  then,  perhaps,  all  the  fingers  of 
one  hand,  and  scoops  out  the  solid  material  till  the  bulk  of  the  cyst  is 
sufficiently  reduced  to  come  through  his  incision.  It  is  preferable, 
however,  to  enlarge  the  incision  upwards  sufficiently  to  allow  of  the 
mass  being  brought  out  entire,  its  long  axis  being  tilted  into  that  of  the 
wound.  In  these  cases  it  is  especially  important  to  avoid  any  leakage 
of  the  contents  into  the  peritonseal  cavity,  as  portions  of  the  tumour 
thus  carried  in  may  give  rise  to  a  recurrence  of  growth. 

If  the  wound  requires  enlargement,  this  is  best  done  with  a  blunt- 
pointed  straight  bistoury  or  a  pair  of  scissors  and  the  use  of  two  fingers 
as  a  director,  the  incision  being  carried  to  the  left  of  the  umbilicus  so 
as  to  avoid  any  still  open  vessel  in  the  round  ligament. 

The  enlargement  of  the  wound  may  be  found  necessary  when  the 
ovarian  tumour  is  solid  or  contains  such  a  proportion  of  solid  material 
as  to  render  its  delivery  through  the  original  incision  difficult.  "When 
feasible,  this  is  a  better  plan  in  the  latter  case  than  scooping  out  the 
contents,  as  this  proceeding  is  often  attended  with  considerable  haunor- 
rhage,  and  is,  moreover,  likely  to  be  followed  by  reinfection  of  the 
peritonaea]  cavity.  The  wound  should  be  enlarged  when,  from  the 
previous  history  or  the  appearance  of  the  tumour,  there  is  reason 
to  believe  that  suppuration  has  occurred.  Many  surgeons  prefer  to 
remove  dermoids,  unless  of  large  size,  entire,  to  obviate  the  risk  of  the 
oily  contents  escaping  into  the  abdominal  cavity. 

Treatment  of  Adlicsions. — As  the  cyst  is  emptied  and  drawn  forwards, 
any  adhesions  that  are  present  must  be  dealt  with,  and  the  ease  with 
which  they  are  separated  will  depend  upon  whether  they  are  recent  or 
not.  Those  between  the  tumour  and  abdominal  wall  are  readily 
separated,  when  recent,  by  sweeping  the  hand  between  the  two 
adherent  surfaces.  If  of  longer  duration  the  separation  must  be 
effected,   bit  by  bit,  with  the   finger-nail   or  scissors,   any  persistent 


OVARIOTOMY.  823 

bleeding  points  being  secured  by  Spencer  Wells's  forceps  and  tied. 
Another  method  is  to  under-run  any  bleeding  points,  especially  any 
obstinate  ones  in  the  parietal peritomeum.  Adhesions  to  the  omentum, 
which  are  the  most  common,  must  be  ligatured  and  divided,  the  number 
of"  ligatures  used  depending  on  the  extent  of  the  adherent  omentum, 
Mr.  Herman  (Diseases  of  Women,  1898,  p.  797)  points  out  that  holes 
frequently  exist  in  large  pieces  of  adherent  omentum,  and  he  advises 
that  in  cutting  the  omentum  away  the  incisions  should  be  carried 
through  these  holes  to  obviate  any  subsequent  risk  of  intestines  being 
strangulated  in  them.  Intestinal  and  other  visceral  adhesions  may 
present  considerable  difficulties.  If  the  bowel  is  adherent  it  should 
be  very  carefully  peeled  by  means  of  the  thumb-nail  from  the  cyst.  If 
it  cannot  be  detached  in  this  waj'  a  thin  strip  of  the  cyst  wall  should 
be  cut  away  and  left  adherent  to  the  intestines.  Firm  adhesions  in  the 
pelvis  present  the  most  difficulty,  and  in  the  separation  of  them  by 
means  of  the  fingers  a  hole  may  be  torn  in  the  rectum.  Injury  to  large 
vessels  is  not  common.  In  Dr.  Baldy's  Gynaecology,  however,  a  case 
is  recorded  in  which  death  resulted  from  haemorrhage  due  to  injury  of  a 
large  vein  in  the  removal  of  an  ovarian  cyst.  Though  bleeding  from 
large  vessels  is  not  common,  it  is  especially  in  cases  of  extensive  pelvic 
adhesions  that  we  get  troublesome  oozing.  Temporary  plugging  with 
sterilised  gauze  may  arrest  this,  but  should  it  fail,  an  attempt  should  be 
made  to  seize  the  bleeding  points  with  forceps  and  secure  them  with 
ligatures.  This  procedure  will  be  much  facilitated  by  having  the 
patient  in  the  raised  pelvis  position.  If  bleeding  cannot  be  arrested 
by  these  means  the  pelvic  cavity  should  be  firmly  packed  with 
long  strips  of  sterilised  or  iodoform  gauze,  the  ends  of  which  are 
brought  out  through  the  lower  part  of  the  wound.  The  sutures  should 
be  introduced  as  usual  into  the  lower  part  of  the  abdominal  incision, 
but  should  be  left  untied,  ready  to  bring  the  edges  of  the  wound 
together  when  the  plug  is  removed.  The  gauze  should  be  taken  out 
forty-eight  hours  after  the  operation.  By  that  time  it  will  have  served 
its  purpose,  the  arrest  of  the  oozing.  It  will  be  found  that  the  plug  is 
more  easily  removed  then  than  later,  though  some  operators  recommend 
that  it  should  be  left  in  a  week.  This  method  of  treatment  by  packing 
is  a  much  more  reliable  and,  on  the  whole,  safer  method  than  the  older 
ones  of  cauterisation  or  touching  with  solid  perchloride  of  iron.  If 
packing  with  gauze  is  used  for  troublesome  pelvic  oozing,  the  cautery 
will  be  very  seldom  required.  Mr.  Herman,  who  has  never  had 
occasion  to  use  the  cauteiy,  says  with  regard  to  its  employment  in 
the  pelvis  :  "  Large  vessels  lie  so  close  under  the  peritonaeum  that 
I  should  fear  to  burn  extensively  in  this  region."  With  regard  to 
the  use  of  iron  perchloride,  the  only  condition  that  demands  its 
use,  viz.,  general  oozing,  is  better  met  by  the  use  of  the  gauze 
tampon. 

Treatment  of  Pedicle. — When  the  cyst  has  been  sufficiently  brought 
outside,  the  pedicle  is  dealt  with. 

The  centre  of  the  pedicle  being  found  by  unfolding  it,  a  blunt 
pedicle  needle  loaded  with  silk  (No.  4)  is  made  to  perforate  it  here  at 
a  spot  devoid  of  vessels.  The  loop  of  silk  being  drawn  through  and 
the  needle  withdrawn,  the  loop  is  cut,  and  the  two  ligatures  tied  firmly 
round  the  two  halves  of  the  pedicle.     To  make  the  silk  hold  in  a  stout 


824 


OPKKATIOXS    ON    TIIK    ABDOMEN. 


(Donui.) 


pedicle,  it  is  well  to  loop  the  ligatures  round  some  blunt  instruments, 
so  as  to  tie  them  with  sufficient  force.  When  they  are  both  tied,  one 
is  cut  short  while  the  other  is  thrown  round  the  whole  pedicle  and  tied 
again.  The  cyst  is  then  cutaway,  not  more  than  three-quarters  of  an 
inch  and  not  less  than  half  an  inch,  from  the  ligatures.  Winn  this  is 
done,  the  cut  end  is  carefully  examined,  to  make  sure  that  no  bleeding 
is  taking  place.  The  pedicle  is  then  allowed  to  drop  in,  and  the  finger, 
following  it  down  to  the  uterus,  finds  and  hooks  up  the  other  ovary.     If 

this  is  found  enlarged  it  must  he 
removed.  When  the  pedicle  is 
very  broad,  a  second  or  a  third 
transfixion  will  be  needed.  The 
second  must  be  thus  performed  : 
The  thread  for  the  outer  loop 
(a,  Fig.  343)  is  twisted  on  one 
side  of  the  pedicle  round  the 
outer  thread  (b)  ;  then  the  outer 
loop  is  tied.  The  pedicle-needle 
(a  long  unhandled  one  with  a 
large  eye  is  the  best)  is  then 
threaded,  first  with  a  single  liga- 
ture (c),  and  then  with  one  end 
(b)  of  the  untied  thread  already 
passed  through  the  pedicle.  The 
transfixion  is  then  performed  (Fig.  343).  The  third  thread  (c)  must 
be  once  twisted  around  the  second  (b)  ;  this  is  best  done,  perhaps,  on 
the  side  where  (b)  forms  a  loop  (Fig.  343).  Then,  on  the  opposite 
side,  the  two  free  ends  of  the  second  thread  (1>)  are  firmly  tied.  The 
ends  of  the  third  thread  (c)  are  then  tied  on  the  inner  side  of  the  pedicle. 
The  threads  will  then  lie  as  in  Fig.  344,  firmly  interlocked  and  holding 
the  pedicle  tightly.     Should  a  third  transfixion  be  required,  the  third 

thread,    instead    of    being    tied,    must    be 

Fig.  344.  threaded   on   the   needle   in  company  with 

a   fourth,   and    the  process  just  described 

repeated,  care  being  taken  to  interlock  the 

threads  as  before.     If  this  precaution    be 

not  taken,  the  unlocked  threads  pulling  in 

different  directions  will  tend   to  tear  the 

pedicle   apart  at  the  point  of  transfixion, 

and   vessels   may  easily  escape  being  com- 

(Doran.)  manded.    A.s  each  of  the  above  loops  is  tied, 

the  ends  of  the  thread  must  be  cut  short, 

or  needless  confusion  will  be  entailed. 

The  Toilet  of  the  PeHtonaum. — The  operator  now  scrutinises  the 
parts,  removes  any  jagged  omentum  or  bands  of  adhesions,  arrests 
any  still  bleeding  points,  takes  out  any  sponges  which  he  may  have 
inserted,  and  has  them  all  counted.  The  next  step  is  to  sponge  out 
thoroughly  the  pelvis,  the  spaces  in  front  of  and  behind  the  uterus,  and 
those  on  either  side  of  the  vertebral  column.  This  is  effected  by 
introducing  again  and  again  aseptic  sponges  or  sterilised  gauze  swabs 
on  sponge  forceps  until  they  return  dry  and  colourless.  In  the  greal 
majority  of  cases  this  will  be   sufficient,  and  many  operators  employ 


344- 
b 


1.    'r. 

££   ^  " 

.^Z^-gr.v,,. 


a- 


OVAIUOTOMY. 


<S25 


practically  no  other  procedure.  If,  however,  a  cyst  has  hurst  during 
the  handling  of*  the  tumour,  as  sometimes  happens  when  the  wall  is 
thin  or  necrotic,  and  viscid  contents  or,  perhaps,  papillary  growths  have 
escaped  into  the  peritoneal  cavity,  it  is  difficult  without  undue  manipu- 
lation of  the  viscera  to  get  the  abdominal  cavity  clean.  Under  thi 
circumstances  it  is  preferable  to  wash  out  with  warm  sterilised  water, 
or  sterilised  water  to  which  "6  per  cent,  of  common  salt  has  been 
added.  This  is  especially  indicated  where  growth  has  escaped  into 
the  peritoneal  cavity  from  a  papillary  cyst,  on  account  of  the  possibility 
of  reinfection  from  a  portion  of  growth  left  behind. 

Suture  of  Abdominal   Wound. — The  abdominal  wound  maybe  closed 
either  by  using  one  row  of  sutures  which  pass  through  skin,  muscle, 

Fig-  345- 


(Doran.) 


and  peritonaeum,  or  by  securing  the  different  layers  separately.  One 
row  only  of  sutures  should  be  used  in  cases  in  which  drainage 
is  employed,  or  in  which  the  contents,  though  freely  removed,  were 
septic,  or,  again,  in  cases  in  which  a  second  operation  appeared 
probable.  The  introduction  of  a  single  layer  is  effected  as  follows  : 
A  flat  sponge  being  introduced  to  catch  any  blood,  the  abdominal 
wound  is  closed  by  means  of  sutures  of  stout  silkworm  gut. 
These  should  be  carried  through  peritonaeum,  muscle,  and  skin,  care 
being  taken  that  the  stitches  pass  through  the  peritonaeum  within  a 
quarter  of  an  inch  of  its  edge,  so  that  this  structure  is  not  tucked 
in  between  the  surfaces  of  the  wound.  Not  only  should  a  good  bunch 
of  muscle  be  included,  but  also  the  fibrous  sheath  overlying  it.  The 
sutures  should  pass  through  the  skin  about  a  third  of  an  inch  from 
the  edge  of  the  wound,  and  they  should  be  inserted  about  half  an  inch 


826  Ol'KlUTIONS    ON    T1IK    AI'.DOMKN. 

from  cadi  other.  When  all  the  sutures  have  heen  introduced  they 
are  collected  near  their  ends  on  either  side  with  pressure  forceps 
(Fig.  345).  The  operator  then  parts  the  sutures,  hooking  them  up  and 
down  so  as  to  obtain  free  access  to  the  abdominal  cavity  without  any 
risk  of  pulling  out  a  suture.  The  flat  sponge  is  now  withdrawn  and 
the  sutures  tied,  care  heing  taken  that  neither  omentum  nor  intes- 
tines become  caught  in  the  loop.  Superficial  sutures  of  fine  silk  or 
horse-hair  should  be  employed  to  accurately  coapt  the  edges  of  the 
skin. 

If  the  layers  of  the  abdominal  wall  are  to  be  sewn  up  separately,  the 
first  procedure  is  to  shut  off  the  peritomeal  cavity  by  bringing  the 
edges  of  the  peritonaeum  together  with  a  continuous  suture  of  fine  silk, 
or  preferably  catgut.  The  recti  are  then  approximated  either  by  a 
continuous  or  by  interrupted  sutures  of  the  same  material,  care  being 
taken  to  bring  together  the  edges  of  the  fibrous  layer  overlying  the 
muscle.  The  edges  of  the  skin  are  finally  sewn  together  in  the  same 
way.  The  modifications  of  these  two  methods  made  use  of  by  different 
surgeons  are  numerous.  Dr.  Galabin  employs  interrupted  sutures  of 
stout  silkworm  gut  passed  through  all  the  layers.  Before  these  are 
tied  he  approximates  the  edges  of  the  fascia  superficial  to  the  recti 
with  a  continuous  suture  of  gossamer  fishing  gut.  The  skin  edges  are 
finally  united  by  a  continuous  horsehair  suture.  I  prefer  to  unite  first 
of  all  the  edges  of  the  peritonaeum  with  a  continuous  fine  catgut  suture. 
Interrupted  silkworm  gut  sutures  are  then  passed  through  skin,  fascia, 
and  muscle,  and  before  these  are  tied  the  rectal  fascia  is  approximated 
with  a  catgut  suture,  the  edges  of  the  skin  being  brought  into  careful 
apposition  with  a  continuous  horsehair  suture  after  the  interrupted 
silkworm  gut  sutures  have  been  tied. 

Drainage. — Different  operators  vary  much  in  their  practice  as  regards 
drainage,  and  it  is  difficult  to  lay  down  any  hard-and-fast  rules  as  to 
when  to  employ  it.  Undoubtedly  the  tendency  is  to  employ  it  less  and 
less.  Experiments  carried  out  within  the  last  few  years  on  the  absorp- 
tive powers  of  the  peritonaeum  have  taught  us  that  this  structure,  when 
in  a  normal  condition,  is  capable  of  absorbing  large  quantities  of  fluid 
and  also  of  disposing  of  a  considerable  number  of  pyogenic  organisms 
introduced  into  the  abdominal  cavity.  We  have  to  bear  in  mind,  however, 
that  a  peritonaeum  thickened  by  inflammation,  such  as  we  find  in  some 
cases  of  ovarian  tumour,  has  its  functions  impaired,  and  is  not  in  a 
condition  to  dispose  of  large  quantities  of  fluid  or  many  organisms. 
Consequently  fluid  collecting  in  the  abdominal  cavity  provides  a  ready 
medium  for  the  growth  of  any  organisms  accidentally  introduced. 

Dr.  Jellett  (Pract.  of  GyikccoL,  1900,  p.  287)  puts  this  question  of 
drainage  very  clearly.  "  It  must  be  regarded,"  he  says,  "  as  a  line  of 
treatment  whose  general  effect  is  by  no  means  beneficial,  but  which  may 
have  to  be  used  at  times  in  order  to  guard  against  a  greater  danger." 
The  risks  of  drainage  should  be  clearly  recognised.  One  serious  result 
is  the  weakening  of  the  abdominal  scar  that  attends  its  use,  with  the 
subsequent  formation  of  a  hernia.  The  drain  may  be  a  cause  of  re- 
infection of  the  abdominal  cavity,  and  when  a  hard  glass  tube  is  em- 
ployed, may,  by  pressure  on  the  bowel,  lead  to  the  formation  of  a  faecal 
fistula.  There  is  one  condition  in  which  drainage  is  certainly  called  for, 
and  that  is  when  any  septic  material,  as  from  a  suppurating  cyst  or  a 


OVARIOTOMY.  827 

pyo-salpinx,  lias  entered  the  peritoneeal  cavity,  or  when  any  septic  focus 
lias  been  imperfectly  removed. 

Drainage  is  less  often  made  use  of  after  the  separation  of  extensive 
adhesions.  In  such  cases  the  surgeon  must  use  his  own  judgment. 
He  should  bear  in  mind  the  fact  that  the  absorptive  powers  of  the 
peritoneum  in  such  cases  are  impaired,  and  if  he  thinks  that  more 
exudation  is  poured  out  than  the  peritonaeum  can  deal  with,  he  must 
employ  some  form  of  drainage.  For  this  purpose  a  glass  tube  (Keith's) 
is  commonly  made  use  of.  One  end  rests  at  the  bottom  of  Douglas's 
pouch  without  pressing  on  the  rectum  ;  the  other  passes  through  a  thin 
sheet  of  india-rubber,  its  neck  being  firmly  gripped  by  a  hole  in  this. 
One  or  two  sutures  should  be  passed  in  the  usual  way  through  the 
abdominal  wound,  above  and  below  the  tube,  but  left  untied  until  the 
tube  is  removed.  A  sponge  is  placed  on  the  end  of  the  tube  to  absorb 
discharges,  and  the  india-rubber  sheeting  wrapped  round  it  to  prevent 
soiling  of  the  dressings.  The  sponge  should  be  changed  at  first  every 
hour,  and  this  is  done  without  disturbing  the  dressings  over  the  wound  ; 
later  on  the  change  should  be  effected  every  two  or  three  or  more  hours. 
At  the  same  time  as  the  sponge  is  changed  the  fluid  should  be  sucked 
out  of  the  drainage  tube  b}r  means  of  a  glass  syringe  with  a  piece  of 
india-rubber  tubing  attached.  The  syringe  and  tubing  should  be  boiled 
before  being  used,  and  the  most  scrupulous  precautions  taken  against 
the  introduction  of  organisms  from  without.  It  is  difficult  to  lay  down 
rules  with  regard  to  the  length  of  time  drainage  should  be  employed. 
When  used  on  account  of  oozing  from  extensive  raw  surfaces  one  to  two 
da}rs  will  usually  suffice.  If  emplo}Ted  for  a  septic  case  drainage  may 
be  dispensed  with  as  soon  as  a  bacteriological  examination  shows  the 
discharge  to  be  sterile.  When,  on  account  of  persistence  of  purulent 
discharge,  drainage  is  required  for  some  time,  the  glass  tube  should  be 
replaced  in  a  few  days'  time  by  a  rubber  one.  Mr.  Herman  recommends 
that  it  should  be  so  replaced  at  the  end  of  twent}r-four  hours  in  all  cases 
where  longer  drainage  is  required.  Owing  to  the  fact  that  a  hard  tube 
is  likely  to  produce  a  faecal  fistula  by  pressure  on  the  bowel,  and  owing 
to  the  danger  of  reinfection  that  attends  its  use,  man3r  surgeons  have 
discarded  it,  and  now  employ  gauze  instead.  Either  sterilised  or  iodo- 
form gauze  may  be  used.  It  should  be  cut  into  strips  and  its  edges 
turned  in  and  sewn  together  to  prevent  the  possibility  of  shreds  being 
detached  and  left  behind  in  the  wound.  As  it  soon  ceases  to  act  as  a 
drain,  it  should  be  removed  twenty-four  to  forty-eight  hours  later,  fresh 
strips  being  replaced  if  necessary.  For  drainage  through  the  abdominal 
wound  gauze  is  not  altogether  satisfactory.  It  soon  fails  to  act,  necessi- 
tating renewal ;  and  I  agree  with  Dr.  Galabin  that  it  appears  to  set  up 
more  adhesions  than  a  glass  tube.  The  advantages  in  certain  cases  of 
drainage  through  the  vagina  are  pointed  out  by  Dr.  Jellett  (loc.  supra 
cit.),  and  he  considers  that  with  a  healthy  vagina  drainage  through  the 
bottom  of  Douglas's  pouch  is  the  correct  treatment  in  the  majority  of 
cases.  It  does  not  weaken  the  abdominal  wound,  and  drainage  is 
carried  out  from  the  most  dependent  point  of  the  abdominal  cavity. 
The  vagina  is  opened  through  the  pouch  of  Douglas  on  the  separated 
points  of  a  pair  of  forceps  pushed  up  by  an  assistant  into  the  posterior 
fornix  of  the  vagina.  A  strip  of  iodoform  gauze  should  be  passed 
through  the  opening  from    Douglas's    pouch  into  the  vagina,  about 


828         OPERATIONS  ON  THE  ABDOMEN. 

half  an  inch  of  the  gauze  being  left  projecting  into  the  peritoneal  cavity. 
The  remainder  of  this  strip  is  left  packed  in  the  vagina,  and  should  he 
removed  in  two  or  three  days'  time. 

EncapmUed  Ovarian  Cysts. — Cysts  of  the  Broad  Ligament. — Intra- 

ligamentous  Cysts. — Cases  are  occasionally  met  with  in  which  the  cyst 
growing  between  the  layers  of  the  broad  ligament  is  imperfectly 
encapsuled  and  has  no  pedicle  that  can  be  ligatured.  In  these  cases 
an  attempt  should  be  made  to  enucleate  the  tumour  after  making  an 
incision  through  the  peritonaea!  covering.  Mr.  Thornton  (Diet.  Surgery, 
vol.  ii.  p.  155)  has  pointed  out  the  advisability  of  isolating  at  an  early 
st .age  the  vessels  and  ligaturing  them.  Dr.  Kelly  (Oper.  Gyntecol.,  1898, 
vol.  ii.  p.  303),  who  also  draws  attention  to  the  importance  of  securing 
the  vessels  early  in  the  operation,  points  out  that  the  blood-supply  is 
derived  from  the  ovarian  and  the  terminal  branches  of  the  uterine 
vessels,  and  that  these  should  be  sought  for,  the  former  on  the  side 
of  the  pelvic  brim,  the  latter  on  the  uterine  side  of  the  cyst,  after 
division  of  the  peritonaeum.  If  these  are  tied  at  once  there  need  be 
but  little  haemorrhage  throughout  the  operation.  The  main  blood- 
supply  having  been  secured  in  this  way,  the  tumour  should  be  enu- 
cleated by  separating  with  the  fingers  the  loose  connective  tissue 
that  holds  it  in  position.  The  removal  of  the  cyst  will  be  facilitated 
by  emptying  it  of  its  contents  with  a  trocar  in  the  usual  way.  Any 
bleeding  points  in  the  capsule  should  be  seized  with  pressure  forceps 
and  secured.  "  In  performing  these  enucleations  the  operator  must 
always  bear  in  mind  the  fact  that  he  is  constantly  brought  into 
dangerously  close  relations  with  bladder  and  ureters,  rectum  and 
sigmoid  flexure,  or  caecum  and  appendix.  The  large  iliac  vessels 
are  also  occasionally  incorporated  with  the  capsule"  (Mr.  Thornton, 
loc.  supra  cit.). 

After  the  removal  of  the  cyst  the  capsule  requires  attention.  If  it 
is  very  redundant  it  may  be  gathered  up  into  a  loose  fold,  transfixed 
and  tied,  like  an  ordinary  pedicle  (Mr.  Bland  Sutton,  Surg.  Dis.  oj 
Ovaries,  1896,  p.  372).  If  the  cavity  is  small,  and  there  is  no  oozing, 
the  cut  edges  of  the  peritonaeum  should  be  drawn  together  by  a  con- 
tinuous silk  ligature.  If,  however,  there  is  much  oozing,  the  edges  of 
the  capsule  should  be  secured  to  the  lower  part  of  the  abdominal  wound, 
and  its  interior  packed  with  gauze  strips.  Sometimes  it  is  found  that 
the  cyst  is  so  firmly  attached  to  important  structures  that  its  removal 
becomes  an  impossibility.  The  edges- of  the  cyst  and  the  capsule  must 
then  be  attached  to  the  abdominal  wound,  and  the  cavity  drained.  Such 
;i  procedure  is  not  entirely  satisfactory,  as  the  cyst  is  likely  to  refill 
later.  When  intra-ligamentary  growths  occur  on  both  sides,  Dr.  Kelly 
considers  that  it  is  easier  and  better  to  remove  uterus  and  tumours 
together,  the  method  adopted  being  practically  the  same  as  that 
employed  by  him  for  hysterectomy. 

Incomplete  Ovariotomy. — The  surgeon  may  be  compelled,  very  early 
in  the  case,  to  abandon  his  operation.  This  will  be  rendered  necessary 
by  the  following  conditions : — (1)  When  the  tumour  is  malignant  and 
has  infiltrated  tissues  which  cannot  be  safely  removed,  or  when  secon- 
dary nodules  are  found  in  the  abdominal  cavity.  (2)  When  the 
peritonaeum  is  found  covered  with  papillary  growths,  the  result  of 
infection  from  a  papillary  cyst.     Dr.  H.  A.  Kelly  (he.  supra  cit.,  vol.ii. 


OVARIOTOMY.  829 

p.  294)  advises  removal  of  the  mother-tumour  whenever  it  is  possihle, 
us  he  ((insiders  it  not  only  relieves  the  pressure  of  the  aseites,  hut 
checks  the  rapidity  of  the  growth.  Moreover,  cases  have  heen  recorded 
hy  Mr.  K.  Thornton  and  others  where  a  disappearance  of  the  secondary 

papillary  growths  and  a  freedom  from  recurrence  have  resulted  from 
this  line  of  treatment.  (3)  When  the  base  of  the  cyst,  whether  intra- 
Ligamentary  or  not,  is  irremovable,  deep  in  the  pelvis,  and  adherent  to 
the  ureters,  large  vessels,  or  adjacent  viscera.  The  surgeon  must  then 
empty  the  cyst  of  its  contents,  and  suture  its  cut  edge  to  the  abdominal 
incision,  all  superfluous  portions  of  the  cyst  being  cut  awa}\  Before 
doing  this  he  must  check  all  haemorrhage,  inspect  any  possibly  damaged 
viscera,  and  carefully  cleanse  the  back  of  the  tumour  and  the  parts 
behind  it.  The  remains  of  the  cyst,  after  being  carefully  sutured  to  the 
lower  part  of  the  abdominal  incision  so  as  to  entirely  shut  off  the 
peritomeal  cavity,  should  be  packed  with  iodoform  gauze.  When  the 
cyst  contains  solid  growth  an  attempt  should  be  made  to  remove  this 
from  the  portion  of  cyst  wall  left  behind,  to  minimise  as  far  as  possible 
the  risk  of  sepsis  and  rapid  recurrence. 
Accidents  during  Ovariotomy. 

(1)  Syncope. — This  appears  to  be  brought  about  in  some  cases  by  too 
rapid  emptying  of  large  cysts.  The  pressure  on  the  abdominal  vessels 
is  relaxed,  and  they  become  filled  with  blood  at  the  expense  of  the  rest 
of  the  body.  This  accident  should  be  avoided  by  slowly  drawing  off 
the  contents  of  large  cysts.  When  it  occurs  it  should  be  treated  by 
lowering  the  head,  keeping  the  patient  warm,  and  administering  brandy 
subcutaneously. 

(2)  Vomiting. — This  chiefly  harasses  by  straining  the  intestines  out 
of  the  abdomen.  If  prolonged,  the  operation  must  be  completed  as 
soon  as  possible,  an  assistant  keeping  the  viscera  in  place  with  a  flat 
sponge  or  gauze  pad. 

(3)  Separation  of  the  Parietal  Peritonceum. — It  has  already  been 
pointed  out  that  this  is  due  to  the  operator  mistaking  the  sub- 
peritoneal fat  for  omentum.  It  is  an  accident  that  may  be  avoided 
by  care. 

(4)  Rupture  of  the  Cyst. — This  accident  may  be  expected  when  the 
walls  are  thin,  necrotic,  or  softened  by  recent  inflammation.  In  such 
cases  the  cyst  should  be  carefully  handled,  suspicious  spots  being  kept 
well  out  of  the  wound  or  packed  around  with  sponges.  If  rupture 
occurs,  the  abdomen  should  be  well  irrigated  with  warm  boiled 
water,  and  if  the  contents  of  the  cyst  are  suppurating,  drained 
subsequently. 

(5)  Injuries  to  Viscera. — Of  these  the  bladder,  small  intestines,  rectum, 
and  ureter  are  most  likely  to  suffer.  The  bladder  may  be  injured 
during  the  abdominal  incision  owing  to  its  being  drawn  up.  This, 
however,  is  not  so  likely  to  happen  as  in  operations  for  fibroids.  Or  it 
may  be  opened  in  the  course  of  removal  of  the  tumour.  Treatment 
consists  in  immediate  suture  of  the  organ,  and  subsequent  drainage  by 
catheter  to  prevent  distension.  The  intestine  is  most  likely  to  be 
injured  in  the  separation  of  adhesions.  When  possible  the  wound  in 
the  bowel  should  be  at  once  sutured.  If  the  damage  is  more  extensive 
the  question  of  resection  of  a  portion  of  gut  will  arise.  The  rectum  is 
sometimes  torn  in  the  separation  of  firm  adhesions  in  the  pelvis.     The 


830  OPERATIONS   ON    THE    ABDOMEN. 

operator  should  attempt  to  sew  up  the  rent,  a  proceeding  that  will  be 
much  facilitated  by  the  raised  pelvis  position  and  a  good  light.  <  )ften 
suturing  will  be  found  to  be  impossible,  and  in  such  case  the  neighbour- 
hood of  the  injury  should  be  well  packed  with  iodoform  gauze,  the  ends 
of  which  are  left  out  of  the  abdominal  wound,  or  through  ;in  opening  in 
the  vaginal  vault.  Sloughing  of  the  bowel  sometimes  occurs  after 
the  operation,  leading  to  the  formation  of  a  faecal  fistula.  This  is 
owing  in  some  cases  to  injury  of  the  intestine  during  the  operation,  in 
others  to  the  pressure  of  the  glass  tube  used  for  drainage.  For  the 
treatment  of  cases  in  which  the  ureter  is  injured  the  chapter  on  that 
subject  should  be  consulted  (p.  149). 

(6)  Severe  Hemorrhage. — It  has  already  been  mentioned  that  severe 
or  fatal  haemorrhage  from  injury  to  large  pelvic  vessels  is  rare.  Very 
severe  and  even  alarming  haemorrhage  may,  however,  take  place  from 
the  cyst  wall  or  its  interior.  This  is  especially  likely  to  happen  when 
the  solid  contents  of  a  papillary  cyst  are  being  scooped  out  by  the  hand. 
If  the  pedicle  can  be  got  at  readily  and  ligatured,  this  should  be 
done  quickly.  If  not,  the  advice  given  by  Dr.  H.  A.  Kelly  (loc.  supra 
cit.,  p.  296)  should  be  followed:  "  The  only  safe  plan  is  to  control  at 
once  the  main  vessels  going  to  the  tumour  by  applying  artery  forceps 
to  the  broad  ligament  at  the  pelvic  brim  so  as  to  catch  the  ovarian 
vessels,  and  one  or  two  pairs  at  the  uterine  corner  to  catch  the  uterine 
vessels." 

(7)  Leaving  in  Instruments. — E.g.,  sponge  or  forceps.  The  fact  that 
this  accident  has  occurred  with  operators  of  the  largest  experience 
should  make  all  careful.  It  is  best  met  by  having  a  sufficient 
definite  number  to  begin  with,  counting  carefully  afterwards,  and  allowing 
no  tearing  of  sponges. 

After-treatment. — The  patient  should  be  kept  on  her  back  for  two 
days  after  the  operation,  and  a  pillow  placed  under  her  knees.  At  the 
end  of  that  time  she  may  be  turned  first  on  to  one  side,  then  on  to  the 
other.  If  a  glass  drainage-tube  is  made  use  of,  she  must  be  kept  on 
her  back  till  the  tube  is  removed.  The  most  careful  attention  should 
be  paid  to  the  bedding  under  her,  and  the  nurse  should  see  that  there 
are  no  creases  in  the  mackintosh  or  sheets.  A  few  wrinkles  will  cause 
the  patient  the  most  acute  discomfort. 

The  retching  and  vomiting  that  patients  suffer  from  after  an 
abdominal  operation  is  considerably  more  than  the  anaesthetic  alone 
will  account  for.  Drugs  should  not  be  employed  to  combat  the 
sickness.  In  fact,  they  will  generally  be  found  to  be  useless.  The 
proper  treatment  of  the  stomach  is  rest  during  the  first  twenty  hours. 
The  only  thing  that  should  be  given  during  this  time  is  hot  water,  and 
of  this  a  tablespoonful  may  be  taken  at  a  time  as  hot  as  can  be  borne 
comfortably.  This  will  be  found  to  be  most  acceptable  to  the  patient, 
reviving  her,  and  often  removing  the  feeling  of  faintness.  Ice  should 
not  be  given  either  for  the  sickness  or  to  allay  thirst.  The  iced  water 
remains  unabsorbed  in  the  stomach,  and  is  sooner  or  later  rejected. 
At  the  end  of  twenty-four  hours  small  quantities  of  nourishment  may 
usually  be  given.  It  is  difficult  to  lay  down  rules  with  regard  to 
quantities.  In  a  straightforward  case  two  drachms  of  milk,  which  has 
been  peptonised  beforehand,  may  be  given  every  half-hour  to  com- 
mence  with,  and   the  quantity  gradually  increased.     Albumen  water, 


REMOVAL   OF   THE   UTERINE    APPENDAGES  831 

made  by  dissolving  the  white  of  an  egg  in  half  a  pint  of  water,  may  be 
usefully  given,  mixed  in  equal  quantities  with  the  milk.  If  vomiting 
is  persistent,  enough  water  should  be  given  to  keep  the  mouth  moist, 
and  the  patient  fed  with  nutrient  enemata  and  suppositories,  given 
alternately  every  four  hours.  In  slighter  cases  of  vomiting  albumen 
water  alone  is  often  well  tolerated. 

The  bowels  should  be  opened  about  the  third  day.  This  is  best 
effected  by  means  of  an  oil  enema  given  on  the  morning  of  the  third 
day,  followed  later  by  a  soap  and  water  one,  or  else  two  or  three  grains 
of  calomel  may  be  administered  on  the  evening  of  the  second  day, 
followed  by  a  saline  purge  the  next  morning.  The  unloading  of  the 
bowels  will,  as  a  rule,  make  the  patient  more  comfortable,  relieve 
flatulence  from  which  she  may  have  been  suffering,  and  allow  her  to 
take  more  nourishment.  The  patient  should  be  allowed  and  encouraged 
to  pass  her  water  naturally  after  the  operation.  If  she  cannot  do  so 
a  catheter  should  be  passed  at  the  end  of  twelve  hours,  every  possible 
precaution  being  taken  to  prevent  infection  of  the  bladder. 

The  routine  use  of  opium  in  any  form  is  to  be  avoided.  On  this 
subject  I  cannot  do  better  than  quote  the  late  Mr.  Greig  Smith's  words  : 
"  All  medicines  are,  if  possible,  to  be  avoided,  particularly  opium.  Pain 
I  believe  to  be  not  so  strong  an  indication  for  opium  as  restlessness. 
Sickness  and  tympanites  are  predisposed  to,  if  not  often  caused  by, 
opium.  One  expects,  after  the  first  dose  has  been  administered,  to  see 
the  patient  wake  up  in  the  morning  with  a  dry  tongue,  increased 
thirst,  and  some  feeling  of  nausea,  which  during  the  day  do  not  pass 
off,  but  culminate  in  restlessness  at  night,  requiring  the  administration 
of  a  second  dose.  We  rarely  see  a  case  treated  throughout  with  a 
perfectly  flat  or  retracted  abdomen  if  opium  has  been  administered. 
When  the  patient  tosses  about  in  bed,  fidgety  and  restless,  without 
any  particular  symptoms  beyond  those  incident  to  a  serious  operation, 
opium  is  undoubtedly  of  great  value  "  (Abclom.  Surg.,  1896,  vol.  i.  p.  210). 

REMOVAL   OF  THE   UTERINE  APPENDAGES.* 

Indications.! — Before  giving  these,  I  would  state  that  there  is  no 
operation  in   which  it  is  more  necessary  to  consider  each  case  on  its 

»  This  term  has  been  used  here  for  convenience'  sake,  as  more  comprehensive  than 
"oophorectomy,"  &c. 

|  A  paper  read  some  years  ago  at  one  of  our  medical  societies,  and  the  discussion 
thereon,  has  brought  this  matter  prominently  before  the  profession.  I  would  strongly 
advise  my  younger  readers  to  study  carefully  a  very  weighty  letter  in  the  journals 
of  February  7,  1891,  bearing  the  well-known  signatures  of  Sir  John  Williams  and  Dr. 
Champneys.  Every  sentence  will  well  repay  perusal.  I  quote  a  few  :  "  Perimetritis  is 
probably  the  very  commonest  of  all  the  serious  diseases  of  women.  It  is  also  perfectly 
certain  that  the  great  majority  of  cases  get  quite  well  without  any  operation.  We  are  far 
from  denying  that  exceptional  cases  call  for  surgical  procedures,  or  that  cases  of  prolonged 
suppuration  in  the  pelvis  are  properly  treated  by  the  application  to  them  of  ordinary 
surgical  principles.  But  this  wholesale  resort  to  a  mutilating  operation,  advocated  by 
several  speakers  at  these  discussions,  calls  for  serious  consideration  by  the  profession.  .  .  . 
A  plea  for  patience  is  to  be  found  in  the  declaration  of  the  operators  that  the  full  benefits 
of  the  operation  are  not  felt  for  months  or  years  after.  If  the  operator  would  exercise  this 
patience  before  the  operation,  there  might  be  less  need  for  its  exercise  by  the  patient  after 
the  operation." 


832  OPERATIONS  ON  THE  ABDOMEN. 

own  bearings,  to  explain  the  object  and  results  with  honourable 
carefulness  to  the  friends  and,  whenever  possible,  to  the  patient  herself, 
and  to  remember  that  this  is  above  all  one  of  those  operations  which 
should  never  be  entertained  if  there  are  any  honest  doubts  as  to  the 
patient's  health  being  really  impaired  beyond  the  aid  of  other  treat- 
ment, and  the  impossibility  of  otherwise  restoring  her  to  usefulness 
in  the  position  of  life  in  which  she  has  been  placed ;  and  that  it  is  an 
operation  which  may  concern  the  happiness  of  another  besides  that  of 
the  patient.  Due  weight  must  be  given  to  the  large  part  played  by 
neuroses  in  this  matter,  and  to  the  fact  that  till  we  have  carefully 
published  cases  in  which  the  results  have  been  submitted  to  the  only 
true  test,  that  of  time,  we  shall  not  be  in  a  position  to  decide  how  far 
the  after-condition  of  a  great  number  of  the  patients  who  have  been 
submitted  to  this  operation  is  one  of  improvement.  Finally,  it  is 
always  to  be  remembered  that  it  is  an  operation  which  has  been  greatly 
misused. 

The  following  is  a  limited  list  of  indications  for  removal  of  the 
uterine  appendages  : 

(i)  Diseases  of  the  Fallopian  Tubes  and  Ovaries. — Of  these  the 
inflammatory  affections  concern  us  chiefly,  in  the  form  of  salpingitis, 
pyo-,  hydro-,  or  haemato-salpinx,  ovaritis,  ovarian  abscess,  or  tubo- 
ovarian  abscess.  Other  diseases  include  ovarian  new  growths  which 
have  been  considered  under  the  heading  of  ovariotomy  and  tumours 
of  the  Fallopian  tube,  which  do  not  call  for  separate  treatment.  It  is 
not  easy  to  make  rules  for  guidance  that  will  apply  to  all  cases  of 
inflammation  of  the  appendages.  Every  case  demands  careful  con- 
sideration on  its  own  merits.  The  broad  lines  of  treatment  may, 
nevertheless,  be  indicated ;  they  are  not  unlike  those  that  guide 
us  in  the  treatment  of  appendicitis.  In  the  following  indications, 
Mr.  Cullingworth  (Syst.  of  Gyn.,  Allbutt  and  Playfair,  1896,  p.  514)  is 
closely  followed : 

(a)  Operation  during  Acute  Attack. — It  is  not  often  that  surgical 
interference  is  called  for  during  au  acute  attack.  The  difficulty,  and 
more  especially  the  danger,  of  the  operation  is  increased  during  this 
stage.  Moreover,  the  advisability  of  treating  the  inflammation,  when 
acute,  by  rest  is  shown  by  the  generally  good  results  obtained.  Even 
if  pus  is  suspected,  the  surgeon  should  not  be  in  too  great  a  hurry  to 
operate.  One  well-defined  indication  for  interference  during  the  acute 
attack  has  "been  laid  stress  on  by  Mr.  Cullingworth,  and  that  is  the 
accumulation  of  fluid,  more  especially  if  it  be  purulent,  in  sufficient 
amount  to  distend  Douglas's  pouch  and  encroach  on  the  vagina  and 
rectum.  Here  "there  can  be  no  hesitation  as  to  the  propriety  of 
niakiiK*  an  opening  through  the  vaginal  roof.  Such  timely  interference 
will  not  only  afford  immediate  relief  to  the  more  urgent  symptoms,  but 
will  prevent  the  bursting  of  an  abscess  into  the  rectum." 

(b)  Recurrent  Attacks. — A  history  of  recurrent  attacks  of  peritonitis 
almost  invariably  means  the  presence  of  pus.  If,  with  this  history,  the 
patient  has  a  swelling  which  has  "  attained  such  dimensions  as  to  make 
it  fairly  certain  that  in  the  midst  of  it  there  is  either  an  occluded  and 
distended  Fallopian  tube,  or  an  ovary  enlarged  by  cystic  growth,  the 
indications  for  the  removal  of  the  disease  are  perfectly  clear." 

(t)   The  class  of  life  to  which  the  patient  belongs  must  be  considered. 


REMOVAL   OF   THE    UTERINE   APPENDAGES.  833 

A  woman  who  has  to  earn  her  living  cannot  afford  to  submit  to  pro- 
longed treatment  by  rest,  if  by  operation  she  can  secure  a  more  rapid 
recovery. 

(d)  Persistence  of  Symptoms  after  Acute  Attack. — In  most  cases,  with 
rest  and  appropriate  treatment,  the  inflammatory  mass  subsides,  the 
pain  disappears,  and  the  patient  is  restored  to  health.  It  occasionally 
happens,  however,  that  the  symptoms  persist,  and  unless  some  relief  is 
afforded  the  patient,  there  is  danger  that  she  will  drift  into  a  condition 
of  chronic  invalidism,  and  become  unfit  for  any  of  the  ordinary  vocations 
of  life.  These  cases  present  many  points  of  difficulty,  and  the 
treatment  to  be  adopted  must  depend  upon  the  existing  condition. 
Should  it  be  found  that  the  inflammatory  mass,  instead  of  subsiding, 
persists,  the  advisability  of  operating  will  have  to  be  considered.  But 
before  resorting  to  an  operation  that  involves  removal  of  tubes  and 
ovaries  the  question  of  how  long  expectant  treatment  should  be 
persevered  in  presents  itself.  The  class  of  life  of  the  patient,  as  a 
factor  to  be  taken  into  consideration,  has  already  been  mentioned. 
Mr.  Herman,  in  answering  this  question,  gives  the  following  practical 
advice : — 

"  Most  cases  will  get  well  within  two  months  ;  but  I  have  seen 
expectant  treatment  followed  out  for  two  months  without  relief,  and 
then  the  patient  has  begun  to  improve.  I  therefore  think  that  three 
months  is  the  minimum  which  in  doubtful  cases  should  be  considered 
a  fair  trial  of  expectant  treatment.  This  is  only  a  statement  as  to 
most  cases,  not  a  rule  to  be  applied  to  every  case  "  (Diseases  of  Women, 
p.  240).  On  the  other  hand,  the  inflammatory  mass  may  have  sub- 
sided as  the  result  of  treatment,  but  pain  persists,  and  we  find  on 
examination  that  the  pelvic  organs  are  displaced  and  fixed  by  adhesions. 
Under  these  circumstances  greater  patience  must  be  exercised,  and  the 
necessity  for  removal  of  the  appendages  most  carefully  considered 
before  such  a  method  of  treatment  is  adopted.  In  some  of  these  cases 
a  conservative  operation  may  be  advantageously  practised,  and  proceed- 
ings limited  to  thorough  freeing  of  adhesions  and  fixation  of  the  organs 
in  better  position.  And,  lastly,  we  meet  with  cases  in  which  the  pain 
does  not  appear  to  have  sufficient  physical  basis  to  justify  us  in 
recommending  any  operation. 

(2)  Fibro-myoma  of  the  Uterus. — Oophorectomy  no  longer  occupies 
the  position  it  did  in  the  treatment  of  fibroids  ;  its  place  has  been 
taken  by  hysterectomy,  and  there  are  several  reasons  for  this.  The 
removal  of  the  ovaries  is  not  followed  by  uniformly  satisfactory  results, 
though,  as  Mr.  Doran  points  out,  we  can  never  feel  sure,  in  cases  of 
failure,  that  all  the  ovarian  tissue  has  been  removed.  As,  however, 
some  fibroids  may  go  on  growing  and  may  require  hysterectomy  after 
the  menopause,  it  is  only  natural  to  suppose  that  a  similar  result  may 
follow  the  induction  of  an  artificial  menopause.  Another  disadvantage 
of  oophorectomy  is  that  the  patient  is  left  with  a  tumour  which, 
diminishing  in  size  slowly,  may  have  time  to  exercise  injurious  pressure 
on  neighbouring  organs.  It  seems  reasonable,  moreover,  to  suppose 
that  a  patient  with  both  her  ovaries,  and  without  a  uterus,  is  in  a 
better  position  than  one  possessing  a  uterus  enlarged  by  fibroids  and 
no  ovaries  ;  and  such  evidence  as  we  possess  at  present  points  to  the 
justice  of  this  conclusion. 

B. — VOL.  11.  53 


834  OPERATIONS   ON   THE    ABDOMEN. 

Removal  of  the  ovaries  is  by  no  means  an  easy  operation  in  all  cases. 
Wheti  the  tumour  is  large  the  operator  will  find  it  often  difficult,  and 
occasionally  impossible,  to  remove  the  ovaries,  more  especially  when 
the  tumour  grows  into  the  broad  ligament. 

There  are  three  conditions  which,  considered  separately  or  together, 
may  influence  us  in  the  choice  of  oophorectomy  rather  than  hyste- 
rectomy. The  most  important  is  the  general  condition  of  the  patient. 
If  this  is  such  as  to  militate  against  a  prolonged  operation,  oophorec- 
tomy should  be  chosen,  provided  that  the  ovaries  can  be  readily  got 
at  and  completely  removed.  When,  from  the  nature  and  situation  of 
the  tumour,  it  is  thought  that  the  risks  of  removal  are  unusually  great, 
removal  of  the  ovaries  may  be  chosen  in  preference  to  that  of  the 
uterus.  There  would  be  less  hesitation  in  removing  the  ovaries  if  the 
patient  were  near  the  menopause,  though  it  should  be  remembered 
that  this  is  often  delayed  till  after  fifty  years  of  age.  Age  alone  does 
not  often  determine  the  choice  of  operation,  but,  taken  in  conjunction 
with  the  condition  of  the  patient  or  the  character  of  the  tumour,  it  is 
a  factor  to  be  borne  in  mind.  In  those  cases  in  which  the  tumour 
gives  trouble  after  the  menopause,  and  an  operation  is  called  for, 
removal  of  the  ovaries  would,  naturally,  not  be  chosen. 

(3)  Dysmenorrhea  and  various  Neuroses. — Oophorectomy  for 
dysmenorrhea  has  been  attended  by  such  disappointing  results  that 
the  greatest  hesitation  should  be  adopted  in  suggesting  its  perform- 
ance or  carrying  it  out.  Practically  the  only  cases  in  which  removal 
of  the  ovaries  for  severe  menstrual  pain  should  be  entertained  are  those 
in  which  the  pain  may  reasonably  be  ascribed  to  some  lesion  affecting 
these  organs.  In  some  of  these  cases  the  ovaries  are  the  seat  of 
chronic  ovaritis,  occasionally  accompanied  by  definite  inflammation 
of  the  tubes.  When  with  such  a  condition  the  patient  has  intolerable 
monthly  pain,  which  has  resisted  all  attempts  at  treatment  by  rest  and 
drugs,  and  when,  as  Dr.  Griffiths  points  out  (Syst.  Gyn.,  Allbutt  and 
Playfair,  p.  864),  the  suffering  is  not  out  of  all  proportion  to  the 
ascertained  lesions,  removal  of  the  inflamed  ovaries  will  have  to  be 
considered.  Whilst  this  operation  may  relieve  the  local  symptoms,  the 
general  nervous  symptoms  from  which  these  patients  suffer  very  often 
persist,  or  become  intensified  and  may  prove  as  grave  a  source  of 
trouble  as  the  original  pain.  A  very  necessary  note  of  warning  has 
been  sounded  by  Mr.  Bland  Sutton,  Dr.  Howard  Kelly,  and  others, 
with  regard  to  the  diagnosis  of  oophoritis.  The  ovary  may  normally 
contain  large  Graafian  follicles,  and  the  presence  of  these  does  not 
constitute  oophoritis.  A  cystic  ovary,  the  result  of  inflammation,  is 
considerably  larger  than  normal,  with  a  thickened  tunica  albuginea, 
and  a  stroma  that  is  more  fibrous  and  denser  than  normal.  With 
regard  to  other  neuroses,  such  as  hysteria,  epilepsy,  and  insanity, 
experience  has  shown  us  that  the  removal  of  the  ovaries  for  these 
conditions  is  not  justified  by  the  results  obtained.  On  this  subject 
Mr.  Bland  Sutton's  remarks  are  worth  careful  attention  :  "  The 
removal  of  the  ovaries  and  tubes  has  been  recommended  and  prac- 
tised for  the  relief  of  such  conditions  as  (1)  epilepsy  and  insanity ; 
(2)  dysmenorrhea ;  (3)  ovarian  neuralgia.  In  this  group  the  pro- 
cedure has  not  been  followed  by  encouraging  results ;  indeed,  they 
are  so  unsatisfactory,  that  those  who  have  had  the  greatest  experience 


REMOVAL   OF   THE    UTERINE    APPENDAGES.  835 

in  this  class  of  surgery  are  almost  unanimous  in  condemning  the 
operation,  save  under  very  exceptional  conditions:  even  then  the 
operator  should  safeguard  himself  by  seeking  confirmatory  opinion. 
The  chief  objections  are  summarised  in  the  following  clauses :  (1)  In 
a  very  large  proportion  of  cases  the  removal  of  the  ovaries  and  tuhes 
fails  to  relieve  the  patient.  (2)  In  many  cases  the  operation  aggravates 
the  symptoms.  (3)  Many  cases,  reported  a  few  weeks  or  months  after 
the  operation,  have  subsequently  relapsed.  ...  In  many  instances 
where  oophorectomy  has  heen  carried  out  for  relief  of  pain,  unaccom- 
panied by  objective  signs  in  the  pelvic  viscera,  the  operators  have 
pointed  out,  in  justification  of  the  interference,  that  the  ovaries  were 
cystic.  .  .  .  Such  men,  .  .  .  when  they  excise  an  ovary  for  pain, 
cut  into  the  organ,  and,  finding  ripe  follicles,  describe  it  as  a  cystic 
ovary.  Every  normal  ovary  is  cystic ;  hence  an  excuse  is  readily 
found."  Even  when  some  definite  lesion  exists  the  results  have  not 
proved  satisfactory.  Writing  of  epilepsy,  Dr.  Weir  Mitchell  (quoted 
by  Dr.  H.  Kelly,  loc.  cit.,  vol.  ii.  p.  194)  says :  "  In  no  case  seen  by 
me  had  ablation  of  the  ovaries  and  termination  of  menstruation  cured 
epilepsy.  I  have  never  sanctioned  such  operations  where  the  appendages 
were  sound.  I  have  agreed  thrice  to  these  operations  in  epilepsy  with 
such  pelvic  disease  as  of  itself  would  justify  oophorectomy.  In  all  three, 
after  some  delay,  the  fits  returned,  and  were  in  no  way  permanently 
aided." 

(4)  Osteomalacia. — The  removal  of  the  ovaries  in  the  treatment  of 
this  disease  has  been  performed  a  number  of  times  since  it  was  suggested 
by  Professor  Fehling,  of  Bale,  in  1887,  and  appears  to  have  met  with 
signal  success,  the  course  of  the  disease  being  arrested  and  the  patients 
restored  to  active  life  (Bland  Sutton,  loc.  supra  cit.,  p.  384). 

(5)  Inoperable  Cancer  of  the  Breast. — The  question  of  oojsho- 
rectomy  for  this  condition  has  already  been  considered  in  Vol.  I.  p.  683. 

The  Operation. 

(1)  When  Appendages  are  not  Inflamed  or  Adherent. — The 
preparation  of  the  patient,  operating-room,  &c,  is  similar  to  that 
already  described  for  ovariotomy.  An  incision  of  about  three  inches 
is  made  in  the  median  line,  and  carried  down  to  within  an  inch  of  the 
pubes.  The  different  structures  of  the  abdominal  wall  are  divided 
until  the  peritonaeum  is  reached.  This  is  then  picked  up  by  a  pair  of 
forceps,  and,  care  being  taken  that  intestine  is  not  included  in  the 
grasp  of  the  forceps,  is  divided  horizontally.  The  peritonaeum  is  then 
incised  for  the  length  of  the  incision  on  two  fingers  used  as  a  director. 
Two  fingers  are  now  inserted  into  the  abdominal  cavity,  and  seek  the 
fundus  uteri.  From  this  starting-point  they  are  passed  along  one  or 
other  broad  ligament,  and  seize  the  corresponding  Fallopian  tube  and 
ovary,  which  are  then  drawn  out  of  the  wound.  With  a  blunt  pedicle 
needle  a  double  ligature  is  passed  through  the  broad  ligament,  and  the 
loop  of  the  ligature  being  divided,  the  two  strands  are  interlocked. 
One  ligature  is  carried  round  the  tube  close  to  its  uterine  attachment 
and  tied  firmly,  and  the  other  one  is  tied  over  the  free  edge  of  the 
broad  ligament.  Whilst  the  ligatures  are  being  tightened  the  traction 
on  the  appendages  should  be  relaxed.  A  pair  of  Spencer  Wells's 
forceps  are  then  applied  just  beyond  the  ligature,  and  the  ovary  and 
tube  cut  away.     The  application  of  the  forceps  enables  the  operator  to 

53—2 


836  OPERATIONS    ON    THE    ABDOMKN. 

carefully  inspect  the  stump  for  haemorrhage  hefore  allowing  it  to  fall 
back  into  the  abdominal  cavity.  The  other  side  having  been  treated 
in  a  similar  way,  the  abdominal  wound  is  sutured.  It  is  not  necessary 
to  wash  out  the  peritoneal  cavity  or  to  drain. 

It  has  been  objected  to  this  mode  of  tying  the  broad  ligament  that  it 
puts  tension  on  it,  and  drags  together  its  pelvic  and  uterine  ends,  so 
leading  to  the  risk  of  the  ligature  slipping,  with  consequent  hemorrhage. 
Dr.  H.  Kelly  (Oper.  Gyn.,  vol.  ii.  p.  198)  therefore  recommends  that 
the  uterine  and  ovarian  vessels  should  be  tied  separately.  "  The  first 
ligature  includes  the  ovarian  veins  and  artery,  and  is  passed  through  the 
clear  space  in  the  broad  ligament  and  tied  near  the  pelvic  brim  over  the 
top  of  the  infundibulo-pelvic  ligament,  well  beyond  the  fimbriated  end 
of  the  tube.  A  second  ligature  is  applied  to  the  utero-ovarian  ligament 
posteriorly.  A  third  ligature  is  passed  over  the  top  of  the  broad  liga- 
ment at  the  cornu  uteri,  embracing  the  uterine  vessels  which  are  visible 
and  the  isthmus  of  the  tube."  Any  bleeding  points  in  the  cut  edge  of 
the  broad  ligament  are  seized  with  forceps  and  tied.  A  longer  incision 
will  be  required  when  oophorectomy  is  performed  for  fibroids.  There 
may  be  considerable  difficulty  in  removing  the  appendages,  and  in  those 
cases  in  which  the  fibroid  grows  into  the  broad  ligament,  spreading  out 
the  mesovarium,  it  may  be  impossible  to  apply  a  ligature  between  the 
ovary  and  tumour. 

(2)  Bemoval  of  Appendages  when  they  are  Inflamed,  and  Adherent. 
— This  is  an  operation  that  may  present  very  grave  difficulties  in  its 
carrying  out.  There  are  two  routes  by  which  the  removal  of  the 
appendages  may  be  effected  :  the  abdominal  and  the  vaginal.  Of  these 
the  former,  besides  being  the  older,  is  the  preferable  form  of  operation. 
The  latter  is  only  suitable  to  those  cases  in  which  the  adhesions  are 
not  dense  and  in  which  extensive  fixation  to  the  abdominal  viscera  does 
not  occur.  And  as  it  is  extremely  difficult  to  estimate  beforehand  the 
character  and  the  extent  of  the  adhesions,  the  operator  had  better 
confine  himself  to  the  abdominal  route  rather  than  run  the  risk  of 
having  to  open  the  abdomen  to  complete  an  operation  that  was  found 
impracticable  from  the  vagina. 

In  dealing  with  the  adhesions  the  late  Mr.  Lawson  Tait  considered  it 
best  to  depend  entirely  upon  the  sense  of  touch ;  and  he  has  been 
followed  in  this  teaching  by  many  surgeons.  The  operation  is  carried 
out  through  a  comparatively  small  abdominal  incision,  and  the  sense  of 
touch  is  relied  on  entirely  in  guarding  the  operator  from  the  infliction 
of  injury  whilst  separating  the  tubes  from  adherent  structures.  The 
operation  will,  however,  be  much  facilitated  for  those  with  less 
experience  by  bringing  into  play  not  only  the  sense  of  touch,  but 
that  of  sight.  For  this  purpose  the  patient  should  be  placed  in  the 
Trendelenburg  position  as  affording  a  better  view  of  the  pelvic  viscera. 

Abdominal  Incision. — The  patient  being  in  this  position,  an  incision 
about  four  inches  long  is  made  in  the  median  line  and  carried  well 
down  to  the  pubes.  The  steps  of  this  part  of  the  operation  are  similar 
to  those  described  in  ovariotomy.  On  reaching  the  peritoneum  care 
must  be  taken  in  opening  the  abdominal  cavity,  and  the  operator  should 
bear  in  mind'the  possibility  of  adhesions  existing  between  the  omentum 
or  intestines  and  the  wall.  The  peritoneum  is  picked  up  and  rolled 
between  the  finger  and  thumb,  and,  the  absence  of  adhesions  being 


REMOVAL   OF   THE   UTERTNE    APPENDAGES.  837 

noted,  is  incised,  when  the  viscera  at  once  fall  away  from  the  parietes. 
Omentum  or  intestines  found  adherent  to  the  abdominal  wall  must  be 
carefully  separated  by  means  of  the  fingers. 

Adhesions. — The  condition  existing  should  then  be  carefully  ascer- 
tained, and  the  first  thing  likely  to  demand  attention  is  adherent 
omentum.  This  is  frequently  found  covering  in  and  adherent  to  the 
pelvic  viscera,  and  it  may  also  be  much  thickened  by  inflammation.  It 
should  be  freed  carefully  from  its  attachments  to  the  pelvic  organs  with 
the  fingers,  care  being  taken  not  to  injure  intestines  or  bladder.  Any 
bleeding  points  should  be  at  once  secured.  If  much  difficulty  exists  in 
freeing  the  omentum  or  in  determining  its  exact  relationship  to  other 
parts,  it  had  better  be  ligatured  and  divided,  the  lower  attached  portion 
being  dealt  with  later.  In  any  case  it  is  better  to  ligature  and  remove 
portions  of  omentum  much  thickened  by  inflammatory  changes.  If 
intestines  are  adherent  they  must  be  separated  with  great  care,  and  it 
is  in  this  stage  of  the  operation  that  the  Trendelenburg  posture  will  be 
found  of  great  assistance.  The  bowel,  more  especially  after  the  separa- 
tion of  firm  adhesions,  should  be  carefully  inspected,  and  any  damage 
to  the  walls  at  once  repaired.  All  adhesions  existing  between  the 
intestines  and  omentum  on  the  one  hand,  and  the  pelvic  viscera  on  the 
other,  having  been  freed,  the  abdominal  organs  are  pushed  back  towards 
the  diaphragm  and  maintained  in  position  with  a  large  flat  sponge  or 
gauze  pad.  There  may  be  some  difficulty  in  doing  so  if  the  abdominal 
walls  are  rigid  and  the  patient  not  fully  under  the  anaesthetic.  A  little 
patience,  however,  will,  as  a  rule,  allow  of  the  viscera  being  pushed  up 
out  of  the  way,  so  as  to  enable  the  operator  to  obtain  a  view  of  the 
pelvic  contents. 

Enucleation  of  Appendages. — The  operator  is  now  in  a  position  to 
set  about  freeing  the  adherent  appendages.  As  far  as  is  possible  the 
condition  present  is  ascertained  by  sense  of  sight  as  well  as  that  of 
touch,  the  position  of  the  uterus  located,  and  the  extent  and  fixity  of 
the  mass,  formed  by  one  or  both  appendages,  noted.  The  matted 
tube  and  ovary  form  a  tumour  lying  to  the  back  of  the  uterus  and 
broad  ligament  in  the  lateral  fossa  or  Douglas's  pouch,  and  the  broad 
ligament  is  drawn  over  the  front  of  the  mass.  The  first  step  in  enuclea- 
tion is  the  separation  of  the  mass  from  its  posterior  connections  and 
from  the  opposite  appendages,  if  inflamed.  To  effect  this,  the  hand, 
with  the  palmar  surface  forward,  is  passed  down  in  the  hollow  of  the 
sacrum  behind  the  mass,  carefully  separating  with  the  tips  of  the 
fingers  the  adhesions  that  fix  it  in  this  situation.  Mr.  Cullingworth 
considers  that  at  this  stage  it  is  often  desirable  for  an  assistant  to  pass 
a  forefinger  into  the  rectum  to  serve  as  a  guide.  Working  down  in 
this  way,  the  lower  part  of  the  mass  is  reached.  The  next  step  is  its 
separation  from  the  back  of  the  broad  ligament  to  which  it  is  fixed,  and 
which  effectually  prevents  the  tube  being  drawn  up  into  the  wound. 
Enucleation  is  consequently  continued  from  below  upwards  with  the 
tips  of  the  fingers  inserted  between  the  mass  and  the  back  of  the  broad 
ligament.     In  this  way  it  is  gradually  freed  from  all  its  connections. 

Removal  oj  Diseased  Parts. — The  affected  parts  are  now  drawn  well 
up  through  the  abdominal  incision,  and  a  suitable  point  in  the  broad 
ligament  chosen  for  transfixion.  A  blunt  pedicle  needle  with  a  double 
ligature  is  then  passed  through  the  broad   ligament,  and   the   loop 


838  OPERATIONS   ON    TIIK    AHDOMKN. 

divided.     The  two  strands  are  interlocked  where  they  pass  through  the 

broad  ligament  to  prevent  the  tearing  apart  of  this  structure,  when 
they  are  tied.  Each  ligature  is  then  tied  separately,  one  round  the 
Fallopian  tube  close  to  the  uterine  cornu,  the  other  round  the  free 
upper  border  of  the  broad  Ligament,  and,  a  pair  of  forceps  being  applied 
to  the  tube  just  beyond  the  ligature,  the  diseased  parts  are  cut  away. 
Where  there  is  likely  to  be  any  tension  after  ligaturing  the  broad 
ligament  in  this  way,  the  method  described  above  of  securing  the 
vessels  separately  had  better  be  employed,  as  considerable  risk  exists 
of  the  ligatures  slipping. 

The  cut  end  of  the  tube  held  in  the  forceps  is  next  brought  into 
view  and  carefully  wiped  with  1-1,000  perchloride  of  mercury  solution, 
or  else  cauterised  with  Paquelin's  cautery  to  obviate  the  risk  of  sub- 
sequent infection  from  the  cut  end.  Before  allowing  the  stump  to  fall 
back  into  the  pelvis,  the  parts  are  carefully  examined  for  bleeding 
points,  which  should  be  seized  with  forceps  or  else  under-run.  Care 
should  be  exercised  in  the  application  of  forceps  in  the  pelvis  lest  a 
portion  of  the  rectal  wall  be  nipped,  and  its  vitality  so  affected  that  it 
subsequently  sloughs. 

Treatment  of  Tube  when  Distended. — If  the  tube  is  found  to  be  dis- 
tended with  pus  or  other  fluid,  it  is  better,  if  possible,  to  remove  it 
without  previously  emptying  it.  This  is  recommended  on  account  of 
the  greater  ease  of  dealing  with  a  distended  tube  than  one  empty  and 
collapsed.  Greater  care  must,  however,  be  exercised  in  the  separation  of 
adhesions,  and  the  parts  packed  round  with  gauze  or  sponges  to  prevent, 
as  far  as  possible,  the  spread  of  infective  material  if  the  tube  ruptures,  as 
it  may  very  possibly  do  in  the  course  of  manipulation.  Should  rupture 
occur,  the  fluid  must  be  removed  as  rapidly  as  possible,  all  infected 
sponges  and  swabs  taken  away,  and  the  parts  thoroughly  cleansed. 

Haemorrhage. — Oozing  from  large  raw  surfaces  is  sometimes  free, 
but  generally  yields  to  pressure  exercised  b}*  sponges  in  the  course  of 
the  operation.  Should  it  still  persist,  and  no  obvious  bleeding  point 
be  visible  at  the  end  of  the  operation,  the  pelvis  should  be  packed 
firmly  with  strips  of  gauze,  the  ends  of  which  are  left  out  of  the  lower 
part  of  the  abdominal  incision  or  carried  through  an  opening  in  the 
vaginal  vault.  The  strips  should  be  removed  at  the  end  of  twenty- 
four  hours.  This  is  preferable  to  the  employment  of  the  cautery  or 
perchloride  of  iron.  Bleeding  to  such  an  extent  as  to  be  alarming  is, 
when  it  occurs,  most  likely  to  be  due  to  injury  to  the  broad  ligament 
and  its  vessels  in  the  separation  of  the  tube  from  its  posterior  surface. 
A  search  may  be  made  for  the  vessel  with  the  patient's  pelvis  raised 
and  a  good  light.  This,  however,  will  be  found  to  be  most  difficult, 
and  will  very  likely  be  unsuccessful.  The  advice  given  in  Dr.  Baldy's 
Gynaecology  (1894,  p.  509)  to  secure  the  ovarian  and  terminal  branches 
of  the  uterine  artery  by  passing  a  threaded  needle  through  the  broad 
ligament  close  to  the  pelvic  wall,  and  a  second  one  through  the  broad 
ligament  near  the  uterine  cornu,  appears  to  be  worthy  of  trial  under 
these  circumstances. 

Drainage  will  be  called  for  more  often  in  the  case  of  pelvic  inflamma- 
tion than  of  ovarian  tumours.  The  following  may  be  regarded  as 
indications  for  its  employment : 

(1)  When  large  raw  surfaces  have  been  left  after  the  separation  of 


REMOVAL    OF    THE   UTERINE    APPENDAGES.  839 

extensive  adhesions,  and  it  is  thought  that  the  amount  of  exudation 
likely  to  be  poured  out  is  more  than  the  damaged  peritonaeum  can 
deal  with. 

(2)  When,  in  the  course  of  removal,  a  pyo-salpinx,  or  abscess-cavity, 
has  ruptured  and  soiled  surrounding  parts. 

(3)  When  the  bowel  has  been  injured  in  the  course  of  the  operation. 
Damage  to  the  small  intestine  can  generally  be  repaired  without  risk 
of  subsequent  leakage.  Injury  to  the  rectum  cannot  be  so  readily 
dealt  with,  and  it  may  be  impossible  for  the  operator  to  gain  such 
access  to  the  damaged  parts  as  will  enable  him  to  repair  the  lesion. 
To  prevent  general  infection  of  the  peritonseal  cavity,  as  the  result  of 
leakage  from  the  bowel,  he  will  have  to  depend  on  careful  gauze  packing. 

(4)  Wlien  the  operation  is  incomplete.  Firmness  of  adhesions  and 
danger  of  injury  to  viscera  will  sometimes  lead  the  surgeon  to  leave 
his  operation  unfinished  rather  than  subject  his  patient  to  unusual 
risk.  He  has  probably  exposed,  in  the  course  of  his  manipulations, 
infected  areas,  such  as  a  pyo-salpinx  or  a  pelvic  abscess.  Under  these 
circumstances  he  will  remove  such  diseased  structures  as  is  found 
possible,  and  provide  free  drainage  by  means  of  gauze  strips  for  the 
infected  parts  left  behind. 

Conservative  Surgery. — By  this  term  is  meant  the  preservation  of 
such  organs  or  parts  of  organs  as  are  not  diseased  or  not  beyond  the 
power  of  recovery.  This,  which  is  the  general  principle  underlying 
all  true  surgery,  receives  special  significance  in  its  application  to  the 
pelvic  organs  on  account  of  the  importance  of  the  latter  in  securing 
the  happiness  and  well-being  of  the  individual.  This  applies  more 
especially  to  the  ovaries,  which  are  not  only  essential  to  the  functions 
of  menstruation  and  child-bearing,  but  which  exercise — probably  by 
means  of  some  internal  secretion — a  wide  influence  over  nutritive  pro- 
cesses in  general.  That  every  effort  should  be  made  to  preserve  a 
portion  at  least  of  one  of  these  organs  is  not  disputed  at  the  present 
time  ;  the  only  question  is  how  far  one  is  justified  by  one's  attempts  at 
conservatism  in  subjecting  the  patient  to  increased  risks  of  recurrence 
of  disease  and  further  operation. 

An  important  step  was  made  in  conservative  surgery  when  it  was 
recognised  that  disease  limited  to  the  appendages  of  one  side  did  not 
necessarily  mean  the  removal  of  the  organs  on  both.  A  further 
advance  was  marked  by  the  recognition  that  certain  conditions,  which 
at  one  time  were  thought  to  be  pathological,  were  not  diseases  at  all. 

The  cystic  ovary  is  a  case  in  point.  Though  a  definite  pathological 
condition  does  exist  in  which  the  ovary  is  the  seat  of  numerous 
small  cysts,  the  mere  presence  of  these  does  not  necessarily  constitute 
an  abnormal  state  of  the  organ,  nor  do  they  justify  its  removal. 

A  further  reason  advanced  for  the  practice  of  conservatism  lies  in 
the  fact  that  portions  of  organs  left  behind  are  capable  of  performing 
the  functions  of  the  entire  organ.  It  has  been  shown  clinically  that 
the  stump  of  an  amputated  tube  may  convey  an  ovum  to  the  uterus, 
which  will  then  pass  through  the  developmental  changes  of  normal 
pregnancy  (B.  F.  Baer,  Ann.  of  Gyn.  and  Pcd.,  January,  1894). 

Dr.  Kelly  (loc.  cit.,  p.  188)  has  recorded  a  case  in  which  pregnancy 
followed  an  operation  involving  the  removal  of  one  tube  and  the  oppo- 
site ovary,  and  where  the  transmission  of  the  ovum  was  effected  by  the 


840  OPERATIONS  ON  THE  ABDOMEN. 

tube  on  the  side  opposite  to  that  of  the  ovary.  Similar  cases  have 
been  recorded  in  which  pregnancy  has  followed  operations  involving 

partial  removal  of  the  appendages.  Whilst  such  an  event  may  not 
be  very  common,  the  mere  fact  that  it  can  occur  constitutes  a  further 
reason  for  exercising  such  conservatism  as  is  possible  in  dealing  with 
the  pelvic  organs. 

The  capacity  for  repair  shown  by  inflamed  pelvic  organs  and  the 
powers  of  absorption  of  the  peritonreal  sac  in  the  case  of  large  inflam- 
matory exudates  are  well-established  facts.  A  similar  course  of  events 
is  known  to  all  surgeons  in  the  case  of  the  vermiform  appendix.  This 
power  of  regeneration  is  a  point  telling  in  two  ways,  for  whilst  it  will 
encourage  the  operator  to  sacrifice  as  little  as  possible  of  the  organs  he 
is  dealing  with,  it  is  also  an  argument  in  favour  of  rest  and  expectant 
treatment. 

There  are  certain  conditions  other  than  disease  of  the  tubes  and 
ovaries  demanding  operation  in  which  there  can  be  no  doubt  as  to 
the  advisability  of  leaving  the  ovaries  or  as  much  of  them  as  can  be 
safely  preserved.  Hysterectomy  for  fibroids  is  a  case  in  point,  where 
one  or  both  ovaries  should  be  left  when  possible.  A  further  example 
is  seen  in  parovarian  cysts,  which  may  be  shelled  out  sometimes  from 
the  broad  ligament  without  sacrificing  tube  or  ovary. 

When  we  come  to  disease  of  the  ovary  itself,  it  is  especially  in  non- 
inflammatory affections  that  an  attempt  may  be  made  to  save  a  portion 
of  the  organ.  Such  conditions  as  cysts  due  to  enlargement  of  Graafian 
follicles  or  corpora  lutea  may  be  dealt  with  on  this  principle,  the  cyst 
being  shelled  out  or  a  wedge-shaped  portion  of  the  ovary  being  removed. 
In  the  case  of  dermoids  and  the  cystomata  the  ovarian  tissue  is,  as  a  rule, 
so  involved  that  an  attempt  to  save  a  part  of  it  will  not  often  be  found 
possible.  Even  when,  as  occasionally  happens,  some  of  the  ovarian 
tissue  remains  unaffected,  the  advisability  of  trying  to  preserve  it  is 
open  to  question  on  account  of  the  risk  of  leaving  behind  sufficient  of 
the  tumour  to  lead  to  a  recurrence.  Nor  does  it  seem  improbable  that 
the  remaining  portion  of  ovary  is  liable  to  a  similar  cystic  change. 
The  chief  justification  for  saving  a  part  of  the  organ  would  be  in  the 
fact  that  the  opposite  ovary  either  required  removal  or  had  already 
been  removed. 

It  is  in  dealing  with  inflammatory  conditions  of  the  appendages  that 
the  widest  difference  of  opinion  with  regard  to  conservatism  exists.  It 
was  the  practice  at  onetime,  if  the  appendages  on  one  side  were  diseased, 
to  remove  those  on  the  other  side,  even  if  found  healthy.  This  was  done 
more  especially  in  those  cases  in  which  the  tubes  were  the  seat  of  sup- 
puration. The  late  Mr.  Greig  Smith  (Syst.  of  Gi/n.,  Allbutt  and 
Playfair,  1896,  p.  910)  said  :  "  The  removal  of  the  appendages  on  one 
side  only  for  suppurative  disease  was  tried  by  Tait,  but  given  up  on 
account  of  the  large  number  of  recurrences  or  relapses.  Other  surgeons 
have  had  similar  experiences  ;  and  the  rule  in  all  cases  of  suppurative 
diseases  of  the  appendages  now  is  that  if  one  set  is  removed,  so  also 
should  be  the  other." 

In  spite  of  the  risks  of  recurrence,  modern  opinion  inclines  strongly 
to  the  preservation  of  healthy  appendages,  and,  as  the  interior  of  the 
uterus  is  the  source  of  infection  in  most  cases,  the  more  rational 
treatment  is  to  attend  carefully  to  this,  and  thus  prevent  the  extension 


REMOVAL   OF   TIIK   UTERINE   APPENDAGES.  841 

of  inflammation,  so  far  as  is  possible,  to  the  sound  appendages.  Before 
deciding  to  leave  them  they  should  be  carefully  examined.  Should  pus 
be  found  to  exude  from  the  end  of  the  tube,  it  should  be  removed. 
Such  a  high  authority  as  Dr.  Howard  Kelly  (loc.  cit.,  vol.  ii.  p.  186) 
recommends  that  under  certain  circumstances  the  contents  of  the 
tube  should  be  squeezed  out  and  its  interior  washed  out  with 
saline  solution,  and  then  sterilised  with  1  in  5,000  corrosive  sublimate 
solution.  It  is  difficult  to  believe  that  the  tube  can  be  effectually 
sterilised  in  this  way,  and  its  preservation  would  seem  to  invite 
reinfection  of  the  peritonreal  cavity.  Until  more  evidence  is  forth- 
coming with  regard  to  this  procedure  it  appears  unsafe  to  recommend 
it  for  general  adoption.  On  the  subject  of  adhesions  Dr.  Kelly  has 
laid  it  down  as  a  rule  that  these  do  not  in  themselves  constitute  a 
reason  for  the  removal  of  organs.  The  mere  presence  of  adhesions 
does  not  imply  that  the  organs  are  beyond  the  power  of  recovery, 
and,  in  fact,  there  is  plenty  of  clinical  evidence  to  the  contrary.  It 
has  already  been  mentioned  that  in  some  cases  the  persistence  of 
symptoms  is  due  rather  to  adhesions  binding  down  the  pelvic  organs 
in  abnormal  positions  than  to  the  presence  of  any  source  of  inflamma- 
tion. Under  these  circumstances,  operative  proceedings  ma}r  be  limited 
to  the  separation  of  adhesions  and  the  fixation  of  organs  in  better 
position.  Dr.  Kelly  has  laid  stress  on  the  importance  of  not  only 
freeing  the  organs  from  surrounding  parts,  but  also  of  liberating  any 
kinks  in  the  tube,  a  condition  that  may  render  the  patient  liable  to 
tubal  pregnancy. 

Whilst  treatment  limited  to  the  freeing  of  organs  may  be  followed  in 
those  cases  in  which  the  inflammation  has  subsided,  it  should  not  be 
adopted  when  they  are  still  inflamed.  The  separation  of  adhesions 
without  removal  of  the  cause  is  certain  to  be  followed  by  the  formation 
of  fresh  ones,  besides  breaking  down  the  barrier  that  limits  the  spread 
of  infection. 

The  question  may  arise  as  to  whether  the  Fallopian  tube  should  be 
preserved  when  removal  of  the  corresponding  ovarj'  is  found  necessary. 

In  inflammatory  conditions  of  the  appendages,  it  is  uncommon  tc 
find  a  case  in  which  the  ovary  requires  removal  and  the  tube  is  found  i: 
a  healthy  state.  Moreover,  the  tube  is  useless  without  the  ovary,  and 
as  the  late  Mr.  Greig  Smith  has  pointed  out,  the  removal  of  the  lattei 
will  probably  cause  kinking  of  the  tube.  Consequently,  if  the  ovary  is 
removed,  it  is  usually  safer  to  remove  the  tube  also  (loc.  supra  cit., 
p.  909).  It  might  be  left  if  operative  measures  have  resulted  in  the 
preservation  of  the  opposite  ovary,  but  removal  of  the  corresponding 
tube.  In  Dr.  Kelly's  case,  quoted  above,  pregnancy  followed  such  an 
operation,  leaving  one  ovary  and  the  opposite  tube. 

Those  conditions  have  been  pointed  out  in  which  the  practice  of 
conservative  surgery  may  be  safely  advised.  But  there  are  certain 
operations  more  open  to  debate,  such  as  the  washing  out  of  tubes 
containing  pus,  the  amputation  or  resection  of  diseased  tubes,  and  the 
opening  of  closed  tubes.  In  the  hands  of  the  chief  advocates  of 
conservatism  these  procedures  have  met  with  results  that  may  be 
regarded  as  encouraging,  but,  with  our  present  information,  they  are 
not  operations  that  can  be  recommended  for  general  adoption. 


CHAPTER   XVIII. 
OPERATIONS  ON  THE  UTERUS. 

REMOVAL  OP  MYOMATOUS  UTERUS  BY  ABDOMINAL 
SECTION.— CANCER  OF  THE  UTERUS.— REMOVAL  OF 
A  CANCEROUS  UTERUS  BY  ABDOMINAL  SECTION.— 
REMOVAL  OF  A  CANCEROUS  UTERUS  PER  VAGINAM. 
—  05JSARIAN  SECTION.  —  PORRO'S  OPERATION.  — 
ECTOPIC    GESTATION. 

REMOVAL    OF    MYOMATOUS    UTERUS    BY    ABDOMINAL 

SECTION. 

Indications  for  Operation. — A  fibroid  tumour  of  the  uterus  does 
not  by  its  presence  merely  afford  a  sufficient  indication  for  operation. 
It  must  either  give  rise  to  symptoms  which  threaten  life,  or  be  a  source 
of  such  discomfort  from  its  size  or  position  as  to  prevent  a  patient 
enjoying  a  reasonably  comfortable  existence  or  earning  a  livelihood. 
The  following  is  a  list  of  indications  that  justify  removal  of  a 
myomatous   uterus  : — 

(i)  Haemorrhage. — Profuse  ha3morrhage  at  the  menstrual  periods  is 
the  symptom  that  is  the  commonest,  and  that  most  often  necessitates 
a  patient  seeking  advice.  The  amount  lost,  and  its  effect  on  the 
patient's  health,  the  influence  of  drugs  and  general  treatment,  the  age 
of  the  patient,  are  all  factors  to  be  taken  into  consideration.  The 
favourable  influence  that  the  change  of  life  often  has  on  these  tumours 
should  be  borne  in  mind,  and  if  a  patient  is  nearing  the  menopause  it 
may  be  advisable  to  recommend  her  to  wait  a  year  or  two.  The  fact 
that  the  climacteric  is  generally  postponed,  and  not  infrequently 
deferred  till  after  fifty  years  of  age,  should  be  remembered,  and  if  the 
haemorrhage  is  very  profuse,  leading  to  profound  anemia,  and  very 
little  relief  is  afforded  b}r  milder  measures  of  treatment,  the  advisability 
of  a  radical  operation  should  be  put  before  the  patient. 

(2)  Pressure  Symptoms. — These  are  most  marked  in  the  case  of 
medium-sized  tumours  impacted  in  the  pelvis.  The  most  common 
symptom  is  frequent  or  difficult  micturition.  There  may  also  be 
trouble  in  keeping  the  bowels  open,  owing  to  pressure  on  the  rectum. 
The  ureters  may  be  pressed  on,  and  hydro-nephrosis  or  pyelo- 
nephritis result.  These  symptoms  are  most  marked  just  before  the 
onset  of  the  menstrual  flow,  when  the  tumour  is  swollen  as  a  con- 
sequence of  the  natural  engorgement  of  the  organs. 

Pain  in  association  with   fibroids   is  due   not  only  to   pressure  on 


IlKMOVAL    OF    MYOMATOUS    UTKRUS. 


843 


nerves  and  neighbouring  organs,  but  also  to  attacks  of  peritonitis  and 
inflammation  of  appendages.  Dr.  Kelly  draws  special  "attention  to 
the  fact  that  those  myomata  which  are  constantly  associated  with  great 
pain  almost  invariably  belong  to  the  class  of  complicated  cases  in  which 
a  tubal  or  ovarian  inflammatory  disease  will  also  be  found"  (loc.  cit., 
vol.  ii.  p.  367). 

(3)  Great  Size. — A  large  tumour  in  the  abdomen  may  not  necessarily 
threaten  life,  but  may  be  a  source  of  grave  inconvenience  and  discom- 
fort.    It  interferes  with  the  return  of  blood  from  the  lower  limbs,  and 


Relation  of  the  ureters  and  uterine  arteries  to  the  cervix.     (Baldy.) 

U,     Uterus.  C,  Cervix. 

Ur,  Ureter.  V,  Vagina. 

A,     Uterine  artery.  B,  Section  of  bladder. 

so  causes  oedema ;  it  presses  on  the  stomach  and  impedes  digestion ;  it 
limits  the  movements  of  the  diaphragm,  and  so  interferes  with  respira- 
tion ;  and,  by  preventing  an  active  existence,  leads  to  a  condition  of 
general  ill-health.  As  Mr.  Herman  {loc.  supra  cit.,  p.  822)  points  out, 
"these  consequences  of  great  bulk  not  only  call  for  operative  cure; 
unfortunately  they  do  more  :  they  add  to  its  risk.  ...  In  the  present 
state  of  abdominal  surgery,  the  risk  to  life  in  the  removal  even  of  a 
big  fibroid  is  small,  and  the  possible  undesirable  after-consequences  are 
less  grave  than  the  constant  presence  of  a  great  tumour.  A  well- 
advised  patient  will,  therefore,  welcome  relief  by  operation." 

(4)  Rapid  Growth  of  the  Tumour. — If  at  intervals  of  a  few  months 


st(  OPERATIONS   ON   THE    ABDOMEN 

the  tumour  is  found  to  be  markedly  increasing  in  size,  the  question  <>f 
its  removal  will  have  to  be  considered.  Very  rapid  enlargement  is 
usually  due  to  secondary  changes  occurring  in  it,  such  as  oedema, 
cystic  formation,  or  haemorrhage.  A  sarcomatous  change  will  also  be 
responsible  for  a  rapid  growth,  but  is  of  rare  occurrence. 

(5)  Complications — due  to  associated  inflammatory  disease  of  the 
appendages  and  peritonaeum,  tumours  of  the  ovary,  cancer  of  the 
uterus — will  call  for  operative  interference. 

There  are  three  methods  employed  in  the  removal  of  a  myomatous 
uterus,  in  two  of  which  the  hysterectomy  is  partial,  in  the  third  total. 
They  are  respectively — 

(i.)  Supra-vaginal  hysterectomy  ;  extra-abdominal  method  of  treat- 
ment of  stump. 

(ii.)  Supra-vaginal  hysterectomy  ;  intra-abdominal  method  of  treat- 
ment of  stump. 

(iii.)   Total    hysterectomy. 

(i.)  Supra-vaginal  Hysterectomy.  Extra-abdominal 
Treatment    of  Stump. 

Incision. — The  patient  having  been  prepared  as  for  ovariotomy,  an 
incision  is  made  in  the  median  line,  proportionate  to  the  size  of  the 
tumour  to  be  removed.  If  necessary  it  is  continued  upwards  to  the 
left  of  the  umbilicus.  The  incision  should  be  carried  well  down  towards 
the  pubes,  as  by  this  means  the  subsequent  steps  in  the  operation  are 
facilitated.  Especial  care  should  be  taken  in  dividing  the  peritonaeum, 
as  the  bladder  is  frequently  drawn  up,  and  thus  rendered  liable  to 
injury ;  moreover,  a  cut  made  accidentally  into  the  tumour  is  likely  to 
lead  to  very  troublesome  haemorrhage,  difficult  to  arrest.  To  avoid  these 
dangers  the  peritonaeum  should  be  pinched  up  towards  the  upper  part 
of  the  incision  and  carefully  examined  before  being  cut  through.  The 
opening  is  then  enlarged  upwards  and  downwards  on  two  fingers  used 
as  a  director,  the  height  to  which  the  bladder  ascends  being  in  this  wax- 
readily  detected. 

Delivery  of  Tumour. — A  hand  is  now  introduced  into  the  abdomen 
and  the  condition  present  noted.  Any  adhesions  found  must  be  dealt 
with.  These  present  much  more  difficulty  than  in  the  case  of  ovario- 
tomy, partly  on  account  of  the  size  of  the  tumour,  and  the  fact  that  it 
cannot  be  diminished  by  tapping,  partly  on  account  of  the  bleeding 
that  follows  their  separation.  Mr.  Thornton  says  on  the  subject  of 
adhesions  :  "  If  they  are  present,  especially  if  they  are  omental,  they 
often  contain  enormous  vessels,  and  in  separating  them  great  care  is 
required  to  avoid  serious  loss  from  the  uterine  side  after  they  are  tied 
and  divided  on  the  proximal  side."  He  points  out  that  "  adhesions  of 
large  surfaces  of  intestine  are  exceedingly  difficult  to  deal  with;  there  is 
no  room  to  apply  ligatures  before  separating,  and  no  room,  or  not  firm 
enough  tissue,  to  apply  pressure  forceps  after  separation  ;  thus  both 
surfaces  frequently  ooze  very  freely.  .  .  .  Sponge  pressure  is  the  only 
way  of  dealing  with  these  oozing  surfaces "  (Allbutt  and  Playfair, 
Sy8t.  oj  Gyn.y  1896,  p.  615). 

In  the  simplest  cases  the  tumour  is  seized  hold  of  and  brought  out  of 
the  wound,  care  being  taken  not  to  exercise  such  traction  as  will  result 
in  tearing  of  its  pedicle,  an  accident  that  may  cause  dangerous  bleeding. 
But  it  sometimes  happens  that  the  delivery  of  the  tumour  from  the 


REMOVAL   OF    MYOMATOUS    UTERUS. 


845 


Fig.  347- 


abdomen  presents  great  difficulty,  and  it  may  be  found  necessary  to 
divide  the  broad  ligament  on  one  or  both  sides  before  this  can  be 
effected. 

Treatment  of  Ovaries  and  Bladder. — Before  the  ligaments  are  dealt 
with  the  operator  must  decide  whether  one  or  both  ovaries  shall  be 
preserved.  The  Importance  of  saving  one  at  least  lias  been  referred  to 
in  the  chapter  dealing  with  the  appendages.  Mr.  Thornton,  as  the 
result  of  his  wide  experience,  says  :  "  I  always  leave  an  ovary  if  I  can, 
as  I  find  that,  if  this  be  done,  the  patients 
recover  more  quickly  and  completely,  and 
suffer  infinitely  less  at  the  change  of  life ; 
especially  do  they  escape  the  depression 
which  is  apt  to  follow  the  complete  removal 
of  uterus  and  ovaries."  If  it  is  found  that 
the  ovaries  are  healthy  and  that  their  preser- 
vation is  feasible,  the  surgeon  proceeds  to 
divide  the  broad  ligaments.  The  method  of 
dealing  with  these  structures  is  described  in 
the  next  section,  on  the  intra-peritonseal 
operation.  Whether  they  have  to  be  liga- 
tured and  divided  with  the  tumour  in  the 
abdomen,  or  brought  outside  it,  the  details 
are  the  same.  The  next  point  requiring 
careful  attention  is  the  bladder.  The  operator 
must  be  very  careful  that  this  is  not  included 
in  the  rubber  or  wire  ligature.  Some  surgeons 
prefer  to  keep  the  bladder  full,  in  order  to 
define  its  limits,  but  this  is  not  necessary. 
If  any  doubt  exists  as  to  the  height  to  which 
this  organ  extends  on  the  front  of  the 
tumour,  a  sound  should  be  passed.  If  it 
ascends  over  the  part  to  which  the  constric- 
tion is  to  be  applied,  it  must  be  reflected 
from  the  uterus.  To  carry  this  out  an  in- 
cision is  made  through  the  peritonaeum,  from 
side  to  side,  half  an  inch  above  the  bladder, 
and  this  organ  carefully  separated  by  means 
of  the  finger  from  the  uterus. 

Treatment  of  Pedicle. — The  constriction 
of  the  pedicle  may  be  effected  either  by  means 
of  wire  or  rubber  ligature.  If  the  former 
method  is  to  be  made  use  of,  thick,  soft  iron  wire,  that  will  not  readily 
cut  through  the  tissues,  should  be  employed,  and  the  best  form  of  clamp 
is  Koeberle's  serre-nceud.  The  wire,  having  been  adjusted  round  the 
neck  of  the  tumour,  is  slowly  tightened  up  by  means  of  the  clamp. 
Two  transfixion  pins  are  then  passed  through  the  pedicle  immediately 
above  the  wire,  and  the  tumour  cut  away  about  an  inch  above  the  pins. 
Instead  of  wire  an  elastic  rubber  ligature  may  be  employed.  Professor 
Hegar  used  an  india-rubber  cord  five  millimetres  thick,  which  by  means 
of  a  special  needle  was  made  to  transfix  the  cervix.  The  two  halves  were 
then  tied  separately,  and  the  whole  cervix  encircled  by  another  ligature 
placed  below  the  two  preceding  ones.     The  double  ligature  does  not 


Koeberle's  serre-noeud. 
(Galabin.) 


846 


OPERATIONS   ON    THE    ABDOMEN. 


appear  to  be  necessary,  and  one  rubber  ligature  drawn  round  the  cervix 
is  sufficient,  means  being  taken  t<>  prevent  it  slipping  by  grasping  the 
knot  in  a  pair  of  forceps.     There  will  probably  be  Borne  shrinkage  of 

the  stump  as  the  tumour  is  cut  away,  necessitating  the  tightening  up 
of  the  wire  by  ;i  lew  turns  of  the  screw  of  the  clamp.  The  stump  is 
pared  carefully,  either  now  or  after  closure  of  the  alxlominal  incision. 
Mr.  Thornton,  to  whom  so  man)- details  of  the  operation  in  its  present 
form  are  due,  pares  down  the  stump  as  much  as  possible,  especially 
cutting  away  the  inside  fibrous  and  muscular  tissue  into  a  somewhat 
cupped  shape.  It  has  been  recommended  that  the  peritomeum  of  the 
pedicle  should  be  drawn  over  the  cut  surface  of  the  stump  and  sutured 


The  lower  part  of  the  abdominal  wound  is  shown  sutured  above  the  stump. 
«,  a,  serrc-nceud  ;  b,  /',  pin  passing  nearer  the  anterior  ;  and  <■.  c,  pin  passing 
nearer  the  posterior  boundaries  of  the  stump.     (Doran.) 

there.  This  is  unnecessary,  and,  as  Mr.  Thornton  points  out,  merely 
serves  to  enclose  materials  which  are  much  better  escaping  into  the 
dressings.  The  peritonaeum  of  the  abdominal  wall  is  now  secured  to 
that  of  the  pedicle  below  the  wire  by  two  or  three  sutures,  and  the 
ventral  incision  closed  in  the  usual  way.  The  stump  is  powdered  with 
iodoform  and  dressed  with  iodoform  gauze,  care  being  taken  to  insert 
several  layers  of  gauze  beneath  the  pins  and  the  clamp. 

After-treatment. — The  dressing  should,  if  possible,  be  left  untouched 
for  a  lew  days,  one  or  two  turns  of  the  screw  being  made  in  the  case 
of  large  pedicles.  The  stump  is  often  ready  to  come  away  in  two  or 
three  weeks'  time.  If  it  does  not  then  show  signs  of  doing  so,  it 
may  be  clipped  down  to  the  wire  and  pins,  and  these  latter  removed 
altogether. 


IlKMOVAL    <)l 


MYOMATOUS     I  TKKHS. 

Intra 


847 
abdominal 


(ii.)    Supra  -  vaginal    Hysterectomy. 
Method. 

The  mode  of  operation  described  is,  in  its  essentials,  that  associated 
with  the  name  of  Dr.  Bncr,*  of  Philadelphia.  The  principles  on  which 
lie  hased  his  operation  were — "  first,  control  of  haemorrhage  hy  ligature 
of  the  blood-vessels  in  the  broad  ligaments  ;  second,  non-constriction  of 
the  cervical  tissues,  so  that  there  shall  he  no  cause  of  suppuration  ;  and 

Fig.  349. 


Operation  of  supra-vaginal  hysterectomy  seen  from  the  front. 
First  stage.     (Galabin.) 

A  double  ligature  is  placed  on  both  ovarian  arteries,  and  a  single  ligature  on 
both  round  ligaments.  The  thick  black  line  indicates  the  line  of  incision  through 
the  broad  ligaments  ;  the  thin  black  line,  the  line  of  division  of  the  anterior 
peritonaeum  ;  LOA,  ligature  on  ovarian  artery  ;  L  R  L,  ligature  on  round  ligament ; 
o,  ovary  ;  O  A,  ovarian  artery  ;  R  B,  reflection  of  bladder. 

third,  non-disturbance  of  the  cervical  canal,  so  that  sepsis  from  the 
vagina  may  be  prevented."  Dr.  Kelly  (loc.  supra  tit.,  p.  365)  draws 
attention  to  the  fact  that  the  very  important  step  of  systematically 
securing  the  ovarian  and  uterine  arteries  in  their  course,  as  a  pre- 
liminary to  hysterectomy,  was  devised  by  Dr.  L.  A.  Stimson,  of  New 
York. 

The  Operation. — The  initial  stages  of  the   operation  are  similar  to 

*  This  method  of  operation  was  published  in  the  Transactions  of  the  American  Gijikpco- 
logieal  Society,  vol.  xvii.  (1892),  p.  234,  and  vol.  xviii.  p.  62. 


848  OPERATIONS  ON  THE  ABDOMEN. 

those  described  in  the  extra-abdominal  method.  It  will  be  considerably 
facilitated  in  some  cases  by  placing  the  patient  in  the  Trendelenburg 
position.  The  incision  having  been  made  through  the  abdominal  wall, 
the  condition  of  the  parts  examined  and  adhesions  dealt  with,  the 
tumour  is  delivered  as  previously  described.  As  in  the  preceding 
method,  it  may  be  found  necessary  to  deal  with  the  broad  ligaments 
before  delivering  the  tumour,  and  to  divide  part  of  them  on  one  or  both 
sides  with  the  uterus  still  in  the  abdomen.  The  steps  of  this  part  of 
the  operation  are  similar  to  those  taken  when  the  tumour  can  be 
brought  through  the  ventral  incision. 

Division  of  Broad  Ligaments. — The  uterus  having  been  drawn  out  of 
the  abdomen,  the  operator  carefully  examines  the  broad  ligaments  and 
appendages  on  each  side,  and  decides  whether  he  will  leave  one  or  both 
ovaries,  or  whether  he  will  remove  them  both.  When  possible,  one  at 
least  should  be  saved,  exception  being  made  in  those  cases  in  which  they 
are  found  diseased,  or  when  it  is  found  impossible  to  leave  them,  or  the 
patient  has  reached  the  menopause.  The  surgeon,  after  carefully 
examining  both  sides,  chooses  that  which  can  most  easily  be  dealt  with, 
and,  seizing  the  upper  part  of  the  broad  ligament,  passes  through  it,  at  a 
point  free  from  vessels,  a  blunt  pedicle-needle  threaded  with  silk  or  catgut. 
The  exact  point  of  perforation  will  depend  upon  whether  the  ovary  is 
to  be  removed  or  not ;  in  the  former  case  the  ligature  will  be  carried 
round  the  free  edge  of  the  broad  ligament ;  in  the  latter  it  will  include 
the  Fallopian  tube. 

This  ligature,  which  secures  the  ovarian  artery,  is  then  firmly  tied, 
and  that  portion  of  the  broad  ligament  next  the  tumour  being  secured 
by  means  of  forceps,  the  part  intervening  between  the  ligature  and  the 
forceps  is  divided  (Fig.  349).  A  second  ligature  is  passed  through  the 
broad  ligament  of  the  same  side,  lower  down,  including  the  round 
ligament,  and  firmly  tied ;  the  proximal  portion  of  the  broad  ligament 
is  clamped,  and  the  part  between  forceps  and  ligature  divided.  In 
most  cases  these  two  ligatures  will  be  found  sufficient,  but  more  can 
be  applied  in  the  same  way  if  required.  The  use  of  forceps  for  clamp- 
ing the  proximal  part  of  the  ligament,  as  described  above,  rather  than 
ligatures,  will  be  found  to  effect  a  saving  of  time.  The  opposite  side 
is  then  dealt  with  in  the  same  way. 

Formation  of  Anterior  Flap. — The  next  step  in  the  operation  is 
the  reflection  of  a  flap  of  peritonaeum  and  the  bladder  from  the  front 
of  the  uterus.  An  incision  is  made  through  the  peritonaeum  covering 
the  front  of  the  uterus,  from  side  to  side,  about  an  inch  above  the  line 
of  attachment  of  the  bladder,  the  position  of  which  should  be  carefully 
ascertained.  It  should  be  carried  across  to  join  at  each  extremity  the 
lower  end  of  the  cuts  in  the  broad  ligaments.  The  bladder  is  then 
separated  from  the  uterus  by  means  of  the  finger,  any  firmer  bands 
(and  these  are  met  with  especially  in  the  median  line)  being  divided 
with  scissors.  Care  should  be  taken  in  this  separation,  as  the  bladder 
is  sometimes  much  thinned  by  stretching,  and  it  does  not  require  much 
force  to  push  the  finger  through  into  its  interior.  Should  this 
accident  happen,  the  opening  must  at  once  be  closed  with  sutures.  A 
small  peritoneal  flap  may  be  raised  on  the  posterior  surface  of  the 
uterus,  but  this  is  not  necessary,  and  may  quite  well  be  dispensed 
with.     By  the  reflection  of  the  anterior  flap  some  loose  cellular  tissue 


REMOVAL  OF  MYOMATOUS  UTERUS. 


849 


on  eacli  side  of  the  neck  of  the  myomatous  uterus  is  exposed,  and  in 
this  there  may  be   felt  pulsating,   and  sometimes    seen,  the    uterine 

artery. 

Ligature  of  Uterine  Artery.— The  position  of  the  artery  is  now 
carefully  denned  on  one  side,  and  a  ligature  threaded  on  a  pedicle- 
needle  is  passed  through  the  cellular  tissue  between  the  artery  and  the 
uterus.     A  pair  of  Spencer  Wells's  forceps  are  now  applied  so  as  to 

Fig.  350. 


Operation  of  supra-vaginal  hysterectomy  seen  from  the  front. 
Second  stage.  (Galabin.) 
The  outer  part  of  the  broad  ligament  is  divided  on  each  side.  The  anterior 
peritonaeal  flap  is  stripped  down  and  held  by  two  pressure  forceps.  One  ligature 
is  placed  on  each  uterine  artery.  A  second  ligature  is  passed  through  the  broad 
ligament  just  within  it,  ready  for  subsequent  use.  h  o  A,  ligature  on  ovarian 
artery ;  l  r  l,  ligature  on  round  ligament ;  L  u  A,  ligature  on  uterine  artery ; 
o,  ovary  ;  o  A,  ovarian  artery  ;  p  p,  anterior  flap  of  peritonaeum. 

include  the  artery  a  little  above  the  ligature,  and  the  latter  is  firmly 
tied.  The  tissues,  including  the  uterine  artery,  are  then  divided 
between  the  ligature  below  and  the  forceps  above,  and  if  the  ligature 
has  been  properly  applied  there  will  be  no  bleeding.  If  the  artery  has 
not  been  secured  it  will  spurt  on  division,  and  should  be  promptly 
seized  with  forceps  and  tied.  The  same  procedure  is  adopted  on  the 
opposite  side. 

Removal  of  Uterus.— A  point  has  now  been  reached  at  which  the 
blood-supply  has  been  secured,  and  nothing  is  left  keeping  the  enlarged 

s. — vol.  11.  -  . 

54 


850 


ol'KKATlnNS    ON    TIIK    AIJDOMKN. 


uterus  in  position  but  the  narrow  neck  below.  The  only  remaining 
step  is  to  divide  this  latter.  The  intestines  being  kept  out  of  the  way, 
the  left  hand  is  passed  down  behind  the  neck  to  prevent  the  possibility 
of  injury  to  bowel,  and  the  pedicle  is  divided  with  knife  or  scissors  just 
above  the  point  at  which  the  uterine  arteries  are  secured. 

The  division  of  the  pedicle  is  effected  in  various  ways.  The 
simplest  method  is  to  make  an  incision  straight  through,  so  as  to 
leave  a  flat  raw  surface,  which  is  subsequently  covered  in  by  the 
peritonaeal  flaps.  Dr.  Baer,  in  his  original  description  (loc.  supra  cit.), 
considered  that  in  most  cases  it  was  sufficient  to  allow  the  flaps  to  fall 


Fig.  351. 


Supra-vaginal  hysterectomy  seen  from  the  front.     Third  stage. 

The  uterus  has  been  cut  away.  The  ligature  on  each  side,  for  stitching  the 
anterior  peritonaeal  flap  over  the  uterine  artery,  is  passed  and  ready  for  t}'ing. 
L  o  A,  ligature  on  ovarian  artery  ;  L  R  L,  ligature  on  round  ligament ;  L  u  A,  liga- 
ture on  uterine  artery  ;  o,  ovary  ;  f  p,  anterior  flap  of  peritonaeum. 

together  over  the  stump,  and  that  there  was  no  need  to  suture  them. 
To  render  the  stump  completely  extra-peritonaeal  it  is  better,  however, 
to  accurately  coapt  the  cut  edges  of  the  peritonaeum.  This  is  effected 
by  means  of  a  continuous  catgut  suture.  The  divided  edges  of  the  broad 
ligament  on  one  side  are  first  sewn  together.  The  anterior  flap  of 
peritonaeum  is  then  drawn  over  the  stump,  and  its  free  border  sutured 
to  the  cut  edge  of  peritonaeum  at  the  back  of  the  stump,  the  operation 
being  completed  by  sewing  together  the  two  edges  of  the  remaining 
broad  ligament.  In  defining  the  principles  on  which  this  operation 
was  based,  Dr.  Baer  laid  stress  on  the  importance  of  not  disturbing 
the  plug  of  mucus  in  the  cervical  canal,  as  he  regarded  this  as  a  bar 
to  the  spread  of  infection.  Though  in  healthy  women  the  interior  of 
the  uterus  appears  to  be  free  from  organisms,  in  some  cases  of  fibroids 


REMOVAL    OF   MYOMATOUS    UTERUS.  851 

there  is  a  purulent  discharge  from  the  organ,  and  one  objection  made 
to  the  simple  division  of  the  cervix  is  that  infection  of  the  wound  may 
take  place  from  the  cervical  canal.  To  prevent  this  happening,  the 
closure  of  the  canal  is  recommended  by  some  operators.  This  may 
be  effected  by  making  the  incision  through  the  cervix  V-shaped,  and 
approximating  closely  the  two  flaps  by  sutures.  Dr.  Kelly  prefers  to 
so  hollow  out  the  stump  as  to  leave  it  cup-shaped,  the  canal  being 
closed  by  sutures,  which  are  passed  from  before  backwards,  and  which 
convert  the  cup  into  a  transverse  linear  wound.  As  a  further  pre- 
caution against  infection  the  canal  may  be  excised,  with  knife  and 
scissors  or  cauterised.  Mr.  Doran,  in  opening  a  discussion  on  the 
treatment  of  fibroids  (Brit.  Med.  Journ.,  Sept.  15,  1900),  did  not 
advocate  the  closing  of  the  stump  by  sutures,  as  he  considered  this 
procedure  was  liable  to  be  followed  by  sloughing.  I  have  not  seen 
this  complication  occur  as  the  result  of  sutures.  Cellulitis  may  occur 
after  either  method  of  treatment  of  the  pedicle,  but  I  have  seen  less  of 
it  since  closure  of  the  cervical  canal  has  been  adopted.  I  prefer  a 
V-shaped  incision,  the  edges  being  brought  together  by  means  of  stout 
catgut. 

Comparison  of  the  Intra  and  Extra-abdominal  Methods. — At  the 
present  time  it  is  scarcely  necessary  to  compare  these  two  methods  of 
treatment  of  the  stump.  The  latter  has  been  almost  entirely  replaced 
by  the  former  operation.  We  have  retained  the  description  of  the 
extra-abdominal  treatment  of  the  stump,  as  it  has  been  found  to  be 
useful  in  cases  of  emergency.  When,  however,  the  operator  is 
possessed  of  some  skill  in  abdominal  surgery,  and  has  adequate 
assistance,  he  should  undoubtedly  leave  the  stump  within  the 
abdominal  cavity.  The  weak  points  of  the  extra-peritonaeal  method 
are  these : — 

(1)  The  prolonged  convalescence,  lasting  for  six  or  eight  weeks, 
while  the  slough  is  separating.  After  the  intra-abdominal  method  the 
wound  quickly  heals,  and  the  patient  is  able  to  get  up  in  three  or  four 
weeks'  time.  This  is  generally  held,  and  I  think  rightly,  to  be  a  great 
advantage  ;  but  Mr.  Herman  does  not  consider  it  to  be  so  great  as 
might  be  thought,  as  the  nervous  shock  caused  by  the  operation,  and 
consequently  the  time  required  to  regain  the  former  energy,  is  the 
same  in  both  cases. 

(2)  The  granulating  area  in  the  abdominal  wall  leaves  a  cicatrix 
which  is  liable  to  yield  and  give  rise  to  a  ventral  hernia.  Though  a 
hernia  may  arise  after  careful  and  close  suture  of  an  abdominal  wound 
in  its  whole  length,  it  is  much  more  common  in  those  cases  in  which 
part  of  the  incision  is  allowed  to  close  by  granulations,  as  when  drainage 
is  employed  or  after  the  separation  of  the  stump  in  extra-peritonseal 
hysterectomy. 

Mr.  E.  S.  Bishop  (Uterine  Fibro-myomata,  1901,  p.  304),  writing  on 
the  subject  of  hernia  after  hysterectomy  for  fibroids,  says  :  "  Since 
drainage  through  the  abdominal  wound  has  been  entirely  given  up, 
and  special  care  has  been  directed  to  the  suture  of  the  fascia,  I  have 
only  seen  one  hernia,  and  that  followed  suppuration  in  the  wound  due 
to  an  imperfectly  asepticised  suture."  As  showing  the  frequency  of 
hernia  after  the  extra-peritonaeal  method,  Mr.  Cullingworth's  experience 
may  be  quoted.     Of  ten  cases  so  treated  by  him,  two   died,  and  five 

54—2 


852 


OPERATIONS    ON    THE    ABDOMKN. 


subsequently  suffered  from  hernia  in  various  degrees  (quoted  by  Mr. 
Bishop,  loc.  supra  tit.,  p.  221). 

(3)  Another  weak  point  in  the  operation  is  the  risk  of  septic  absorp- 
tion attending  the  necessary  sloughing  of  the  stump. 

(4)  It  is  not  easy  to  compare  the  mortality  of  the  two  operations,  as 
the  intra-abdominal  method  is  applicable  to  a  very  large  number  of 
cases  that  could  not  be  dealt  with  by  drawing  up  the  stump  into  the 


Fig.  352. 


Abdominal  panhysterectomy  seen  from  the  front.     Final  stage.     ((Jalahin.) 

The  uterine  arteries  have  been  tied,  and  thin  clamps  placed  upon  the  remaining 
parts  of  the  broad  ligaments,  posterior  and  anterior  vaginal  fornices  being  opened. 
The  dotted  lines  show  the  lines  of  incision  to  separate  the  uterus.  L  o  A,  ligature 
on  ovarian  artery  ;  L  R  L,  ligature  on  round  ligament  ;  L  TT  A,  ligature  on  uterine 
artery  ;  O,  ovary  ;  o  A,  ovarian  artery. 

abdominal  wound.  Mr.  Thornton,  with  a  considerable  experience  of 
the  extra-peritonaeal  method  of  treatment  of  the  stump,  stated  that 
the  mortality  of  his  cases  was  just  under  8  per  cent.  This  included 

all  his  early  cases.  Practice  with  the  serre-nceud  reduced  his  mortality 
by  fully  one-half;  and  he  considered  that  "cases  suitable  for  the 
serre-noeud,  in  which  there  are  no  unusually  severe  complications,  may 
fairly  be  said  to  have  a  mortality  of  only  3  or  4  per  cent."  (loc.  supra 
tit.,  p.  621). 

The  intra-abdominal  method,  with  a  much  wider  range  of  cases  and 


KKMOVAL    OF   MYOMATOUS    UTERUS.  853 

including  all  kinds  of  complications,  has  given  better    results  than 
this,  and  in  the  hands  of  expert  operators  has  yielded  a  death-rate  as 
low  as  2  per  cent, 
(iii.)  Total  Hysterectomy. 

This  may  be  called  for  in  certain  cases,  when  the  uterus,  for  instance, 
is  the  seat  of  malignant  growth,  or  when  the  position  of  a  fibroid  tumour 
does  not  permit  of  division  through  the  cervix. 

The  operation  is  similar  to  that  of  partial  hysterectomy  as  far  as  the 
ligature  of  the  uterine  arteries. 

Opening  of  Vagina. — These  arteries  having  been  secured,  the 
tumour  is  held  forward,  and  an  opening  is  made  through  the  bottom 
of  Douglas's  pouch  into  the  posterior  fornix,  upon  the  end  of  a  pair  of 
forceps  previously  introduced  through  the  vagina.  A  finger  is  then 
passed  through  the  opening  thus  made,  and  carried  forward  across  the 
cervix  to  act  as  a  guide  to  the  opening  of  the  anterior  fornix.  The 
position  of  the  already  reflected  bladder  is  then  carefully  noted,  and 
the  vagina  again  opened  with  scissors  upon  the  finger  in  the  anterior 
fornix.  The  anterior  and  posterior  incisions  are  next  freely  lengthened, 
leaving  the  lateral  attachments  only  of  the  vagina  to  the  uterus.  These 
should  be  secured  with  clamp  forceps,  and  the  uterus  removed  by 
incisions  carried  between  the  forceps  and  the  cervix.  The  forceps  are 
then  removed,  one  at  a  time,  and  a  careful  examination  made  for  any 
bleeding  points,  which  should  be  secured  and  tied  separately. 

Closure  of  Peritonaeum. — The  next  step  is  to  unite  the  cut  edges  of 
peritonaeum,  and  thus  shut  off  the  opening  into  the  vagina  from  the 
peritonseal  cavity.  An  iodoform  gauze  plug  is  introduced  into  the 
vagina  from  above,  and  drawn  down  until  its  upper  end  is  level  with  the 
cut  edges  of  the  vagina.  The  operator  then  proceeds  to  approximate 
the  edges  of  the  peritonaeum  with  a  continuous  suture.  Having  sewn 
together  the  two  layers  of  the  lower  part  of  the  broad  ligament  on  one 
side,  the  anterior  peritonaeal  flap  is  brought  over  the  vaginal  opening 
and  secured  to  the  posterior  cut  edge  of  peritonaeum,  the  operation 
being  completed  by  the  closure  of  the  broad  ligament  on  the  remaining 
side. 

Dr.  Howard  Kelly's  Method  of  performing  Partial 
Hysterectomy   (Hystero-myomectomy). 

Dr.  Kelly  adopts  a  different  procedure  from  that  described  above. 
Instead  of  tying  and  dividing  the  broad  ligaments  on  both  sides  before 
severing  the  pedicle,  he  works  across  the  pelvis  from  one  side  to  the 
other,  dividing  first  one  broad  ligament,  then  the  pedicle,  and  finally 
dealing  with  the  other  broad  ligament. 

The  stages  of  the  operation  as  described  by  him  (loc.  supra  cit.,  p.  368) 
are  shortly  as  follows  : — 

(a)  Preliminary  Preparation  of  the  Field  of  Operation,  including 
the  Skin  and  Vagina. 

(b)  Opening  the  Abdomen. 

(c)  Delivering  the  Tumour  if  possible. 

(d)  Ligation  of  the  Ovarian  Vessels  and  Round  Ligament  of  one 
side,  usually  the  left. 

In  a  woman  under  forty  years  of  age  he  considers  it  better  to  leave 
both  ovaries  in  the  pelvis,  with  or  without  the  uterine  tubes.  The 
broad  ligament  is  divided  between  two  sets  of  ligatures,  or  between 


■s54 


OPERATIONS    ON    THE    ABDOMEN. 


forceps  on  the  proximal  and  ligatures  on  the  distal  side,  as  previously 
described. 

(e)  Detachment  of  the  Vesico-uterine  Fold  of  Peritonaeum. — The 
uterus  being  drawn  back,  "the  anterior  loose  peritonaeal  fold  along  the 
curved  line  of  the  utero-vesical  reflection  is  cut  through  from  round 
ligament  to  round  ligament.  As  the  bladder  is  raised,  the  loose  cellular 
tissue  beneath  it  is  exposed,  and  it  may  be  still  further  freed  by  a 
rapid  dissection  with  knife  or  scissors."  The  separation  of  the  bladder 
is  completed  by  pushing  it  well  down  with  a  sponge  firmly  compressed 


Fig-  353- 


V      xNv*' 


The  operation  of  hystero-myomectomy.    (Kelly.) 
By  a  continuous  incision  from  left  to  right,  ligating  or  clamping — at  the  points 
indicated  by  the  arrows— first  the  left  ovarian  vessels  (Ov.  ves.),  next  the  round 
ligament,  and  then  the  left  uterine  artery  (Ut,  Art.).     Finally,  the  cervix  is  cut 
across,  and  the  uterus  pulled  away  until  the  right  uterine  vessels  are  exposed. 

in  sponge-forceps,  until  the  cervix  is  bared  almost  or  quite  down  to  the 
vaginal  junction. 

(/)  Ligation  of  the  Uterine  Vessels  of  the  same  side. — These 
vessels  are  now  securely  tied  close  to  the  cervix  by  a  silk  ligature  on  a 
curved  needle  passed  close  to  the  cervical  tissue,  but  not  entering  it. 

{(/)  Amputation  of  Uterus  in  Cervical  Portion. — The  uterus  is 
now  drawn  to  the  other  side,  and  the  uterine  vessels  are  divided  from 
6-10  mm.  above  the  ligature,  an  assistant  being  ready  with  artery- 
forceps  to  grasp  any  bleeding  vessel  left  by  chance  out  of  the  ligature. 
The  uterus  is  now  completely  divided  in  its  cervical  portion,  at  a  point 
just  above  the  vaginal  junction,  and  in  such  a  way  as  to  leave  a  cup- 
shaped  pedicle.  It  is  a  good  plan,  when  the  cervix  is  nearly  divided,  to 
cut  upward  for  one  or  two  centimetres  so  as  to  leave  behind  a  thin  shell 


CANCER   OF   THE    UTERUS.  855 

of  cervical  tissue,  and  expose  the  opposite  uterine  vessels  at  a  higher 
level,  when  it  is  much  easier  to  tie  them  without  risk  of  including  the 
ureter. 

(//)  Clamping  the  Uterine  Vessels  of  opposite  side,  the  Round 
Ligament,  and  the  Ovarian  Vessels,  followed  by  Removal  of  the 
Tumour. — As  the  uterus  is  drawn  up  and  rolled  over  on  to  its  side,  the 
uterine  vessels  come  into  view ;  these  are  seized  in  clamp  forceps  and 
divided.  The  uterus  is  rolled  over  still  more  till  the  round  ligament  is 
seen.  This  is  clamped  and  divided,  and  is  followed  by  similar 
treatment  of  the  ovarian  vessels.  The  whole  mass  is  thus  freed  and 
taken  away. 

(i)  Application  of  Ligatures  in  place  of  Forceps. — The  parts  now 
held  in  forceps  (the  ovarian  vessels,  the  round  ligament,  and  the  uterine 
vessels)  are  successively  tied  with  firm  silk  ligatures  and  the  forceps 
removed. 

(J)  Suturing  the  Cervical  Stump. —  The  stump  is  carefully  examined 
for  any  bleeding  points,  which  should  be  tied.  It  is  now  closed  over 
the  cervical  canal  by  passing  from  three  to  five  or  more  catgut  sutures 
in  an  antero-posterior  direction,  and  tying  each  one  as  it  is  passed.  By 
suturing  in  this  way  the  cup-shaped  pedicle  is  changed  into  a  transverse 
linear  wound.  Should  there  be  a  discharge  of  pus  from  the  uterus  or  a 
muco-purulent  plug  in  the  canal,  this  latter  should  be  wiped  out  with 
gauze  as  soon  as  cut  across,  and  afterwards  dissected  out  with  a  sharp 
knife  and  forceps. 

(k)  Covering  the  Wound-area  with  Peritonaeum. — The  large  flap 
of  peritonaeum  which  lies  in  front  of  the  pedicle  is  drawn  over  the 
stump  and  sutured  to  the  posterior  peritonaeum  by  a  continuous  suture. 

CANCER  OP  THE  UTERUS. 

Cancer  of  the  Body. — In  cases  suitable  for  radical  treatment  the 
uterus  may  be  removed,  either  through  the  vagina  or  by  an  abdominal 
incision,  the  choice  of  route  being  determined  by  the  size  of  the  body. 
The  indications  for  operation  are  practically  the  same  as  those  given  in 
the  next  section,  on  cancer  of  the  cervix.  Should  the  abdominal  route 
be  chosen,  the  operation  is  in  all  essentials  similar  to  that  described  for 
fibroids,  the  whole  of  the  uterus  being  of  necessity  removed.  Hyste- 
rectomy by  the  vaginal  route  is  similar  to  that  described  for  carcinoma 
of  the  cervix. 

Vaginal  Hysterectomy  for  Carcinoma  of  the   Cervix. 

To  determine  ivhether  Case  is  suitable  for  Removal  of  the  Uterus. — It 
is  not  easy  in  a  case  of  cancer  of  the  cervix  to  say  whether  the  whole 
disease  can  be  eradicated,  as  growth  may  have  extended  beyond  the 
limits  of  the  uterus,  and  yet  be  inappreciable  on  the  most  careful 
examination. 

To  determine  whether  a  case  is  operable,  the  different  routes  by 
which  the  growth  may  advance  must  be  carefully  borne  in  mind,  and 
a  systematic  examination  made  of  each.     They  are  as  follows  : — 

(1)  The  growth  may  involve  the  fornices  or  extend  down  on  to  the 
vaginal  walls. 

(2)  It  may  extend  forwards  and  involve  the  bladder. 

(3)  It  may  extend  outwards  in  the  broad  ligaments, 


,s3(,  OPERATIONS  ON  THE  ABDOMEN. 

(4)  Or  extend  backwards  in  the  utero-sacral  folds  and  involve  the 
rectum. 

In  examining  a  case  the  first  thing  to  he  noted  is  the  mobility  of  the 
uterus.  This  may  be  tested  most  efficiently  by  fixing  a  pair  of  tena- 
culum forceps  into  the  cervix,  and  observing  whether  the  organ  can 
be  drawn  down  readily  towards  the  vulva.  If  there  is  complete  or 
considerable  fixation  and  wide  extension  of  growth  in  any  of  the  above- 
mentioned  directions  the  case  is  inoperable,  and  should  be  left  alone. 
The  cervix  should  be  examined,  not  only  digitally,  but  through  a 
speculum,  and  the  extent  to  which  the  fornices  or  the  walls  of  the 
vagina  are  involved  carefully  noted.  To  determine  whether  extension 
laterally  in  the  broad  ligaments  or  backwards  in  the  utero-sacral  folds 
has  taken  place,  the  vaginal  examination  must  be  supplemented  by  a 
rectal  one,  and  a  search  made  for  any  masses  or  thickening  in  these 
situations. 

If  the  uterus  is  freely  movable,  and  can  be  pulled  down  to  the  vulva, 
and  there  is  nothing  to  be  felt  in  the  broad  ligaments  or  utero-sacral 
folds,  the  case  is  a  favourable  one  for  operation,  and  there  are  good 
grounds  for  hope  of  permanent  relief. 

But  between  the  eminently  favourable  cases  and  those  that  are  to  be 
regarded  as  inoperable  certain  cases  are  to  be  met  with,  not  infre- 
quently, in  which  there  exists  an  element  of  doubt  as  to  whether  the 
growth  can  be  entirely  removed.  On  this  point  Dr.  Howard  Kelly's 
remarks  are  worth  quoting:  "  In  concluding  whether  or  not  to  operate, 
the  patient  should  in  all  cases  have  the  benefit  of  any  reasonable  doubt, 
and  the  operator  must  not  be  too  exacting  in  restricting  his  indications. 
I  have  operated  several  times  where  the  disease  was  found  so  advanced 
that  there  could  be  no  reasonable  question  but  that  some  portion  of  it 
was  left  behind,  and  this  was  confirmed  by  a  microscopic  examination 
of  the  specimen,  which  showed  cancer  cells  right  up  to  the  cut  edge  of 
the  broad  ligament,  and  yet  one  of  these  patients  enjoyed  perfect  health 
for  five  years,  when  the  disease  reappeared  in  the  glands  of  the  neck ; 
another  had  a  local  return  after  three  years  of  good  health,  and  two 
others  are  living,  apparently  in  perfect  health,  three  and  four  years  after 
the  operation  "  (loc.  supra  cit.,  p.  319). 

Is  an  operation  justifiable  in  cases  in  which  no  hope  can  be  reason- 
ably entertained  of  a  permanent  cure  ?  In  considering  this  question, 
the  influence  that  repeated  losses  of  blood  and  continuous  septic  absorp- 
tion from  the  breaking-down  cancerous  mass  have  on  the  health  of  the 
patient  should  be  borne  in  mind.  If  under  the  circumstances  there  is 
reason  to  think  that  the  uterus  can  be  removed  without  unusual  risk, 
the  surgeon  is  justified  in  operating  after  laying  the  facts  of  the  case 
fairly  before  the  patient.  For  recurrence  of  the  disease,  so  long  as  it 
does  not  take  place  in  the  vaginal  roof,  will  be  attended  with  less  pain, 
an  absence  of  haemorrhage,  and  a  relief  from  the  distress  dependent  on 
a  foetid  discharge. 

No  radical  operation  should  be  undertaken  if  extension  of  growth 
has  led  to  involvement  of  bladder,  ureters,  or  rectum.  Wide  extension 
into  the  broad  ligaments  will  give  rise  to  grave  danger  of  injury  to  the 
ureters.  Moreover,  difficulty  will  be  experienced  in  the  application  of 
ligatures  or  forceps,  which  are,  further,  likely  to  slip  oil* from  the  friable 
cancerous  «n*owth. 


CANCER   OF   THE    ITTERUSf  857 

Palliation  ma}'  bo  afforded  in  some  inoperable  cases  by  a  free  scraping 
away  of  the  growth  in  the  cervix,  followed  by  the  application  of 
Paqnelin's  cautery.  Great  hopes  of  relief  should  not  be  held  out  to 
the  patient  as  likely  to  follow  this  procedure,  nor  should  the  operation 
be  urged  on  her.  Whilst  considerable  benefit  follows  in  some  cases,  in 
others,  and  especially  when  the  growth  is  very  advanced,  scraping  has 
done  more  harm  than  good  by  hastening  communication  with  the 
bladder  and  other  organs. 

Operation. — There  are  many  modifications  in  the  various  stages  of 
this  operation  adopted  by  different  surgeons,  the  chief  of  which  is  the 
treatment  of  the  broad  ligaments,  some  preferring  to  tie  these  with  silk 
or  catgut,  others  to  clamp  them. 

Preliminary  Treatment. — For  some  days  beforehand  the  vagina 
should  be  freely  douched  with  some  antiseptic  lotion,  such  as  1-500 
formalin. 

For  the  operation  the  patient  is  placed  in  the  lithotomy  position,  and 
the  legs  secured  by  means  of  a  Clover's  crutch.  The  perinaeum  is 
retracted  with  a  Sim's  or  Simon's  speculum.  Lateral  retractors  may 
be  found  useful  at  certain  stages  of  the  operation.  The  cervix  is  drawn 
down  to  the  vulva  by  vulsella,  one  pair  of  forceps  being  applied,  as  a 
rule,  to  the  anterior  lip,  one  to  the  posterior.  The  point  of  attachment 
will,  however,  depend  to  some  extent  on  the  condition  of  the  cervix. 
In  the  case  of  large  cauliflower  excrescences  it  will  often  be  found 
necessary,  as  a  preliminary  to  freeing  the  uterus,  to  remove  the  growth 
freely  with  scissors  and  sharp  spoon.  Some  surgeons  prefer,  in  all 
cases  in  which  there  is  exposed  cancerous  growth  on  the  cervix,  to 
remove  it  before  commencing  the  operation.  This  procedure  is  based 
on  sound  principles.  In  the  removal  of  cancer  elsewhere  in  the  body, 
every  precaution  that  is  possible  is  taken  against  the  reinfection  of  the 
wound  surfaces  by  cancerous  material.  That  raw  surfaces  may  be 
inoculated  in  this  way  is  abundantly  proved  by  clinical  and  experi- 
mental evidence.  Mr.  Herman,  amongst  others,  recommends  that  all 
exposed  growth  should  be  thoroughly  scraped  away  with  a  sharp  spoon 
until  firm  tissue  is  reached.  A  Paquelin's  cautery  is  then  applied  to 
the  whole  surface.  By  this  means  the  chance  of  reinfection  of  the 
operation  wounds  is  greatly  minimised  (Dis.  of  Women,  p.  380). 
In  Dr.  Baldy's  Gynecology  (1894,  p.  389)  it  is  further  recommended 
that  the  funnel-shaped  excavation  made  by  the  spoon  and  cautery  be 
stuffed  with  iodoform  gauze,  and  the  lips  of  the  cavity  sewn  together 
by  means  of  a  continuous  suture. 

Separation  of  Bladder. — It  is  not  a  matter  of  great  importance 
whether  the  surgeon  begins  by  separating  the  bladder  or  by  opening 
Douglas's  pouch.  If  he  choose  the  former,  the  line  of  reflection  of  the 
bladder  from  the  cervix  is  ascertained  by  passing  a  bladder  sound,  or, 
as  Mr.  Herman  recommends,  by  grasping  the  mucous  membrane  and 
noting  the  line  at  which  you  begin  to  be  able  easily  to  pull  it  from  the 
uterus. 

With  a  blunt-pointed  pair  of  scissors  the  mucous  membrane  of  the 
anterior  fornix  is  incised  in  the  median  line  just  below  the  line  of 
reflection  of  the  bladder,  and  the  incision  prolonged  laterally  so  as  to 
surround  the  cervix  in  front.  The  operator  cuts  down  until  the  wall  of 
the  uterus  is  reached,  and  then  proceeds  to  strip  off  the  bladder  from  the 


858  OPERATIONS  ON  THE  ABDOMEN. 

front  of  the  cervix  with  the  fingers,  keeping  close  against  the  uterus 
the  whole  time.  Any  hands  that  resist  separation  hy  the  fingers  may 
be  divided  with  scissors.  It  is  most  important  that  this  separation  be 
extended  well  to  the  sides  of  the  uterus,  for  by  doing  so  not  only  is  the 
bladder  saved  from  chance  of  injury  in  the  subsequent  manipulations, 
but  the  ureters  are  pushed  well  out  of  the  way.  The  anterior  peri- 
tonaeum having  been  reached,  is  opened  by  pushing  a  sound  or  blunt 
pair  of  forceps  through  it,  or  divided  carefully  with  a  pair  of  scissors, 
the  opening  being  subsequently  enlarged  with  the  fingers.  In  some 
cases,  on  account  of  peri-uterine  inflammation,  difficulty  may  be  experi- 
enced in  separating  the  bladder  from  the  uterus,  and  considerable  risk 
incurred  of  opening  the  former.  Should  this  happen,  the  injury  should 
be  at  once  repaired.  If  growth  is  found  to  have  extended  forwards  and 
involved  the  walls  of  the  bladder,  the  operation  may  have  to  be 
discontinued.  If  the  amount  involved  is  small,  has  not  involved  the 
ureters,  and  there  is  not  wide  extension  of  growth  in  other  directions, 
a  portion  of  the  bladder-wall  may  be  removed,  the  opening  being 
sutured  subsequently  with  catgut. 

Opening  Douglas's  Pouch. — An  incision  is  next  made  through  the 
mucous  membrane  of  the  posterior  fornix,  so  as  to  open  Douglas's 
pouch.  It  is  prolonged  laterally  so  as  to  meet  the  extremities  of  the 
anterior  incision,  care  being  taken  not  to  cut  so  deeply  as  to  wound  the 
uterine  arteries.  There  is  no  fear  of  this,  if  the  incision  at  the  sides  is 
made  through  the  mucous  membrane  only.  In  making  the  posterior 
division  the  cervix  should  be  held  well  forward  by  the  vulsella,  and  the 
points  of  the  scissors  directed  towards  the  uterus  to  avoid  risk  of 
injury  to  the  rectum.  With  care  there  is  no  great  risk  of  this  accident, 
unless  the  posterior  fornix  has  been  much  encroached  on  by  the  growth. 
The  opening  in  the  peritonaeum  is  then  prolonged  laterally  with  scissors, 
or,  as  some  prefer,  enlarged  by  tearing  with  the  two  forefingers.  A 
difficulty  met  with  at  this  stage  in  entering  Douglas's  pouch  may  be  due 
to  the  incision  being  carried  through  the  mucous  membrane  only,  and 
the  peritonaeum  separated  and  pushed  before  the  finger.  It  is  un- 
necessary to  pass  a  sponge  through  the  posterior  opening  into  Douglas's 
pouch,  as  recommended  by  some  operators,  unless  actual  protrusion  of 
intestines  takes  place.  Any  bleeding  points  in  the  cut  edges  of  the 
vagina  should  be  secured  by  pressure-forceps.  A  fear  of  haemorrhage 
occurring  some  hours  after  the  operation  has  led  to  various  modifications 
of  this  part  of  the  operation.  In  Dr.  Baldy's  work  (loc.  supra  cit.,  p.  389), 
for  instance,  it  is  recommended  that  the  peritonaeum  be  sewn  to  the  cut 
edge  of  the  vagina  by  a  continuous  catgut  suture;  and  Dr.  Sinclair 
(Allbutt  and  Playfair,  Syst.  of  Gyn.,  p.  688)  ligatures  the  vaginal  wall 
before  dividing  it.  By  these  proceedings,  the  operation  is  unnecessarily 
complicated,  and  they  are  not  required  as  a  routine  measure. 

The  Management  of  the  Broad  Ligaments. — This  stage  of  the 
operation  is  the  one  that  has  met  with  the  greatest  variety  of  treatment 
at  the  hands  of  different  surgeons;  and  it  is  not  difficult  to  see  the 
reason  of  this.  The  inconveniences  connected  with  long  silk  ligatures, 
the  dangers  attendant  on  the  use  of  clamps,  the  advantages  or  disad- 
vantages of  closing  the  vaginal  vault,  have  influenced  in  various  degrees 
different  operators  in  the  choice  of  one  variety  or  another.  I  will  first 
describe  jihe  method  of  securing  the  broad  ligaments  by  sutures.     For 


CANCER    OK    THE    UTERUS. 


«59 


this  purpose  a  needle  curved  in  a  plane  nearly  at  right  angles  to  the 
handle  is  made  use  of,  or  two  may  be  employed,  curved  respectively 
to  the  right  and  left  for  the  corresponding  broad  ligaments.  Com- 
mencing at  the  lower  part  of  these  structures,  and  working  first  on  one 
side,  then  on  the  other,  successive  portions  are  tied  with  silk  and 
divided.  As  the  division  proceeds,  the  uterus  is  pulled  lower  and  lower, 
first  of  all  the  cervix  and  then  the  body  being  freed  from  its  lateral 
attachments.     Dr.   Galabin  (Dis.  of  Women,  1893,  p.  323)  points  out 


Fig.  354. 


Vaginal  hysterectomy  with  clamps.     (Baldy.) 
Single  clamp  operation. 

that  "  as  soon  as  the  centre  of  the  uterus  is  divided  from  the  utero- 
sacral  ligaments,  the  fundus  can  generally  be  drawn  down  much  further 
and  the  upper  part  of  the  broad  ligament  brought  within  reach." 

The  tying  of  the  upper  part  of  the  broad  ligaments  is  facilitated  by 
seizing  the  fundus  with  vulsella,  retroflexing  it,  and  dragging  it  out 
through  the  posterior  opening  made  into  Douglas's  pouch.  By  this 
manipulation  the  upper  parts  of  the  broad  ligaments  are  brought  within 
easy  reach,  and  are  readily  transfixed  by  a  double  ligature  and  tied  in 
two  halves.  If  silk  is  made  use  of  for  the  ligatures,  the  ends  should  be 
left  long  to  facilitate  their  removal.  The  use  of  this  material,  however, 
presents  certain  disadvantages.       If  the  ends  are  left  long,  and  the 


86o 


OPERATIONS   ON    THE   ABDOMEN. 


stumps  cannot  be  drawn  down  and  fixed  in  the  vaginal  roof,  so  as  to 
render  them  extra-peritoneal,  the  silk  strands  serve  as  a  track  along 
which  infection  may  spread  upwards  from  the  vagina.  If  cut  short  and 
left  in  the  pelvis,  they  are  very  likely  to  serve  as  septic  foreign  bodies, 
round  which  accumulations  of  pus  may  take  place.  In  their  stead 
catgut  has  been  recommended  as  being  absorbable,  and,  further,  as  being 
less  likely  to  slip  than  silk.  These  are  cut  short,  whether  left  within 
or  outside  the  peritonaeum.     The  objections  to  ligatures,  whether  silk  or 


Fig.  355. 


Vaginal  hysterectomj'  with  clamps.     (Bakly.) 
Multiple  clamp  operation  :  first  step. 

catgut,  are  these:  they  are  more  difficult  to  apply  than  clamps,  and  the 
operation  takes  longer.  Whether  ligatures  or  suitable  clamps,  properly 
applied,  are  the  more  liable  to  slip  is  a  point  difficult  to  decide ; 
secondary  hemorrhage  may  result  from  the  use  of  either.  The  greatest 
objection  to  the  ligature  is  the  fact  that,  whatever  precautions  are  taken, 
it  may  serve  as  a  septic  foreign  body.  Not  even  the  catgut  ligature  is 
free  from  this  reproach.  A  point  in  favour  of  tying  the  stumps  is  that 
these  latter  can  be  drawn  down  into  the  vaginal  vault,  and  thus  rendered 
entirely,  or  almost  entirely,  extra-peritoneal.  The  method  of  doing  so 
will  be  referred  to  later. 

Although  an  equal  number  of  objections  may  be  urged  against  the  use 


CANCER   OF   THE    UTERUS. 


861 


of  clamps,  I  prefer  this  latter  method  of  operating,  largely  on  account 
of  the  greater  ease  and  rapidity  of  procedure. 

Against  their  use  it  has  been  urged  that  they  prevent  closure  of  the 
vaginal  vault,  and  that  the  large  open  channel  thus  left  invites  con- 
tamination of  the  pelvic  peritonaeum.  But  this  open  space  provides 
such  free  drainage  that  peritonitis  is  a  very  rare  accident,  and  pelvic 
abscess  is  seldom  seen.  It  is  thought  that  there  is  a  greater  risk  of 
including   the    ureter   in   the    grasp    of  the   forceps,  or  a  danger  of 


Fig.  35G 


Vaginal  hysterectomy  with  clamps.    (Baldy.) 
(Multiple  clamp  operation  :  second  step. 

catching  the  intestine  in  the  points  of  the  forceps.  This  latter  may  be 
avoided  with  care,  and  the  former  accident  by  freely  separating  and 
pushing  aside  the  soft  parts  at  the  side  of  the  uterus. 

Numerous  forms  of  forceps  are  employed  for  clamping  the  broad 
ligaments.  The  ones  I  prefer  are  Doyen's,  with  strong  spring  blades, 
which  come  into  close  apposition  when  closed.  Either  one  long  pair 
(Fig.  354)  may  be  applied  on  each  side,  embracing  the  whole  ligament, 
or  two  or  more  shorter  pairs  may  be  employed  (Figs.  355,  356,  357). 
The  latter  method  is,  I  think,  preferable  to  the  former.  It  is  easier  to 
apply  the  forceps  to  a  half  or  less  of  the  broad  ligament  than  to  the 
whoie  of  it ;  there  is  less  risk  of  slipping,  and  as  the  uterus  is  separated 


NO  J 


OPKKATIONS    ON    TIIK    AP.DOMKN. 


from  its  attachments  and  brought  lower  down,  there  is  less  risk  of 
catching  a  loop  of  intestine  in  the  ends  of  the  blades.  There  is  less 
objection  to  the  single-clump  operation  if  the  broad  ligaments  are  short 
and  the  finger  can  readily  be  passed  beyond  them;  but  when  they  are 
long  and  the  upper  border  cannot  be  felt,  the  forceps  should  be  applied 
no  farther  than  the  finger  can  reach,  the  upper  part  of  the  ligament 
being  secured  by  a  second  pair. 

In  applying  the  forceps  the  front  and  back  of  the  ligament  are  care- 
fully examined   by  the  finger,  to  make   certain  that  the  bladder  has 


Fig.  357. 


Vaginal  hysterectomy  with  clamps.     (Baldy.) 
Multiple  clamp  operation  :  third  and  final  step. 

been  well  separated  at  the  sides,  and  that  there  is  no  intestine  in  close 
contiguity.  With  one  finger  in  front  and  another  behind  the  broad 
ligament,  the  two  blades  of  the  forceps  are  guided  into  position,  and 
the  parts  being  again  carefully  examined,  tightened  up.  If  the  entire 
ligament  is  to  be  secured  in  the  grasp  of  one  pair,  they  must  be 
passed  beyond  its  upper  border,  and  care  taken  that  no  intestine  is 
included. 

A  similar  proceeding  is  carried  out  on  the  opposite  side.  The 
forceps  having  been  applied,  the  ligament  is  divided  between  the 
forceps  and  the  uterus.  If  the  clamps  have  embraced  a  part  only  of 
the  broad  ligament  on  each  side,  a  second  pair  are  now  applied,  and 


CANCER    OF    THE    UTERUS. 


863 


the  uterus  thus  separated  in  successive  portions.  The  operation  as 
performed  by  Dr.  Galabin  consists  in  a  combination  of  these  two 
methods  (Dis.  of  Women,  1903,  p.  429).  He  clamps  the  lower  half  of 
the  broad  ligament,  and  ties  the  upper  half.  The  bladder  having  been 
separated  in  front  and  Douglas's  pouch  opened  behind,  as  described 
above,  a  clamp  is  applied  on  each  rib  to  the  lower  half  of  the  broad 
ligament,  reaching  a  little  above  the  centre  of  the  uterus.     The  uterus 


Fig.  358. 


Vaginal  hysterectomy.     (Galabin.) 

Fundus  retroflexed  and  drawn  down  externally.  Double  ligature  passed 
through  upper  half  of  left  broad  ligament.  One  loop  tied  (1).  End  of  second 
loop  (2)  being  passed  round  broad  ligament  by  curved  pedicle  needle, 

is  then  cut  away  on  each  side  as  high  up  as  the  tips  of  the  blades.  The 
next  step  is  to  draw  down  the  fundus  through  the  opening  in  Douglas's 
pouch  (Fig.  358)  by  means  of  vulsella.  The  upper  half  of  the  broad 
ligament  is  now  within  reach.  It  is  transfixed  on  one  side  by  a  pedicle 
needle  threaded  with  silk  and  tied  in  two  halves.  The  uterus,  now  cut 
away  on  one  side,  is  left  attached  by  the  upper  half  of  the  opposite 
broad  ligament,  which  is  tied  and  divided  in  the  same  way.  The 
pedicles  of  the  broad  ligaments  are  finally  secured  to  the  edges  of  the 


864 


OPERATIONS    ON    THE    ABDOMEN. 


opening  in  the  vaginal  vault  in  the  way  described  in  the  next  paragraph, 
the  ligatures  which  have  secured  them  being  left  long  for  this  purpose. 
This  mode  of  performing  the  operation  is  a  most  satisfactory  one.  It 
avoids  the  risk  that  ligatures  applied  to  the  lower  half  of  the  broad 
ligament  have  of  slipping  and  the  difficulties  that  often  attend  the 
application  of  forceps  to  the  upper  half.  To  allow  of  retroflexion  of 
the  uterus  and  the  drawing  of  the  fundus  through  the  vaginal  vault, 
care  must  be  taken  that  the  clamps  are  not  applied  too  high  up  on  the 
broad  ligaments.  A  cervix  greatly  elongated  or  enlarged  by  disease, 
an  enlarged  body,  or  a  small  opening  in  the  vaginal  vault,  may  prevent 
the  operation  being  terminated  in  this  way.     The  uterus  should  then 


Fig.  359. 


Vaginal  hysterectomy  with  the  ligature-stumps  drawn  into  the  vagina,  with  sutures 
in  place  ready  to  close  the  opening  in  the  vaginal  vault.     (Baldy.) 

be  drawn  down  as  far  as  possible  and  the  remainder  of  the  broad  ligament 
secured  with  clamps. 

Closure  of  Vault  of  Vagina. — In  this,  as  in  the  other  stages  of  the 
operation,  practice  varies  widely,  some  surgeons  employing  no  sutures 
at  all,  others  partially  or  entirely  shutting  off  the  peritonreal  cavity. 
Where  silk  ligatures  are  employed  the  stumps  should,  if  possible,  be 
rendered  extra-peritonseal.     This  is  effected  as  follows  : — 

By  means  of  the  ligatures,  which  have  been  left  long,  the  pedicle  on 
one  side  is  pulled  down  below  the  level  of  the  cut  edge  of  the  vagina 
and  fixed  in  position  by  two  or  three  catgut  sutures.  The  same  pro- 
ceeding is  carried  out  on  the  opposite  side  (Fig.  359).  By  this  means 
the  peritonaeal  cavity  is  almost  entirely  shut  off,  a  small  opening  only 
being  left  in  the  centre  of  the  vault  for  drainage.  Even  this  is  dis- 
pensed with  by  some  surgeons,  the  vaginal  wound  being  completely 
closed  by  the  insertion  of  one  or  two  stitches  in  the  median  line  (Fig. 


CANCER   OF   THE   UTERUS.  865 

359).  By  the  employment  of  catgut,  Olshauscn  has  been  enabled  to 
completely  close  the  peritonaeal  cavity,  leaving  the  stumps  in  the 
pelvis.  The  gut  ligatures  are  cut  short  and  the  pedicles  allowed  to 
retract  within  the  peritonaeal  sac.  The  wound  is  then  closed  by 
sutures  passed  from  before  backwards  through  the  edges  of  the  anterior 
vaginal  wall,  the  anterior  layer  of  peritonaeum,  the  posterior  peritonaeum, 
and  the  posterior  wall  of  vagina.  His  success  has  not  been  obtained 
b}r  others  who  have  followed  his  methods.  Dr.  Sinclair  (loc.  supra  cit., 
p.  690)  says  :  "  After  Olshausen's  success  in  completing  the  operation 
by  cutting  short  the  broad  ligament  ligatures,  and  completely  closing 
the  wound  in  the  pelvis,  I  tried  for  a  time  to  do  without  drainage,  but 
found  the  result  unsatisfactory.  Several  times,  owing  to  unfavourable 
symptoms  which  followed,  it  was  necessary  to  undo  some  stitches  in 
order  to  permit  of  the  escape  of  retained  fluid."  Considering  the  diffi- 
culties of  cleansing  the  vagina,  there  must  always  be  some  risk  of 
infection  during  the  operation,  and  it  appears  on  the  whole  safer  to 
provide  for  drainage  of  the  pelvic  pouch,  especially  when  ligatures  are 
left  within  it.  When  forceps  are  employed  the  stumps  cannot  be 
rendered  extra-peritonaeal.  If  at  the  time  of  operation  there  appeared 
to  be  a  tendency  to  prolapse  of  the  intestines,  a  stitch  or  two  might  be 
inserted  in  the  centre  of  the  vaginal  roof;  but  otherwise  they  are  not 
necessary. 

After-treatment. — After  the  removal  of  the  uterus,  the  vagina  is 
loosely  packed  with  a  strip  of  iodoform  gauze,  and  if  forceps  are  used 
the  gauze  should  be  wrapped  round  their  handles  where  they  lie  in  con- 
tact with  the  vulva.  The  forceps  are  removed  at  the  end  of  thirty-six 
hours,  and  the  plug  of  gauze  renewed.  When  sutures  are  employed 
the  gauze  plug  may  be  left  in  three  or  four  days.  No  douche  should 
be  employed  for  five  or  six  days  after  the  operation. 

Abdominal  Hysterectomy  for  Carcinoma  of  the  Cervix. — This 
operation  has  been  extensively  practised  of  late  years  as  a  routine 
method  of  treatment.  It  allows  of  a  more  thorough  removal  of  the  pelvic 
cellular  tissue  and  enables  one  to  detect  and  remove  any  enlarged 
glands.  The  uterus,  moreover,  can  be  freed  from  the  bladder  more 
easily  from  above,  and  the  detachment  can  be  carried  lower  down  on 
the  vaginal  walls.  The  mortality,  however,  remains  considerably 
higher  than  that  for  the  vaginal  operation,  being  at  least  15  per  cent, 
as  compared  with  5  per  cent,  for  the  latter  method.  Sufficient  time 
has  not  elapsed  yet  to  allow  for  a  comparison  of  the  results  of  the  two 
operations.  It  would  appear  at  the  present  time  better  to  adopt  the 
vaginal  route  for  removal  of  the  uterus  when  the  growth  is  earl}''  and  is 
confined  to  the  cervix.  Abdominal  hysterectomy  is  suitable  to  cases 
where  the  growth  is  more  advanced  and  yet  appears  possible  of  removal. 
There  is  no  doubt  that  cases  can  be  successfully  dealt  with  by  the 
abdominal  route  that  one  would  not  deal  with  by  vaginal  hysterectomy. 
The  former  method  should  be  adopted  when  the  body  is  much  enlarged, 
and  I  think  it  preferable  to  extensive  division  of  the  passages,  when 
the  vagina  is  very  small. 

The  operation  in  its  essentials  is  the  same  as  that  described  for  the 

removal  of  the  uterus   for   fibro-myomata.     Before  commencing   the 

abdominal  operation,  the  growth  in  the  cervix  should  be    removed 

freely  with  curette  and  cautery,  and  the  cavit}^  plugged  with  iodoform 

s. — vol.  11.  55 


,SG6  OPERATIONS   ON   THE   ABDOMEN. 

gauze.     The  chief  features  of  the  operation  as  performed  for  carcinoma 

are  as  follows  : — 

(i)  The  ovarian  vessels  and  round  ligaments  are  tied  and  divided 
well  out  towards  the  pelvic  brim,  and  the  hroad  ligament  divided. 

(2)  The  bladder  is  separated  for  an  inch  or  more  from  the  upper 
part  oi'  the  vaginal  wall. 

(3)  The  position  of  the  ureters  should  he  ascertained  and  the  uterine 
arteries  tied  as  far  out  as  possihle.  The  ureter  should  not  be  dissected 
hare,  as  it  is  liable  to  slough  from  interference  with  its  blood  supply. 

(4)  The  pouch  of  Douglas  is  opened  into  the  vagina,  and  the  uterus 
removed  with  the  upper  inch  or  more  of  the  vagina,  which  has  heen 
stripped  from  the  bladder  and  rectum.  Right-angled  clamps  applied 
to  the  vagina  before  division  will  help  to  prevent  infection  from  the 
cancerous  cervix. 

(5)  Search  is  then  made  for  glands  along  the  course  of  the  iliac 
vessels. 

(6)  A  plug  is  passed  into  the  vagina,  and  the  cut  edges  of  peritonaeum 
brought  together  and  sutured  over  it. 

The  risks  attached  to  this  operation  are  haemorrhage,  sepsis,  injury 
to  the  ureters  or  bladder,  the  former  heing  sometimes  tied  or  divided, 
and  infection  of  the  urinary  tract.. 


OEISARIAN    SECTION. 

Indications. — (1)  An  extreme  degree  of  pelvic  contraction,  when 
the  smallest  diameter  through  which  the  child  has  to  pass  is  less  than 
two  inches. 

(2)  Solid  tumours  of  the  pelvis  or  uterus,  which  cannot  be  pushed 
out  of  the  way ;  cancer  of  the  cervix  and  cicatricial  contraction  of  the 
passages. 

(3)  In  any  case  in  which  there  is  no  hope  of  obtaining  a  living 
child,  even  by  the  induction  of  premature  labour,  it  is  reasonable  to 
offer  the  mother  the  option  of  undergoing  a  somewhat  greater  risk  to 
save  the  life  of  the  child. 

Time  of  Operating. — There  are  three  possibilities  :  (1)  To  wait  until 
labour  comes  on  spontaneously.  (2)  To  operate  at  a  certain  fixed  time 
before  the  commencement  of  labour  pains.  (3)  To  induce  labour  by 
the  passage  of  a  bougie  and  operate  at  a  pre-arranged  time. 

The  great  objection  to  waiting  for  the  onset  of  natural  labour  is  that 
the  operation  may  have  to  be  performed  at  night,  often  without  the 
necessary  assistance  and  with  the  patient  imperfectly  prepared.  For 
these  reasons  many  surgeons  prefer  to  operate  at  a  definite  time,  which 
is  arranged  for  a  few  days  before  full  term.  This  is  undoubtedly 
the  most  satisfactory  plan.  The  operation  can  be  undertaken  in  day- 
light, the  needful  assistance  is  forthcoming,  and  the  patient  can  undergo 
the  proper  preliminary  treatment — as  necessary  in  Caesarian  section  as 
for  any  other  abdominal  operation.  The  chief  objection  made  to 
operating  before  the  onset  of  labour  is  that  the  uterus  may  not  contract 
well,  -with  the  risk  of  haemorrhage  that  imperfect  contraction  entails. 
Practical  experience  has,  however,  shown  that  the  fear  of  uterine 
inertia    and    bleeding    is    unfounded.       If    the    surgeon    prefers    to 


OESARIAN   SECTION.  867 

operate  after  labour  pains  have  commenced,  he  may  still  do  so  at  a  pre- 
arranged time  by  passing  a  bougie  over-night.  It  is  possible  that  the 
pains  may  not  come  on  by  the  time  arranged.  Under  these  circum- 
stances he  must  either  defer  his  operation  until  they  appear,  which  may 
be  at  a  most  unsuitable  time,  or  operate  without  pains.  The  latter 
alternative  is  the  better  one.  Dr.  Kelly  says  that  he  has  met  with  no 
such  accident  as  the  failure  of  the  uterus  to  contract  and  haemorrhage 
as  the  result  of  operating  without  waiting  for  the  pains  to  come  on 
{loc.  supra  cit.t  vol.  ii.  p.  417). 

Operation. — The  patient  is  prepared  as  for  ovariotomy,  attention 
being  paid  to  the  diet,  the  regulation  of  the  bowels  and  the  points 
previously  mentioned.  The  abdomen  is  thoroughly  cleansed,  and  the 
vagina  douched  with  1-1000  sublimate  solution  or  other  antiseptic. 
There  should  be  two  assistants  in  addition  to  the  anaesthetist,  one  to 
stand  opposite  the  surgeon  and  assist  in  the  various  manipulations,  the 
other  to  hand  instruments,  whilst  someone,  in  addition,  should  be 
present  who  is  competent  to  attend  to  the  child  when  delivered. 

Abdominal  Incision. — The  incision  through  the  abdominal  wall 
should  be  six  inches  long,  of  which  about  a  third  will  be  above  the 
umbilicus,  whilst  the  lower  end  should  not  be  nearer  than  two  or 
three  inches  to  the  pubes.  The  incision  is  made  deliberately  in  the 
median  line,  as  already  described  in  the  operation  for  ovariotomy,  all 
bleeding  points  being  carefully  arrested.  The  peritonaeum,  being 
reached,  is  picked  up  and  opened,  and  then  divided  on  the  fingers  for 
the  full  length  of  the  skin  incision.  In  dividing  this  structure  down- 
wards towards  the  pubes,  the  fingers,  used  as  directors,  will  serve  to 
detect  the  bladder  if  this  is  much  drawn  up — a  complication  most  likely 
to  be  found  when  labour  has  been  protracted.  It  has  been  the  custom 
to  employ  the  rubber  tube  introduced  by  Miiller  to  control  haemorrhage 
from  the  uterus  during  the  operation.  This  tube,  which  is  about  a  yard 
long,  is  passed  over  the  fundus  of  the  uterus  and  adjusted  round  its 
lower  segment.  By  its  employment  the  loss  of  blood  during  the  opera- 
tion is  very  slight,  and  the  surgeon  may  be  as  deliberate  as  he  pleases. 
If  applied  for  too  long  it  has  the  grave  disadvantage  of  producing 
uterine  inertia  and  haemorrhage  from  interference  with  the  blood-supply 
to  the  muscle.  When  competent  assistance  is  at  hand,  the  operator 
will,  therefore,  do  well  to  discard  it,  and  trust,  if  haemorrhage  is  severe, 
to  compression  by  the  assistant's  hands  of  the  broad  ligaments  against 
the  lower  uterine  segment.  If  good  assistance  is  not  obtainable,  it  may 
be  thrown  round  the  uterus  as  a  precautionary  measure,  to  be  employed 
if  necessity  arises.  The  next  step  is  the  opening  of  the  uterus,  and  this 
and  the  following  stages  in  the  operation  should  be  performed  as 
rapidly  as  possible. 

Incision  of  Uterus. — The  assistant  should,  as  recommended  by  Mr. 
Herman,  place  a  hand  on  each  side  of  the  abdominal  wall,  and  press  it 
downwards  and  backwards,  so  as  to  make  the  wound  gape  and  prevent 
fluid  entering  the  peritonaeal  cavity.  The  surgeon  cuts  through  the 
uterine  wall  at  one  spot  till  the  membranes  are  reached,  and  then 
rapidly  enlarges  the  incision  up  and  down  till  it  is  nearly  the  length  of 
the  abdominal  incision,  that  is,  nearly  six  inches  long.  If  the  placenta 
is  beneath  the  incision  it  is  usually  recommended  that  it  be  cut  through. 
Dr.  Kelly  thinks  this  a  mistake,  and  recommends  that  the  nearest 

55—2 


868  OPERATIONS   ON    TIIK    AUDOMKN. 

border  be  sought  for  and  tbe  membranes  opened  there.  Haemorrhage 
is  usually  moderate,  unless  the  placenta  is  attached  to  tbe  anterior 
wall.  I  f  from  this  cause  tbe  bleeding  is  alarming,  it  sbould  be  controlled 
by  an  assistant  grasping  the  lower  part  of  the  uterus  and  compressing 
the  broad  ligaments,  or  by  tightening  the  elastic  ligature  if  this  has 
been  previously  applied. 

Extraction  of  Child. — The  uterus  having  been  opened,  the  surgeon 
introduces  a  hand  and  seizes  a  knee  or  foot  and  delivers  the  child.  It 
has  been  recommended,  on  account  of  occasional  trouble  in  the  extraction 
of  the  after-coming  head,  that  this  should  be  delivered  first.  It  is  not, 
however,  easy  to  grasp,  and  will  probably  require  both  hands,  which 
take  up  more  room  than  is  convenient  in  the  uterine  wound.  Difficulty 
in  extraction  of  the  head  is  generally  due  to  too  small  an  incision  in 
the  uterine  wall.  The  child  having  been  delivered,  the  funis  is  tied 
and  divided,  or  time  may  be  saved  by  clamping  it  temporarily  and 
tying  the  foetal  end  after  division.  After  the  removal  of  the  child,  the 
uterus,  being  sufficiently  diminished  in  size,  is  brought  out  through  the 
abdominal  wound,  and  a  large  flat  sponge  or  gauze  swab  placed  behind  it. 
If  the  elastic  ligature  is  employed,  it  may  now  be  tightened  up,  but,  on 
account  of  the  objections  given  above,  its  use  is  not  recommended  under 
ordinary  circumstances,  compression  b}'  the  assistant's  hands  being 
employed  instead.  The  placenta  and  membranes  are  then  carefully 
peeled  off  the  uterine  wall  and  removed,  and  the  interior  of  the  uterus 
mopped  over  with  i-iooo  sublimate  solution.  If  the  uterus  does  not 
contract  readily,  it  should  be  stimulated  to  do  so  by  compression. 

Uterine  Sutures. — Both  silk  and  catgut  sutures  are  employed  for 
this  purpose.  Though  catgut  has  been  largely  used,  one  or  two  cases 
have  been  recorded  where  ligatures  of  this  material  have  given  way,  an 
accident  I  have  seen  happen.  On  the  other  hand,  silk  ligatures  may 
become  infected  and  lead  to  sinuses.  On  the  whole,  stout  catgut  that 
will  not  become  absorbed  too  soon  appears  to  be  the  best  material. 
About  ten  deep  sutures  should  be  inserted  half  an  inch  or  rather  more 
apart.  They  are  introduced  half  an  inch  from  the  edge  of  the  wound 
on  a  half-curved  or  fully-curved  needle,  and  are  brought  out  on  the  cut 
surface  close  to,  but  not  including,  the  decidual  surface  of  the  uterus. 
These  are  tied  tightly,  and  if  bleeding  is  free  it  is  a  good  plan  to 
secure  some  of  the  ligatures  before  they  are  all  introduced.  Superficial 
gut  sutures  are  then  employed  to  bring  into  apposition  the  cut  edges 
of  the  peritonaeum. 

Sterilisation  of  Patient. — To  within  the  last  few  years  the  usual 
practice  was  to  sterilise  patients  when  the  condition  requiring 
Caesarian  section  was  one  which  could  not  be  remedied.  At  the 
present  time  many  surgeons  are  opposed  to  this  practice.  On  ethical 
grounds  it  has  been  held  that  the  responsibility  for  future  pregnancies 
does  not  rest  with  the  doctor,  and  in  Dr.  Herbert  Spencer's  words 
"  that  it  was  his  duty  to  deliver  the  woman  and  restore  her  as  nearly 
as  possible  to  a  natural  condition,  a  result  obtained  by  the  conservative 
operation  without  sterilisation  "  (Obstet.  Trans.,  1904,  vol.  xlvi.  p.  334). 
One  strong  point  against  sterilisation  is  that  the  child  may  die,  and 
that  the  mother's  chances  of  further  pregnancy  have  been  destroyed. 
On  tbe  other  hand,  the  mortality  of  the  operation  is  about  8  per  cent., 
that    for    second    operations   being   about  the    same    as   that   for    the 


POHRCS    OPERATION.  869 

first.  Consequentl}-  in  repeated  operations  the  patient  runs  a  con- 
siderable risk.  There  is  further  the  danger  of  rupture  of  the  uterus,  and 
that  this  is  a  real  one  is  shown  by  the  number  of  cases  reported  of  this 
accident.  If  sterilisation  is  decided  upon  it  is  performed  as  follows  : — 
The  tube  being  picked  up,  a  double  ligature,  threaded  on  a  pedicle 
needle,  is  passed  through  the  broad  ligament  a  sufficient  distance  below 
it.  The  loop  having  been  divided,  the  two  strands  are  interlocked,  and 
one  is  tied  round  the  tube  close  to  its  uterine  end,  whilst  the  other  is 
tied  round  the  free  edge  of  the  broad  ligament  beyond  the  fimbriated 
extremity.  The  ovary  should  not  be  included  in  the  ligature,  which 
should  be  carried  between  it  and  the  Fallopian  tube.  The  tube  is  then 
cut  away  between  the  two  ligatures. 

The  subsequent  stages  of  the  operation  and  the  after-treatment  are 
similar  to  those  described  in  the  operation  of  ovariotomy. 

PORRO'S  OPERATION. 

Porro's  modification  of  Caesarian  section  consists  in  supra-vaginal 
amputation  of  the  uterus  and  fixation  of  the  stump  in  the  lower  angle 
of  the  wound.  But  under  this  heading  are  now  included  partial 
hysterectomy  with  intra-peritonseal  treatment  of  the  stump  and  total 
hysterectomy. 

The  simplest  method,  andthe  one  best  adapted  for  those  inexperienced 
in  abdominal  surgery,  is  the  operation  devised  by  Porro.  It  has  received 
various  modifications,  and  that  described  by  Mr.  Herman  (Difficult 
Labour)  after  the  method  of  the  late  Mr.  Lawson  Tait,  may  be  regarded 
as  the  best  on  account  of  the  simplicity  of  its  details  and  the  few 
instruments  required. 

The  abdomen  having  been  opened,  as  described  in  Caesarian  section, 
a  rubber  tube,  two  feet  long,  is  slipped  over  the  fundus  and  adjusted 
round  the  lower  part  of  the  uterus.  The  ends  of  the  tube  are  tied  in  a 
single  hitch,  and  prevented  from  slipping  by  being  grasped  in  a  pair 
of  forceps.  The  uterus  is  then  opened  at  one  point,  and  the  incision 
enlarged  by  tearing  with  the  fingers.  The  child  is  then  extracted. 
The  uterus  is  now  brought  out  of  the  abdomen,  the  ligature  tightened 
if  necessary  and  tied  a  second  time.  Two  knitting  needles  are  passed 
from  side  to  side  through  the  flattened  rubber  tube  and  the  cervix,  and 
the  uterus  cut  off  about  three-quarters  of  an  inch  above  the  needles. 
The  abdominal  wound  is  sewn  up  with  interrupted  silkworm  gut 
sutures  about  two-thirds  of  an  inch  apart,  the  lowest  stitch  being  passed 
through  the  stump  below  the  elastic  ligature,  as  well  as  through  the 
abdominal  wall.  The  stump  is  dressed  with  iodoform  and  tannic  acid 
powder,  and  covered  with  a  layer  of  dry  dressing. 

This  operation  carries  with  it  the  risks  and  disadvantages  already 
mentioned  in  the  section  on  hysterectomy,  and  the  expert  operator  will 
prefer,  after  removing  the  uterus,  to  treat  the  stump  by  the  intra- 
peritonseal  method.  The  details  of  this  operation  are  similar  to  those 
mentioned  above  in  the  removal  of  the  uterus  for  fibroids. 

Indications  for  the  operation  are  as  follows  : — 

1.  Failure  of  the  uterus  to  contract  after  removal  of  the  child. 

2.  Injuries  to  the  uterus  sustained  in  efforts  to  deliver  through  the 
pelvis,  such  as  rupture. 


870  OPERATIONS   ON   THE   ABDOMEN. 

3.  The  fact  that  the  operator  is  inexperienced.  In  this  case  he 
should  adopt  the  method  of  amputation  with  fixation  of  the  stump 
in  the  abdominal  wound,  as  described  above. 

Removal  of  the  uterus  may  be  indicated  in  the  radical  treatment  of 
the  condition  giving  rise  to  the  obstruction.  This  gives  such  further 
indications  as  follows  : — 

4.  "When  the  uterus  contains  myomatous  tumours  which  block  the 
pelvis,  or  which  cannot  safely  be  removed  by  myomectomy  (Kelly). 

5.  When  there  are  bilateral  ovarian  tumours,  and  no  sound  part  of 
an  ovary  can  be  found  and  left  (Kelly). 

6.  When  the  patient  is  suffering  from  osteo-malacia  (Herman).  The 
removal  of  the  ovaries  has  been  found  to  have  a  curative  effect  on  this 
disease.  In  the  two  latter  conditions  the  uterus  is  removed,  as  it  is  no 
longer  of  use  to  the  patient  after  the  ovaries  have  been  taken  away. 

7.  When  there  is  cancer  of  the  cervix  (Kelly).  If  this  condition  is 
found  to  exist,  and  hysterectomy  is  decided  on,  the  whole  uterus  must 
be  removed. 

ECTOPIC   GESTATION. 

From  the  point  of  view  of  treatment  cases  of  extra-uterine  gestation 
are  best  considered  under  three  headings  :  (1)  Before  rupture  has  taken 
place;  (2)  at  the  time  of  rupture  ;  (3)  after  rupture. 

1.  Cases  in  which,  the  Tube  is  Unruptured. 

As  rupture  of  the  tube  almost  invariably  occurs  before  the  tenth 
week,  this  class  may  be  held  to  include  cases  of  extra-uterine  gestation 
up  to  two  and  a-half  months.  If  there  is  any  suspicion  that  a 
tubal  pregnancy  exists,  the  patient  should  submit  to  operation  at 
once.  Dela}T  means  the  risk  of  rupture  and  severe  or  fatal  haemor- 
rhage. The  operation  is  practically  identical  with  that  described  for 
removal  of  the  appendages.  Adhesions  are  recent,  and  do  not  give 
rise  to  much  trouble.  Care  must  be  taken  not  to  rupture  the  sac  in  the 
separation  of  adhesions  or  in  drawing  it  up  into  the  wound  for  the 
purpose  of  ligaturing  the  broad  ligament.  Should  severe  haemorrhage 
from  this  cause  occur,  it  should  be  controlled  by  quickly  applying  the 
ligatures  to  the  pedicle,  or  by  controlling  the  blood -supply  at  the  uterine 
cornu  and  the  brim  of  the  pelvis. 

2.  At  the  time  of  Rupture. 

The  condition  most  often  calling  for  operative  measures  is  the  result 
of  rupture  of  the  tube,  or  abortion.  Rupture  may  take  place  either 
into  the  peritonaeal  cavity  or  between  the  layers  of  the  broad  ligament. 
It  more  often  happens,  however,  that  haemorrhage  from  the  tube  is 
preceded  by  the  formation  of  a  mole,  which  the  tube  attempts  to  expel, 
though  generally  without  success,  from  the  abdominal  ostium.  This 
event  is  known  as  tubal  abortion.  Though  likely  to  be  continuous 
or  frequently  repeated,  the  bleeding  is  much  more  moderate  in  amount 
as  a  rule  than  that  following  a  rupture,  which  is  often  profuse  and 
attended  with  grave  danger  to  life. 

Should  an  operation  be  performed  in  all  cases  in  which  this  accident 
is  diagnosed  ?  We  know  that  many  cases  get  well  if  left  alone,  though 
what  proportion  they  bear  to  those  requiring  operation  we  cannot  at 
present  say.  A  patient  occasionally  dies  of  haemorrhage  before  assist- 
ance can  be  obtained,  whilst  in  many  instances,  on  the  other  hand,  the 


ECTOPIC   GESTATION.  871 

initial  symptoms  are  so  slight  that  the  patient  pays  but  little  attention 
to  them,  and  it  is  only  on  account  of  a  persistence  or  a  recurrence  of 
pain  that  a  surgeon  is  called  in,  perhaps  weeks  after  the  onset.  When 
the  symptoms  are  so  grave  that  life  is  threatened,  there  can  be  no  doubt 
as  to  the  advisability  of  immediate  operation.  But  if  the  patient  is 
recovering  when  first  seen,  and  the  collapse  and  signs  of  haemorrhage 
are  not  severe,  the  indications  are  less  clear.  There  is  no  doubt  that 
in  many  cases  no  ill  results  will  follow  from  delay  for  a  time.  But 
though  the  initial  bleeding  is  slight,  it  may  recur  later  with  greater 
severity,  and  the  danger  of  temporising  in  any  recent  case  should  con- 
sequently be  fully  recognised.  In  addition  to  the  risk  of  recurrent 
haemorrhage  which  may  prove  fatal,  there  are  other  points  to  be 
borne  in  mind.  The  foetus  may  have  survived  the  initial  accident, 
and  an  operation  performed  later  in  pregnancy,  on  this  account,  will 
be  attended  with  greatly  increased  risk.  Bleeding  may  continue  or 
recur  until  a  large  mass  is  formed  sufficient  to  press  on  the  bowel  and 
cause  symptoms  of  obstruction.  Or  the  haematocele  resulting  may  tail 
to  absorb  or  may  suppurate.  I  have  seen  a  round  solid  clot,  the  size 
of  a  cricket  ball,  lying  loose  in  the  pelvis  a  year  after  bleeding  had 
occurred.  Even  if  absorption  does  take  place,  it  will  be  followed 
probably  by  occlusion  of  the  tubes  and  the  formation  of  adhesions. 
When  rupture  or  abortion  has  occurred  recently,  operation  is  easy. 
There  are  no  adhesions  or  such  only  as  can  be  dealt  with  readily. 
On  these  grounds  it  would  appear  to  be  safer  to  operate  in  all  cases 
in  which  a  recent  rupture  or  abortion  has  been  diagnosed,  abdominal 
section  being  performed  and  the  tube  removed.  Putting  on  one 
side  those  cases  in  which  an  operation  is  immediately  demanded 
on  account  of  profuse  haemorrhage,  the  mortality  of  the  operation 
is  very  small.  Convalescence  after  removal  of  the  tube  and  blood-clot 
is,  moreover,  much  shorter  than  in  those  cases  where  we  wait  for  the 
absorption  of  the  haematocele.  If  a  diagnosis  of  rupture  into  a  broad 
ligament  can  be  made,  it  is  perfectly  justifiable  to  wait  awhile,  as  the 
haemorrhage  will,  in  all  probability,  soon  cease,  and  the  haematocele  can, 
if  necessity  arises,  be  dealt  with  later  by  drainage. 

The  Operation. — An  incision,  four  to  five  inches  long,  is  made  in  the 
median  line  and  carried  well  down  to  the  pubes.  If  the  case  is  a 
severe  one,  blood  may  at  once  escape  from  the  abdomen  when  the 
peritonaeum  is  opened.  This  is  mopped  and  scooped  out  as  rapidly  as 
possible,  and  if  it  appears  that  haemorrhage  is  continuing,  no  attempt 
should  be  made  to  cleanse  the  peritonaeal  sac,  but  the  bleeding  con- 
trolled at  once.  This  is  done  by  identifying  the  fundus  and  tracing  the 
affected  tube  outwards  from  this.  The  sac  is  drawn  up  towards  the 
wound,  and  a  pair  of  Spencer  Wells's  forceps  are  applied  to  the  uterine 
end  of  the  tube,  so  as  to  include  in  its  grasp  the  terminal  branches  of 
the  uterine  artery,  and  a  second  pair  to  the  broad  ligament  at  the  brim 
of  the  pelvis  to  secure  the  ovarian  artery.  The  abdomen  can  then  be 
cleansed  by  means  of  sponges  or  by  washing  out  with  warm  water,  and 
the  parts  inspected.  The  tube  is  then  brought  up  into  the  wound  and 
ligatures  applied,  as  described  in  the  section  on  the  removal  of  the 
appendages. 

3.  After  rupture  of  Sac. 

Under  this  heading  may  be  included  those  cases  which  are  seen  some 


872  OPERATIONS  ON  THE  ABDOMEN. 

time  after  rupture  or  abortion  Las  occurred.  Treatment  then  resolves 
itself  into  dealing  with  a  collection  of  hlood  in  the  pelvis,  either  shut  off 
by  adhesions  and  matted  viscera  from  the  general  peritonseal  cavity,  or 
Lying  between  the  layers  of  the  broad  ligament. 

[f  on  account  of  recurrent  attacks  of  pain  and  marked  anaemia  there 
is  reason  to  suspect  repeated  haemorrhages,  abdominal  section  should 
be  performed  and  the  tube  removed.  This  will  differ  from  the  opera- 
tion undertaken  at  the  time  of  rupture  in  that  the  tube  and  blood-clot 
will  be  found  enclosed  by  adhesions  and  matted  bowel  and  omentum. 
These  latter  must  be  carefully  separated  until  the  sac  and  surrounding 
blood-clot  are  brought  into  view.  The  tube  is  then  dealt  with  as 
previously  described.  If  some  time  has  elapsed  since  the  accident  and 
the  hematocele,  more  especially  if  it  is  a  small  one,  shows  signs  of 
undergoing  absorption,  the  case  may  be  treated  by  rest,  in  the  hope 
that  the  swelling  will  subside. 

If  there  are  no  signs  of  fresh  bleeding,  and  the  hematocele,  which 
is  bulging  down  Douglas's  pouch,  shows  little  tendency  to  diminish  in 
size  as  the  result  of  rest,  it  should  be  treated  by  drainage  through  the 
vagina.  This  operation  should  not  be  performed  within  the  first  two 
weeks  following  the  rupture,  or  when  evidence  exists  that  bleeding  is 
continuing.  Violent  haemorrhage  may  be  set  up  on  opening  the  sac, 
and  a  fatal  result  has  been  known  to  follow.  It  would  be  better'  under 
these  circumstances  to  open  the  abdomen,  clear  out  the  blood  clot  and 
remove  the  tube.  When  rupture  has  taken  place  into  the  broad  liga- 
ment, Dr.  Kelly  (loc.  supra  cit.,  vol.  ii.  p.  456)  considers  that  the 
proper  treatment  is  to  evacuate  and  drain  the  sac  extra-peritoneaUy, 
either  by  the  vagina  or  above  Poupart's  ligament.  It  should  be  opened 
in  the  latter  situation  when  "  the  sac  elevates  the  peritonaeum  of  the 
anterior  abdominal  wall,  so  as  to  be  easily  accessible  from  the  front."  In 
most  cases,  however,  blood  poured  out  in  this  situation  is  moderate  in 
amount  and  undergoes  absorption.  Unless,  therefore,  the  swelling  is 
a  large  one  or  it  is  undergoing  suppuration,  a  rare  accident,  it  may  be 
left  alone. 

If  the  foetus  survives  the  patient  runs  the  risk  of  a  secondary  rupture, 
and  as  pregnancy  advances  operation  is  attended  with  increasing 
danger.  It  is  said  by  Pinard  to  be  no  greater  at  full  time  than  it  is 
during  and  after  the  fifth  month.  During  the  first  four  months  of 
gestation  there  is  no  doubt  about  the  advisability  of  immediate  opera- 
tion, and  the  removal  of  sac,  foetus  and  placenta  may  be  attempted. 
After  this  time  the  increase  in  size  of  the  placenta  calls  for  a  different 
line  of  treatment.  The  best  time  to  operate  is  not  yet  agreed  upon, 
but  a  strong  point  in  favour  of  interference  as  soon  as  the  condition  is 
recognised  is  the  risk  of  secondary  rupture.  Operations  undertaken 
after  the  death  of  the  foetus  at  full  term  are  attended  by  less  danger  of 
hemorrhage,  owing  to  the  shrinkage  of  the  placental  vessels.  In  any 
case  that  is  diagnosed  towards  the  end  of  pregnancy  it  would,  in  con- 
sequence, be  sound  treatment  to  defer  the  operation  for  some  weeks 
after  full  term.  Though  the  risk  of  death  from  hemorrhage  is  thereby 
greatly  diminished,  this  delay  is  attended  by  the  possibility  of  putre- 
factive changes  taking  place  in  the  placenta.  As  the  child  will  most 
probably  be  weakly  and  is  often  malformed,  any  measures  undertaken 
should  be  in  the  interest  of  the  mother  rather  than  of  the  child.     The 


ECTOPIC   GESTATION.  873 

question  of  operating  at  full  term  for  the  sake  of  saving  the  child  is 
consequently  not  one  that  should  carry  much  weight. 

An  incision  should  be  made  in  the  median  line,  and  low  down  to 
begin  with  between  the  symphysis  and  umbilicus  to  avoid  the  possibility 
of  injury  to  a  placenta  seated  in  the  upper  part  of  the  sac  (Jellett,  Manual 
of  Midwifery,  1905,  p.  672).  The  difficulties  of  removal  of  the  sac 
are  so  great  and  so  fraught  with  danger,  that  the  safest  plan  of  dealing 
with  it  is  to  suture  its  edges  to  the  abdominal  incision.  Where  possible 
the  peritonfflal  cavity  should  not  be  opened.  The  greatest  difficulty 
that  the  surgeon  has  to  contend  with  is  the  placenta.  If  some  weeks 
have  elapsed  since  full  term  it  can  be  removed  as  a  rule  without 
difficulty.  It  can  also  be  detached  in  some  cases  in  which  it  is  situated 
in  the  upper  part  of  the  sac.  If  attached  below  the  foetus,  the  best 
plan  is  to  tie  the  cord  close  to  the  placenta  without  disturbing  the 
latter,  and  to  pack  the  cavity  with  iodoform  gauze.  At  the  end  of  a  fort- 
night to  three  weeks  an  attempt  is  made  to  remove  the  placenta,  the 
packing  of  the  sac  being  continued  till  it  is  obliterated.  The  great  risk 
of  this  procedure  is  septic  infection  before  the  placenta  can  be  removed. 
Another  plan  is  to  close  the  abdominal  wound  leaving  the  placenta  in 
situ,  trusting  to  atrophy  and  absorption  of  the  latter  taking  place. 
Owing  to  the  close  proximity  of  the  bowel,  infection  is  a  not  unlikely 
contingent,  and  the  wound  may  have  to  be  re-opened  on  account  of 
suppuration. 


CHAPTER    XIX. 
SACROILIAC    DISEASE. 

ARTHRECTOMY. 

It  has  been  shown  that  the  prognosis  in  this  disease,  usually  looked 
upon  as  so  grave,  is  much  better  if  the  same  radical  methods  of  treat- 
ment, which  have  proved  so  satisfactory  in  other  joints,  are  applied  to 
the  sacro-iliac  synchondrosis. 

Mr.  Collier  first  drew  attention  to  the  above  fact  with  a  case  success- 
fully treated  by  trephining  (Lancet,  1889,  vol.  ii.  p.  787),  and  Mr. 
Makins  and  Mr.  Golding  Bird  followed,  each  surgeon  publishing  three 
successful  cases  (Clin.  Soc.  Trans.,  vol.  xxvi.  p.  127,  and  vol.  xxviii. 
p.  186).     The  following  points  are  taken  from  these  papers  : 

Operation. — The  joint  is  exposed  by  a  crucial  incision  (Makins),  or 
by  a  flap  (Collier,  Golding  Bird).  In  the  words  of  the  last-named 
surgeon,  "  a  semicircular  flap  of  skin  and  subcutaneous  tissue  over  the 
iliac  area  of  the  joint,  and  having  its  convexity  corresponding  to  the 
posterior  edge  of  the  ilium,  is  dissected  upwards  and  forwards,  and  the 
underlying  glutsei  are  detached.  The  bone  being  thus  freely  exposed, 
a  large  trephine  is  applied  at  the  root  of  the  posterior  inferior  iliac 
spine,  and  in  a  line  drawn  from  the  top  of  that  spine  to  the  junction  of 
the  anterior  with  the  middle  third  of  the  iliac  crest.  .  .  .  The  ilium 
at  the  seat  of  operation  is  very  thick,  but  the  disc  of  bone  removed 
should  reach  quite  down  to  the  joint."  The  trephine-opening  is  then 
sufficiently  enlarged,  the  articular  surfaces  cut  away  with  a  gouge  or 
forceps  sufficiently  to  enable  the  surgeon  to  explore  the  pelvic  surface 
of  the  joint,  and  to  liberate  any  pus  lying  on  this  aspect.  The  sharp 
spoon,  or  Barker's  flushing  gouge,  is  then  thoroughly  used,  all 
fragments  of  bone,  granulation  tissue,  or  loosened  cartilage  removed, 
and  any  sinuses  present  laid  open.  Sterilised  iodoform  having  been 
next  applied,  the  soft  parts  are  lightly  drawn  together  with  a  few 
sutures.  A  long  outside,  or  a  Thomas's  hip-splint,  should  be  used  at 
first,  but  subsequently  all  that  is  needed  is  a  well-fitting  pelvic  belt, 
as  advised  by  Mr.  Hilton. 


PAET  V. 
OPERATIONS  ON  THE  LOWER  EXTREMITY. 


CHAPTER    I. 
OPERATIONS    ON   THE   HIP  JOINT. 

AMPUTATION    AT     THE     HIP-JOINT.       EXCISION     OF     THE 

HIP-JOINT.         OPERATIVE    TREATMENT    OF    HIP-DISEASE. 

INCISION     OF    THE    JOINT. 

AMPUTATION    AT    THE    HIP- JOINT    (Figs.  360-369). 

The  numerous  methods  which  have  been  described  are  easilv  simpli- 
fied. The  indications  for  this  operation  are  tuberculous  disease,  and, 
occasionally,  osteo-myelitis,  growths,  and  injury.  For  tuberculous  and 
other  infective  disease  the  method  of  Furneaux  Jordan,  performed  in 
two  stages  as  advised  by  Sir  H.  Howse,  for  growths  or  injury  either 
the  methods  of  Wyeth  or  Lynn  Thomas,  or,  where  these  are  not  available, 
some  modification  of  lateral  skin-flaps,  and  division  of  the  muscles 
high  up  should  be  adopted.  While  a  few  others  will  be  described, 
the   above  will   suffice  for  all  practical  purposes. 

Methods. — I.  Furneaux  Jordan's,  performed  in  two  stages 
(Sir  H.  Howse).  II.  Lateral  Flaps.  III.  Modified  Lateral — viz., 
Antero-internal  and  Postero-external — Flaps.  IV.  Antero-posterior 
Flaps. 

Methods  of  Controlling  Haemorrhage  during  Amputation  at  the 
Hip-Joint. 

1.  Elastic  Compression  by  Jordan  Lloyd's  Method  (Fig.  363). — This 
may  be  applied  at  the  junction  of  the  limb  and  trunk,  without  inter- 
fering with  the  operator,  by  the  following  method  :  While  the  patient 
is  passing  under  the  anaesthetic,  the  limb  is  emptied  of  blood  by  eleva- 
tion and  application  of  Esmarch's  bandages  as  far  upas  the  tissues  are 
healthy  ;  the  patient  is  then  rolled  over  on  to  his  sound  side,  and  a 
piece  of  rubber  bandage  about  two  yards  long,  and  stout  enough  to 
require  decided  exertion  to  stretch  it  fully,  is  doubled  and  passed 
between  the  thigh  and  trunk,  its  centre  lying  between  the  anus  and 
tuber  ischii  over  a  narrow  pad  of  gauze.  A  sterilised  white  roller 
bandage,  of  appropriate  size,  is  then  laid  over  the  termination  of 
the  external  iliac  artery.      The  ends   of  the  rubber  bandage  are  now 


876  OPERATIONS   ON   THE   LOWER   EXTREMITY. 

to  be  firmly  and  steadily  drawn  in  a  direction  upwards  and  outwards, 
one  in  front  of  the  groin  and  one  over  the  buttock,  to  a  point  above  the 
centre  of  the  iliac  crest,  sufficient  tightness  being  employed  to  stop  all 
pulsation  in  the  femorals  or  tibials.  The  front  part  of  the  band 
passing  over  tbe  white  bandage  occludes  the  external  iliac  and  runs 
parallel  to  and  above  Poupart's  ligament.  The  posterior  part  runs 
across  the  great  sacro-sciatic  notch  and  controls  the  branches  of  the 
internal  iliac.  If  the  surgeon  is  short-handed,  instead  of  tbe  cords 
being  held  by  an  assistant,  they  may,  by  means  of  tapes  strongly  stitched 
to  them,  be  thus  secured  :  having  been  drawn  with  full  tightness  up 
to  the  centre  of  the  iliac  crest,  they  may  be  crossed  over  to  the 
opposite  side  and  tied  firmly  (over  lint)  midway  between  the  crest  and 
the  top  of  the  great  trochanter.  If  a  strong  and  trusty  assistant  is 
forthcoming,  it  will  be  better  to  leave  the  bandage  in  his  hands,  but  in 
the  case  of  an  adult  whose  tissues  are  not  wasted,  and  on  a  hot  day, 
the  exertion  is  not  a  slight  one.* 

Whether  the  bandage  be  held  or  tied,  especial  care  must  be  taken 
that  it  does  not  slip  from  oft' the  external  iliac  nor  over  the  tuber  ischii. 
It  is  a  good  plan  to  pass  the  ends  of  the  india-rubber  band  over  a  slip 
of  wood,  so  as  to  diminish  the  prolonged  pressure  on  the  hands.  To 
prevent  the  bands  slipping  down  in  the  way  of  the  surgeon,  two  loops 
of  tape  or  bandage  may  be  thus  employed  :  each,  about  two  feet  in 
length,  is  placed  longitudinally,  before  the  elastic  band  is  applied,  the 
one  over  the  groin,  the  other  well  behind  the  great  trochanter,  the 
centre  of  each  being  where  the  elastic  band  will  go.  When  the  band 
has  been  applied,  these  form  loops  by  means  of  which  the  band  is  kept 
well  out  of  the  operator's  way,  both  at  Poupart's  ligament  and  behind 
the  great  trochanter  (Jordan  Lloyd,  Lancet,  1883,  vol.  i.  p.  897). 

2.  Wyeth's  Bloodless  Method  of  Amputation  at  the  Hip-Joint. — I  have 
mentioned  this  in  the  account  of  amputation  at  the  shoulder-joint  at 
p.  181,  Vol.  I.  It  has  been  largely  used  by  American  surgeons,  and 
has  given  excellent  results.  Amongst  these  Dr.  Hancock,  of  Georgia, 
records  {Ann.  of  Surg.,  July  1906,  p.  98)  a  successful  amputation  at 
the  hip-joint,  and  one  at  the  shoulder  and  hip-joints,  for  railway 
accidents.  Primary  shock  was  absent  in  each  case  to  a  very  unusual 
degree.  The  pins  must  be  passed  with  exactness,  and,  unless  of  suffi- 
cient strength,  will  certainly  bend  under  the  strain  of  the  cord  above. 
Their  use  is  thus  described  {Ann.  of  Sun).,  1897,  vol.  i.  p.  132) :  "  The 
limb  to  be  amputated  should  be  emptied  of  blood  by  elevation  of  the 
foot,  and  by  the  application  of  the  Esmarch  bandage,  commencing  at 
the  toes.  Under  certain  conditions,  the  bandage  can  be  only  partially 
applied.  AVhen  a  growth  exists,  or  when  septic  infiltration  is  present, 
pressure  should  be  exercised  only  to  within  five  inches  of  the  diseased 
portion,  for  fear  of  driving  diseased  material  into  the  vessels.  After 
injuries  with  great  destruction,  crushing  or  pulpefaction,  one  must 
generally  trust  to  elevation,  as  the  Esmarch  bandage  cannot  always  be 

*  As  will  be  seen  from  the  description  of  the  operation  below,  this  exertion  is  only 
required  during  shelling  out  of  the  femur,  a  step  often  simplified  by  a  previous  excision. 
During  the  circular  amputation  in  the  lower  third  of  the  thigh,  and  the  securing  the  large 
vessels  here,  there  is  abundant  room  to  control  these  at  first  by  an  Esmarch's  bandage 
applied  over  sterile  gauze.     The  parts  should  be  resterilised. 


OPERATIONS   ON    THE   HIP-JOINT. 


877 


applied.  While  the  member  is  elevated,  and  before  the  Esmarch 
bandage  is  removed,  the  rubber-tubing  constrictor  is  applied.  The 
object  of  this  constriction  is  the  occlusion  of  every  vessel  above  the 
level  of  the  hip-joint,  permitting  the  disarticulation  to  be  completed, 
and  the  vessels  secured  without  haemorrhage  and  before  the  tourniquet 
is  removed.  To  prevent  any  possibility  of  the  tourniquet  slipping,  I 
employ  two  large  steel  needles  or  skewers,  three-sixteenths  of  an  inch 
in  diameter  and  ten  inches  long,  one  of  which  is  introduced  one-fourth 
of  an  inch  below  the  anterior  superior  spine  of  the  ilium  and  slightly 
to  the  inner  side  of  this  prominence,  and  is  made  to  traverse  super- 
ficially for  about  three  inches  the  muscles  and  fascia  on  the  outer 
side  of  the  hip,  emerging  on  a  level  with  the  point  of  entrance  (Fig.  360). 
The  point  of  the  second  needle  is  thrust  through  the  skin  and  tendon 

Fig. 3G0. 


Wyeth's  bloodless  method  of  amputation  at  the  hip-joint. 

of  origin  of  the  adductor  longus  muscle  half  an  inch  below  the  crotch, 
the  point  emerging  an  inch  below  the  tuber  ischii.  The  points  should 
be  shielded  at  once  with  cork  to  prevent  injury  to  the  hands  of  the 
operator.  No  vessels  are  endangered  by  these  skewers.  A  mat  or 
compress  of  sterile  gauze,  about  two  inches  thick  and  four  inches 
square,  is  laid  over  the  femoral  artery  and  vein  as  they  cross  the  brim 
of  the 'pelvis;  over  this  a  piece  of  strong  white  rubber  tubing,  half 
an  inch  in  diameter  when  unstretched,  and  long  enough  when  in  position 
to  go  five  or  six  times  around  the  thigh,  is  now  wound  very  tightly 
around  and  above  the  fixation-needles  and  tied.  Except  the  small 
quantity  of  blood  between  the  limit  of  the  Esmarch  bandage  and  the 
constricting  tube,  the  extremity  is  bloodless  and  will  remain  so. " 

The  Esmarch's  bandage  is  now  removed  and  a  circular  incision  is 
made  six  inches  below  the  tourniquet  joined  by  a  longitudinal  incision 
commencing  at  the  tourniquet  and  passing  over  the  trochanter  major. 
A  cuff  including  the  subcutaneous  tissue  down  to  the  deep  fascia  is 


878 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


Fia.  361. 


dissected  off  to  the  level  of  the  trochanter  minor.  About  this  level  the 
remaining  soft  parts  are  divided  down  to  the  bone  with  a  circular  cut 
iind  are  rapidly  dissected  from  the  femur.  The  vessels  should  now  be 
searched  for  and  both  arteries  and  veins  securely  tied.  It  is  advisable 
to  tie  all  the  vessels  that  can  be  seen  at  this  stage,  i.e.,  before  disarti- 
culation, to  prevent  their  retraction.  The  muscular  attachments  are 
separated  so  that  the  capsular  ligament  may  be  exposed  and  divided. 
The  limb  beint;  used  as  a  lever,  the  thigh  is  forcibly  elevated,  abducted, 
and  adducted,  letting  in  air  and  rupturing  the  ligamentum  teres.* 
The  tourniquet  may  now  be  carefully  loosened 
and  all  bleeding  points  at  once  seized.  In  cases 
of  great  exhaustion  Dr.  Wyeth  would  do  the 
operation  in  two  stages,  securing  the  vessels, 
dividing  the  femur  below  the  lesser  trochanter, 
closing  the  wound  and  turning  out  the  head  of 
the  femur  about  two  weeks  later.  While  the  633 
cases  of  amputation  at  the  hip-joint  collected  by 
Ashurst  showed  a  mortality  of  64*1  per  cent.,  of 
69  cases  performed  in  this  manner  only  11  died 
— a  mortality  of  15*9. 

3.  Forceps-tourniquet  of  Lynn  Thomas  (Figs. 
361  and  362).+  An  account  of  this  instrument, 
with  its  advantages,  will  be  found  in  the  Lancet, 
April  23rd,  1898,  Brit.  Med.  Journ.,  April  20, 
1901,  and  Oct.  1,  1904.  Fig.  362  shows  the 
method  of  applying  the  forceps  in  disarticulation 
at  the  hip,  or  in  any  amputation  of  the  lower 
extremity.  A  small  skin  incision  is  made  in  the 
front  of  the  thigh,  one  to  three  inches  below  the 
anterior  superior  spine  according  to  the  size  of 
the  limb.  The  smooth  probe-pointed  blade  is 
pushed  forcibly  through  the  skin  incision  well 
down  towards  the  neck  of  the  femur,  and  in  a 
transverse  direction  towards  the  spine  of  the 
pubes,  the  serrated  blade  of  the  forceps  being 
outside,  and  when  the  tourniquet  is  driven  well 
beyond  the  line  of  the  common  femoral  vessels, 
it  is  clamped  like  an  ordinary  catch-forceps.  Mr. 
Griffiths,  of  Cardiff,  gives  the  following  additional 
details  as  to  the  employment  of  tins  instrument  in 
a  successful  case  of  amputation  at  the  hip-joint  for  a  periosteal  sarcoma 
{Brit.  Med.  Journ.,  Dec.  19,  1903,  p.  1583).  The  vertical  limb  of  a 
racket-shaped  incision  was  commenced  about  two  inches  above  the  great 
t lot  banter,  and  into  this  incision,  at  its  upper  part,  was  inserted  the 
smooth  blade  of  Lynn-Thomas's  tourniquet  forceps.  This  having  been 
pushed  on  in  the  direction  described  above,  and  the  forceps  clamped,  the 

*  Where  in  cases  of  disease,  the  femur  gives  way  high  up,  or  where  it  is  extensively 
crashed,  the  required  traction  and  leverage  will  be  afforded  by  tying  a  piece  of  sterile 
gauze  round  the  neck  (Hancock,  lor.  tupra  cit."),  if  no  appropriate  forceps  are  at  band. 

t  The  use  of  this  instrument  is  also  figured  under  the  account  of  Byrne's  amputation. 

I  The  most  recent  form  of  his  forceps-tourniquet,  and  the  method  of  carrying  it  in  field- 
service  are  figured  by  Mr.  Lynn  Thomas  (Brit.  Med.  Jbum.,  Oct.  i,  1904"). 


Lynn  Thomas's  forceps 
tourniquet.! 


OPERATIONS    ON    T1IK    H  IP-JOINT. 


87g 


vessels  in  the  anterior  flap  were  secured.  To  control  the  circulation  in 
the  posterior  Hap,  another  pair  of  forceps  were  used,  the  deep  blade 
passing  this  time  behind  the  neck  of  the  femur.  The  oval  part  of  the 
incision  was  next  marked  out,  and  the  skin  retracted  a  little  way  all 
round.  The  muscles  attached  to  the  great  trochanter  and  in  front  of 
the  hip-joint  were  now  divided,  the  joint  opened,  and  the  limb  disarticu- 
lated, the  only  spouting  vessel  seen  at  this  stage  being  a  tiny  artery  in 
the  capsule.  All  the  vessels  which  could  be  seen  were  next  picked  up 
and  tied,  and  then  the  value  of  the  tourniquet-forceps  was  demonstrated 
in  the  search  for  the  smaller  vessels,  which  were  found  by  loosening  the 
forceps  and  immediately  closing  them  when  a  bleeding  point  shewed 
the  position  of  a  vessel. 

Mr.  Lynn  Thomas  gives  the  following  additional  proofs  of  the  sim- 


Fig.  362. 


The  forceps-tourniquet  applied  for  amputation  of  the  hip-joint, 
superior  spine  of  ilium.     B,  Spine  of  pubes. 


A,  Anterior 


plicity  and  efficiency  of  his  instrument.  In  a  case  which  was  believed 
to  be  one  of  central  sarcoma  of  the  lower  end  of  the  femur,  he  had 
amputated  through  the  lower  third  of  the  thigh,  controlling  the 
haemorrhage  by  the  method  given  above.  As  after  the  ligature  of 
all  visible  blood  vessels  and  loosening  the  forceps,  unusually  free 
oozing  took  place  along  the  linea  aspera,  close  inspection  showed  that 
the  growth  had  extended  here.  The  forceps  were  reclamped  in  a 
second,  and  after  the  upper  limit  of  the  growth  had  been  defined,  the 
limb  was  amputated  in  the  upper  third  of  the  thigh.  Primary  union 
followed.  "  Though  the  tourniquet  compressed  the  common  femoral 
vessels  and  the  accompanying  nerves  for  fifty  minutes,  the  only  evidence 
of  vaso-motor  paresis  was  confined  absolutely  to  the  skin  under  the 
outer  blade  of  the  forceps-tourniquet." 

The  following  are  amongst  the  cases  in  which  the  forceps-tourniquet 
has  been  successfully  used  by  Mr.  Lynn  Thomas  (Brit.  Med.  Jourii., 
Oct.  1,  1904).     Three  amputations  through  the  hip-joint,  with  three 


88o  OPERATIONS   ON   THE   LOWER   EXTREMITY. 

recoveries;  three  interscapulo-thoracic  amputations  with  three  recoveries. 
The  application  of  the  instrument  in  this  operation  is  well  shown. 
(  hie  arterio-venons  aneurysm  in  Hunter's  canal,  which  recovered.  Here 
Mr.  Lynn  Thomas  used  two  pairs,  one  to  control  the  vessels  at  the 
upper  end  of  the  skin  incision,  and  the  other  at  the  lower  end.  "  In 
this  operation  I  made  the  skin  incision  down  to  the  fascia  lata,  but  not 
injuring  it,  as  it  formed  the  outer  barrier  to  the  traumatic  aneurysm  ; 
the  probe-shaped  blade  was  pushed  boldly  through  in  the  direction 
of  the  inner  aspect  of  the  femur,  and  driven  in  as  far  as  it  would  go,  and 
then  clamped  (the  flat  blade  being,  of  course,  outside  the  skin),  and 
the  other  forceps-tourniquet  was  applied  in  a  similar  manner  at  the 
lower  border  of  the  skin  incision.  The  fascia  lata  was  then  divided 
and  the  clots  turned  out,  the  partially  divided  artery  and  veins  were 
easily  found,  divided  and  ligatured.  Control  of  haemorrhage  was  as 
complete  as  if  one  had  the  vessels  divided  between  two  ordinary  pairs 
of  haemostatic  forceps." 

Mr.  Lynn  Thomas  further  points  out  that  his  instrument  will  be  found 
especially  valuable  in  injuries  to  the  femoral  vessels  by  gunshot  or  other 
wounds,  and  especially  so  where  the  injury  lies  close  to  Poupart's  ligament, 
as  here  prompt  treatment  is  especially  called  for,  and  the  control  of 
haemorrhage  a  matter  of  much  difficulty.  Any  wound  present  would, 
of  course,  be  enlarged,  as  needed.  The  following  are  the  advantages 
of  the  forceps-tourniquet  over  other  instruments,  especially  Esmarch's 
bandage  :  (i)  It  is  not  affected  by  climate  ;  (2)  it  is  easily  sterilised; 
(3)  it  is  most  useful  in  major  operations;  (4)  it  does  not  require  an 
assistant  to  look  after  it ;  (5)  in  no  case  has  Mr.  Lynn  Thomas  seen  its 
use  followed  by  that  oozing  which  is  so  common  after  the  employment 
of  Esmarch's  bandage. 

4.  Madewen's  Method  of  Compression  of  the  Abdominal  Aorta  (Ann. 
of  Surg.,  1894,  vol.  i.  p.  1). — Prof  Macewen  has  used  the  following  for 
many  years,  and  has  found  it  simple,  always  ready,  easily  applied  and 
efficient.  No  injury  has  followed  to  the  small  intestines.  If  the 
patient  vomits  or  coughs  violently,  the  pressure  must  be  temporarily 
increased.  As  the  patient  lies  on  his  back  on  the  table,  the  assistant, 
facing  the  patient's  feet,  stands  on  a  stool  at  the  left  side  of  the  table 
in  a  line  with  the  umbilicus.  He  then  places  his  closed  right  hand 
upon  the  abdomen,  a  little  to  the  left  of  the  middle  line,  the  knuckles 
of  the  index  finger  first  touching  the  upper  border  of  the  umbilicus  so 
that  the  whole  shut  hand  will  embrace  about  three  inches  of  the  aorta 
above  its  bifurcation.  The  assistant  then  standing  upon  his  left  foot, 
his  right  foot  crossing  his  left,  leans  upon  his  right  hand,  and  thereby 
exercises  the  necessary  amount  of  pressure.  With  the  index  finger 
resting  upon  the  common  femoral  at  the  brim  of  the  pelvis,  the 
assistant  can  easily  estimate  the  weight  necessary  for  the  purpose. 
In  this  way  an  efficient  assistant  can  control  the  circulation  for  half  an 
hour  without  fatigue. 

5.  Compressing  the  Common  Femoral  or  the  Termination  of  the  External  IKaoby  the 

fingers  or  hands,  aided,  if  need  be,  by  a  weight.  This  is  only  possible  in  the  case  of  a 
child,  and  the  assistant  thus  employed  is  liable  to  be  in  the  way  of  the  operator. 

6.  Lister's  Tourniquet. — This  means  of  compressing  the  termination  of  the  abdominal 
aorta  is  not  a  light  matter,  apart  Erom  the  very  grave  operation  into  which  itcnters.  This 
is  owing  to  the  difficulty  of  making  sure  of  avoiding  such  important  structures  as  the 


OPERATIONS   ON   THE   HIP-JOINT.  881 

duodenum,  pancreas,  solar  plexus,  and  small  intestines,  and  to  its  interference  with 
respiration  and  circulation.  The  bowels  must  be  thoroughly  emptied  beforehand,  and 
got  out  of  the  way  by  gently  rolling  the  patient  on  to  his  right  side  before  the  pad  is 
applied.  Tn  the  Amer.  Text-Book  of  Sit rg.,  p.  1193,  two  useful  hints  are  given,  one  to 
apply  a  soft  sponge  between  the  pad  and  the  skin,  and  the  other  not  to  lose  a  moment 
in  putting  catch-forceps  on  the  chief  bleediDg  points  after  the  main  vessels  have  been 
tied,  so  that  the  tourniquet  may  be  promptly  loosened. 

7.  Compression  of  the  Common  Iliac  through  an  Abdominal  Incision.  (Dr.  C.  McBurney 
Ann.  of  Surg.,  Aug.  1894,  p.  181.) 

8.  Ligature  of  the  Common  Femoral  Artery. — The  incision  is  utilised  afterwards  in 
shaping  lateral  or  some  modification  of  lateral  Haps.  The  surgeon  must  be  prepared  for 
the  haemorrhage  from  the  gluteal  and  other  branches  of  the  internal  iliac  artery. 

9.  Commanding  the  Main  Artery  during  the  operation  by  seizing  it  in  the  flap 
(Figs.  367  and  368). 

Purneaux  Jordan's  Method  (Fig.  363). — By  amputating  through  the 
thigh  as  low  down  as  possible,  and  shelling  out  and  disarticulating  the 
femur,  it  is  now  possible  to  avoid,  in  large  measure,  those  dangers 
which  were  formerly  inseparable  from  the  operation — viz.  :  1.  Shock, 
the  limb  being  removed  much  farther  from  the  trunk.  2.  Haemorrhage. 
a.  Abundant  room  is  afforded  for  compression  of  the  common  femoral, 
and  the  vessels  behind,  b.  The  large  vessels  can  easily  be  secured  on 
the  face  of  the  stump,  low  down.  c.  The  gluteal  and  sciatic  arteries 
remain  untouched,  the  haemorrhage  from  these,  in  the  older  operations, 
being  a  source  of  serious  danger.  3.  Infection.  By  the  other 
methods,  the  copious  discharge  of  bloody  serum  from  the  large  wound,* 
being  poured  out  close  to  the  anus  and  genitals,  was  very  liable  to 
infection.  By  this  operation,  both  the  end  of  the  stump  and  the 
wound  on  the  outer  side  can  be  more  easily  drained  and  kept  aseptic. 
In  making  use  of  this  amputation,  especially  for  hip  disease  or  failed 
excision,  the  surgeon  should  not  attempt  too  much  to  secure  primary 
union.  4.  The  stump  is  a  better  one.  It  is  longer,  more  mobile, 
and  occasionally,  as  in  amputation  for  acute  periostitis  or  necrosis,  it 
is  possible  to  preserve  much  of  the  periosteum  from  the  upper  half  of 
the    femur,    and    a   cord  t   will  be  left  which  will  render  the   stump 


*  While  the  wound  in  a  Furneaux  Jordan  amputation  is  also  a  large  one,  it  is  much 
more  happily  placed  for  drainage. 

t  The  committee  of  the  Clinical  Society  appointed  to  examine  Mr.  Shuter's  case  of 
sub-periosteal  amputation  of  the  hip-joint  reported  (Tratis.,  vol.  xvi.  p.  89),  (1)  that, 
though  there  was  a  firm,  resisting  cord  of  considerable  size  in  the  centre,  which  afforded 
the  muscles  a  common  point  of  attachment,  there  was  not  sufficient  evidence  to  enable 
them  to  state  that  this  cord  contained  bone ;  (2)  that  the  muscles  were  in  a  high  state 
of  nutrition,  the  patient  not  only  powerfully  flexing,  extending,  abducting,  and  adducting 
his  stump,  but  being  able  to  communicate  all  these  movements  to  the  artificial  limb. 

Mr.  Shuter  in  his  paper  (loc.  supra  cit.')  said  that  his  patient  was  able  to  wear  an 
artificial  limb  "  for  some  hours  nearly  every  day  for  a  period  of  about  five  months.  I  then 
forbad  his  wearing  it  for  a  time  on  account  of  a  tender  sinus  which  opened  opposite  to 
the  acetabulum."  I  have  now  performed  this  amputation  seven  times.  Six  recovered, 
and,  in  one  of  my  three  cases  in  adults,  a  delicate  girl  of  22  has  been  able  to  wear  a  very 
light  limb,  made  by  Messrs.  S.  Maw,  Thompson  and  Sons,  for  three  hours  at  a  time.  In  such 
cases  as  these,  where  the  patient  is  much  reduced  by  long-standing  hip  disease,  and  the 
periosteum  is  still  adherent  to  the  wasted  femur,  it  is  not,  in  my  opinion,  advisable  to 
spend  time  in  stripping  it  off.  While  the  shock  of  the  hip-joint  amputation  is  much 
lessened  by  the  Furneaux  Jordan  method,  it  cannot,  of  course,  be  entirely  removed. 

S. — VOL.  II.  56 


snj  operations  on  the  lower  kxtukmity. 

movable.     Whether  in  any  case  an  artificial  limb  can  be  worn  for  more 

than  a  short  time  is  very  doubtful. 

I.  Furneaux  Jordan's  Operation  (Fig.  363).* — The  modification  of 
sir  II.  House  in  two  Btages  is  given  at  p.  884.  Every  provision  must 
be  taken  against  shock.  The  limbs  should  be  bandaged  in  cotton- 
wool, the  body  well  wrapped  up  on  a  hot-water  table,  the  head  kept  low, 
ether  given,  saline  infusion  employed  intravenously  or  into  the  cellular 
tissue,  or  by  both  means  (vol.  i.  p.  141).  Injection  of  eucaine  into  the 
chief  nerve  trunks  is  referred  to  at  vol.  i.  p.  226,  and  subcutaneous 
injections  of  brandy  and  strychnine  should  be  given  from  time  to 
time. 

Before  commencing  the  circular  amputation,  I  have  the  limb  elevated, 
an  Esmarch  bandage  applied  up  to  the  knee,  the  thigh  emptied  of 
venous  blood  by  firm  stroking,  and  a  second  Esmarch  bandage  then 
applied  firmly  just  below  the  trochanters,  and  the  lower  one  removed. 
The  india-rubber  band  is  also  (p.  875)  placed,  lightly,  ready  in  situ. 
The  circular  amputation  is  then  performed,  and  the  large  vessels 
secured.  The  upper  bandage  is  next  removed,  the  region  which  it 
occupied  resterilised,  and  the  india-rubber  band  firmly  tightened  while 
the  femur  is  shelled  out  or,  perhaps,  disarticulated,  if  the  whole 
operation  is  performed  in  one  stage. 

The  patient's  pelvis  is  brought  to  the  edge  of  the  table  and  the  body 
rolled  a  little  on  to  the  sound  side,  the  surgeon  standing  usually  to  the 
right  of  the  diseased  limb — i.e.,  inside  on  the  left  and  outside  on  the 
right  side — draws  up  the  soft  parts  forcibly  with  his  left  hand,  and 
makes  a  circular  incision  through  the  lower  third  of  the  thigh,  using 
his  knife  as  at  p.  933,  the  assistant  who  is  in  charge  of  the  limb 
rotating  it  so  as  to  make  the  tissues  meet  the  knife.  A  circular  cuff- 
like flap  of  skin  and  fasciae  is  then  quickly  raised  for  about  two  inches 
and  a  half,t  an  assistant,  who  stands  opposite  the  surgeon,  giving  much 
help  here,  by  seizing  and  everting  the  cut  edge  of  the  flap  as  the 
surgeon  raises  it.  The  flap  being  drawn  upwards  out  of  the  way,  the 
soft  parts  are  severed  by  one  or  two  vigorous  circular  sweeps  down  to 
the  bone,  and  the  large  vessels  and  any  others  that  can  be  seen  are 

*  Dr.  W.  K.  Arnold,  assistant-surgeon  U.S.  Navy,  has  kindly  drawn  my  attention  to 
the  fact  that  an  amputation,  in  all  essentials  the  same  as  Furneaux  Jordan's,  was 
performed  as  long  ago  as  1806  by  Dr.  W.  Brashear  in  Bardstown,  Kentucky.  The 
following  account  taken  from  a  letter  by  Dr.  Brashear  will  be  found  in  Dr.  Mott's  edition 
of  Velpeau's  Surgery,  in  a  summary  of  hip-joint  amputations  by  Dr.  Eve,  of  Tennessee. 
The  patient  was  a  lad,  aged  17.  An  operation  on  the  thigh  in  the  ordinary  manner  was 
determined  upon,  as  remote  from  the  hip-joint  as  circumstances  might  justify  (in  this 
case,  about  mid-thigh).  The  amputation  was  performed  and  the  arteries  secured.  The 
next  step  was  to  make  an  incision  to  and  from  the  lower  end  of  the  bone  externally  over 
the  great  trochanter,  to  the  head  of  the  bone  and  upper  part  of  the  socket.  The 
dissection  of  the  bone  from  the  surrounding  muscles  was  simple  and  safe,  by  keeping  the 
edge  of  the  knife  resting  against  it.  The  bone  being  disengaged  from  its  integuments  at 
its  1  mity,  was  then  turned  out  at  a  right  angle  from  the  body,  so  as  to  give 

every  facility  in  the  operation  to  separate  the  capsular  ligament  and  remove  the  head 
from  its  socket.  The  patient  made  a  good  recovery.  Judging  from  a  letter  from  Prof. 
Oilier  to  Mr.  Bhnter  (loe.  supra  <vY.)  the  former  surgeon  had  recommended  this  method  in 
1859,  and  performed  such  an  operation  once. 

t  The  surgeon  need  not  trouble  to  raise  a  larger  circular  flap.  As  the  femur  is 
removed,  the.  muscles  lose  their  fixed  point  to  contract  from,  and  are  thus  easily  covered. 


OI'KKATIONS    OX    TIIK    III  I'-.HM  \T. 


883 


next  secured.     Pressure  "  is  now  made  with  sterilised  pads  on  the  still 
oozing  wound,  the  upper  india-rubber  bandage  (p.  876)  is  tightened, 

and  the  patient  being  rolled  well  over  on  to  his  sound  side,  tin;  surgeon 
cuts  along  the  outer  side  of  the  thigh,  starting  from  the  circular  wound 
and  ending  about  midway  between  the  iliac  crest  and  top  of  the  great 
trochanter.  This  incision  goes  straight  down  to  the  bone  and  runs 
into  any  excision  wound,  or  sinuses  which  may  exist  over  the  joint. 
The  soft  parts  are  then  rapidly  stripped  off  the  femur,  partly  with  the 
knife,  partly  with  the  finger,  the  only  dilliculty  met  with  heing  along 
the  linea  aspera.  If  an  excision  has  been  performed,  the  operation  is 
rapidly  completed,  but  if  the  head  and 
neck  remain  intact,  the  final  steps  will 
be  rendered  more  difficult,  and  the 
joint  must  be  opened  from  the  outside 
by  cutting  strongly  on  the  neck  of  the 
bone,  this  being  facilitated  b}r  the 
assistant  moving  the  limb,  in  accord- 
ance with  the  surgeon's  directions,  as 
different  parts  require  to  be  put  on  the 
stretch,  strong  outward  rotation  of  the 
femur  and  dragging  of  the  head  away 
from  the  acetabulum  being  required  at 
the  last. 

Free  drainage  must  be  provided,  for 
it  must  be  remembered  that  the  wound 
left  by  this  method  is  a  very  large  one, 
though  it  has  the  advantage  of  being 
farther  removed  from  sources  of  infec- 
tion. Thus,  especially  if  the  tissues 
are  riddled  with  sinuses,  too  much  of 
the  wound  must  not  be  closed,  and,  if 
shock  is  present,  the  surgeon  must  not 
wait  to  insert  many  sutures,  but,  trust- 
ing to  firm  bandages  over  an  aseptic 
dressing,  get  his  patient  quickly  back 
to  bed.  If  disease  of  the  acetabulum 
be  present  the  surgeon  will,  if  the 
patient's  condition  admit  of  it,  attend 
to  this,  the  use  of  a  sharp  spoon  (Fig. 
371)  and  the  insertion  of  a  drainage- 
tube  through  this  bone  being  specially  required  if  pelvic  suppuration 
be  present. 

In  some  cases  shock  is  marked  from  the  very  beginning  of  the 
operation.  This  was  most  markedly  the  case  in  one  of  the  patients 
mentioned  in  the  footnote,  p.  881,  a  very  delicate  young  lady  of  22. 
It  was  only  by  not  waiting  to  do  more  than  secure  the  femoral,  making 
firm  sponge-pressure  on  the  flaps,  tilting  up  the  end  of  the  table  so  as 
to  keep  the  head  low,  inserting  no  sutures,  but  trusting  only  to  firm 
bandaging  over  dry  gauze  dressings,  that  a  fatal  result  was  averted. 


Furneaux  Jordan's  amputation. 
Above  is  shown  the  means  of  control- 
ling haemorrhage  described  at  p.  875. 
Lower  down  are  seen  the  sinuses  of  an 
unhealed  excision,  and  the  method  of 
shelling  out  of  the  femur,  after  a  cir- 
cular amputation  has  been  performed, 
and  the  large  vessels  secured. 


*  Valuable  time  should  not  be  wasted  in  trying  to  secure  every  bleeding  point  either 
now  or  later. 

56—2 


884  OPERATIONS    ON    THE   LOWER    EXTREMITY. 

Sir  H.  Howse's  Two-stage  Modification  of  the  Above. — As  in 
spite  of  its  advantages  the  Furneaux  Jordan  method  must  always  be 
accompanied  by  shock,  and  as  in  spite  of  strenuous  use  of  elastic  com- 
pression the  loss  of  blood,  especially  in  adults,  may  be  too  much  for  the 
patients  where  their  usual  exhausted  vitality'  is  remembered,  I  strongly 
advise  my  readers  to  follow  Sir  H.  Howse,  and  to  remove  the  limb  in 
two  stages  whenever  this  is  possible,  as  in  cases  of  tuberculous  disease. 
My  own  experience  is  based  upon  four  cases,  in  which  I  superintended 
its  performance  by  my  house-surgeons.  Two  of  the  patients  were  in 
a  most  unfavourable  condition :  all  recovered.  The  limb  is  first 
removed  by  a  circular  amputation  through  the  lower  third  of  the 
thigh,  and,  about  a  fortnight  later,  the  rest  of  the  femur  is  taken  away. 
By  the  adoption  of  this  course,  the  shock  is  greatly  diminished.  The 
blood  which  would  have  been  circulating  in  the  rest  of  the  limb  is 
returned  into  the  trunk  before  the  first  operation.  By  the  removal  of 
the  limb  the  length  of  leverage  which  exerts  a  disturbing  influence  on 
the  diseased  joint  and  the  need  of  a  splint  are  done  away  with.  The 
patient  rapidly  recovers  lost  ground,  and  is,  at  the  close  of  the  second 
operation,  in  a  much  better  condition  for  the  curetting  of  sinuses,  now 
usually  needful.  These  advantages,  in  my  experience,  outweigh  the 
disadvantage  of  two  operations,  and  the  double  anaesthetic. 

Amputation  by  Different  Flap  Methods. — The  following  will  be 
given  here,  it  being  understood  that  in  no  case  can  any  of  them  be 
recommended  if  the  above  method  is  available.  In  all,  shock  should 
be  diminished  by  the  injection  of  eucaine  into  the  chief  nerve 
trunks  preliminary  to  their  division,  by  the  method  of  Crile  and 
Cushing  (vol.  i.  p.  226).  Whenever  available,  the  method  of  Lynn 
Thomas  or  Wyeth  for  arresting  haemorrhage  (pp.  878  and  876)  should 
always  be  employed. 

II.  Lateral  Flaps. — The  methods  of  Larry  and  Lisfranc  need  not  be  more  than 
alluded  to  here.  In  both,  the  flaps  were  cut  by  transfixion,  and  were  about  four  inches 
long.  Larry  tied  the  common  femoral  as  a  preliminary  step.  Flaps  made  by  either 
method  are  so  bulky  as  not  to  be  recommended. 

If  the  surgeon  wishes  to  use  lateral  flaps,  as  in  a  case  involved  by  growth  in  front .  he 
may  make  them,  thus,  from  without  inwards  :  Standing  on  the  right  side  of  either 
limb,  he,  e.g.,  in  the  case  of  the  right  limb,  marks  out  an  inner  flap  by  means  of  an 
incision  starting  from  below  the  tuber  ischii,  carried  downwards  along  the  inner  aspect 
of  the  thigh  for  about  four  inches  and  then  curving  upwards  to  the  centre  of  the  groin  and 
ending  a  little  below  Poupart'a  Ligament,  to  the  outer  side  of  the  femoral  vessels  ;  next, 
without  taking  oft  his  knife,  he  marks  out  an  outer  flap  by  cutting  between  the  same 
points,  but  in  the  reversed  direction.  This  incision,  as  it  passes  downwards,  outwards, 
and  backwards,  should  leave  the  front  of  the  limb  about  a  hand's-breadtta  below  the 
great  trochanter.  The  flaps  having  been  dissected  up,  the  soft  parts  are  cut  through  from 
without  inwards,  the  femoral  vessels  being  secured  before  they  are  cut,  and  disarticulation 
performed  last. 

III.  Antero-internal  and  Postero-external  Flaps  (Figs.  364,  365). 
■ — This  is  a  modification  of  the  last  method,  and  will  be  useful  in 
cases  of  growth  extending  high  up,  where  it  is  impossible  to  perform  a 
Furneaux  Jordan's  amputation.  Some  such  flaps  as  the  above  may  be 
the  only  ones  obtainable.  They  may  be  made  as  follows  :  The  pre- 
cautions as  to  shock  given  at  p.  882  having  been  taken,  haemorrhage 
will  be  best  met  by  the  details  given  at  p.  878,  if  Mr.  Lynn  Thomas's 


OPERATIONS    ON    THE    HIP-JOINT. 


885 


forceps-tourniquet  is  available.  The  patient's  pelvis  is  then  brought 
well  down  to  the  edge  of  the  table,  and  the  opposite  limb  being  held  aside 
but  not  tied,  the  surgeon,  standing  to  the  right  of  either  limb,  reaches 

somewhat  over  and  marks  out  (in  the  case  of  the  right  limb)  an  antero- 
internal  flap,  hut  cutting  from  a  point  close  to  the  tuber  ischii  to  one  a 
little  below  and  internal  to  the  anterior  superior  iliac  spine.  The  skin 
and  fasciee  having  heen  dissected  up,  the  muscles  are  cut  through  till 
the  femoral  vessels  are  reached  and  secured.  Sterilised  gauze  is  now 
packed  into  this  wound,  and,  the  patient  having  been  rolled  a  little 

Fig.  364. 


Amputation  at  the  hip-joint  by  modified  lateral  flaps  (anterior  racquet-shaped 
incision).  1,  The  sartorius.  2,  The  ilio-psoas.  3,  The  rectus.  4,  The  tensor 
vaginse  femoris.  These  have  been  cut  and  retractors  have  exposed  (5  and  6)  the 
internal  and  external  vasti.  A  double  ligature  has  been  placed  upon  the  common 
femoral  vessels.     (Farabeuf.) 

over,  a  postero-external  flap  is  marked  out  and  dissected  up  from  the 
glutasal  region,  passing  between  the  above  points,  but  in  the  reverse 
order.  The  gluteal  vessels  are  next  cut  through,  the  chief  vessels 
being  secured  by  Spencer  Wells's  forceps  ;  the  capsule  is  then  opened 
(p.  886),  the  round  ligament  severed,  and  the  limb  removed. 

IV.  Anteroposterior  Flaps  (Figs.  366—369).  Methods  of  Guthrie  and  Liston. 
—The  patient  having  been  prepared  against  shock  (p.  882),  and  the  main  vessels  secured 
by  one  of  the  methods  already  given,  the  limb  being  brought  over  the  table  and  supported 
in  the  semi-flexed  position  by  an  assistant,  while  the  opposite  limb  is  secured  over  the 
table  by  a  bandage,  the  surgeon,  standing  outside  the  left  and  inside  the  right  limb, 
raising  the  tissues  in  front  of  Scarpa's  triangle  with  his  left  hand,  enters  his  knife  {e.g.,  on 
the    left    side)  midway  between;  the  anterior  superior  spine  and  the  top  of  the  great 


886 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


trochanter,  and  send-;  it  across  the  limb  so  that  it  emerges  close  to  the  tuberosity  of  the 
ischium.  In  traversing  the  limb  the  knife  should  pass  as  close  to  the  capsule  as  possible, 
so  as  (O  to  get  behind  the  large  vessels,  and  (2)  to  facilitate  the  opening  of  the  capsule 
later  on.  As  the  knife  emerges  the  surgeon  will,  of  course,  be  careful  of  the  scrotum  and 
the  opposite  thigh,  and  at  this  moment  the  point  should  be  well  depressed,  so  as  to 
include  all  the  tissues  possible  in  the  anterior  flap.  With  a  rapid  sawing  movement  a 
broad  flap  is  cut,  five  inches  long,  an  assistant  thrusting  his  fingers  into  the  wound  as  it 
is  made,  and  following  the  back  of  the  knife,  to  secure  the  large  vessels  (Fig.  3G7,  368). 
As  he  then  draws  up  the  anterior  flap  the  capsule  is  exposed,  covered  with  more  or  less 
of  soft  parts,  according  to  the  skill  with  which  the  knife  has  been  first  inserted  ;  the 
assistant  in  charge  of  the  limb   at   this    moment    extending,   depressing,  and   rotating 

Fig.  365. 


The  same  operation  as  in  the  last  figure,  in  a  more  advanced  stage.  The 
capsule  has  been  opened  and  its  outer  lip  drawn  aside  by  a  retractor.  The  other 
retractor  draws  inwards  and  protects  the  vessels.  1.  Sartorius.  2,  Psoas. 
3.  Rectus.  4,  Tensor  vaginaj  femoris.  5.  Attachment  of  gluteus  minimus. 
(Farabeuf.) 


out  the  femur,  so  ;is  to  put  the  capsule  on  the  stretch,  the  Burgeon  forcibly  draws  the 
knife  across  the  capsule,  opens  it  freely,  and  divides  t  he  ligamentum  teres  |  Fig.  369). 

The  limb  being  now  Blightly  flexed,  adducted,  and  pulled  away  from  the  body,  the 
Burgeon  severs  the  parts  attached  to  the  great  trochanter  and  the  outer  aspect  of  the 
limb,  and.  passing  his  knife  behind  the  bone,  cuts  a  posterior  Bap  about  four  inches  long. 
The  assistant  in  charge  of  the  limb  will  facilitate  this  step,  and  further  the  dislocation  of 
the  femur,  if  he  bring  the  thigh  upwards  and  forwards  with  one  hand  placed  at  the 
back.  A  large  sterilised  pad  is  at  once  pressed  against  the  posterior  flap  while  the  femoral 
Is  *  are  secured,  or,  if  these  are  well  in   hand,   those  in  the  hinder  flap  arc  taken  first. 

*  Of  these  the  femoral  lies  superficially,  the  profunda   more  deeply,  in  the  anterior 
flap  :  they  are  shown  much  too  close  to  each  other  in  Fig.  368. 


OPERATIONS    ON    THE    HIP-JOINT. 


887 


The  gluteal  will  be  found  in  the  gluteal  muscles,  the  sciatic  with  the  nerve  nearer  (he 
posterior  margin  of  the  flap,  and  the  circumflex  and  obturator  closer  to  the  acetabulum. 
If  the  patient's  condition  admits  of  it,  any  sinuses  are  now  laid  open  or  scraped  out 
the  acetabulum  examined,  and,   if    perforated,   drained.      If   the   amputation   has   been 

Fig.  366. 


(Fergusson.)* 

performed  for  a  growth,  any  outlying  masses  are  looked  for  and  removed.  Any  nerves  or 
muscles  which  need  it  are  now  trimmed  short,  a  large  drainage-tube  inserted,  and  the  flaps 
carefully  united. f 

Advantages  of  this  method  :  Chief  of  these  is  its  rapidity. — Disadvantages  :     i.j  The 


Fig.  367. 


iFlG.  368. 


hemorrhage  which  takes  place  from  the  vessels  from  the  posterior  flap  may  be  considerable. 
2.  The  large  amount  of  sero-sanguineous  oozing  which  takes  place  from  so  many  large 


*  The  knife  represented  here  is  needlessly  long. 

f  If  grave  shock  is  present,  the  head  should  be  lowered  and  sutures  put  in,  but  not 
now  tied,  any  oozing  being  stopped  by  firm  spica-bandaging,  and  Spencer  Wells's  forceps 
left  in  situ.  The  lower  end  of  the  bed  should  be  kept  raised,  and  brandy  given  subcuta- 
neously  and  per  rectum.     Infusion  should  also  be  employed  early  (p.  882,  and  vol.  i.  p.  141). 


888  OPERATIONS   ON    THE    LOWER   EXTREMITY. 

Irs  cut  obliquely.  3.  The  fact  that,  in  an  adult,  it  requires  a  special,  long  knife,  not 
always  found  in  an  ordinary  collection  of  instruments.  Difficulties:  1.  Not  passing  the 
knife  deeply  enough,  and  thus  nut  exposing  the  capsule.  2.  Passing  the  knife  too  deeply, 
and  hitching  iis  point  on  the  bone.  3.  Getting  the  knife  stopped  in  passing  it  behind  the 
head  of  the  femur.     4.  Fracture  of  the  femur. 

Guthrie's  Method  by  Antero-posterior  Flaps. — Antero-posterior  flaps  arc  again 
made  use  of,  bul  litre  they  are  made  from  without  inwards,  and  thus  can  easily  be 
rendered  less  bulky.     A  small  knife — i.e.,  one  four  inches  long— suflices. 

The  preparatory  steps  being  taken  as  before,  the  surgeon,  standing  on  the  right  side 
of  either  limb,  marks  out  his  anterior  flap,  about  five  inches  long,  by  an  incision,  starting 
(on  the  left  limb)  from  just  above  the  great  trochanter,  passing  across  the  thigh  with  a 
broadly  curved  convexity,  and  ending  just  below  the  tuber  ischii.  A  posterior  Bap  is  then 
marked  out  by  carrying  the  knife  in  a  similar  manner  across  the  back  of  the  limb  between 
the  same  points,  the  limb  being  raised  and  the  surgeon  stooping  somewhat.  This  flap 
should  be  about  two-thirds  the  length  of  the  first.  Both  consist  of  skin  and  fascia?.  The 
Haps  being  held  out  of  the  way,  the  muscles,  first  on  the  front  and  then  on  the  back,  are 

Fig.  369. 


next  cut  obliquely  from  below  upwards,  the  femoral  vessels,  hot li  superficial  and  t\vc\i, 
being  secured  as  soon  as  they  arc  exposed, and  before  they  are  cut,  cither  by  underrunning 
them  with  an  aneurysm-needle  loaded  with  silk,  or  by  dividing  them  between  two  pairs  of 
forceps.     The  capsule  being  exposed,  disarticulation  is  performed  as  before. 


EXCISION   OF  THE   HIP.      OPERATIVE  TREATMENT   OF 
HIP-JOINT    DISEASE.       INCISION   OF   THE  JOINT. 

Indications. — A.  Disease,  chiefly  tuberculous.  B.  Injury,  especially 
gunshot. 

A.  Disease. — Few  will  deny  that  the  progress  in  the  treatment  of  hip 
disease  has  not  made,  of  late  years,  advances  in  accordance  with  the 
advantages  of  modern  surgery,  and  the  progress  made  in  operations  on 
other  parts  of  the  body.  While  the  immediate  mortality  after  operative 
interference  here  lias  been  lessened,  the  results  as  to  real  cures  are  still 
little  creditable  to  surgeons.  The  explanation  of  this  fact  lies  chiefly 
in  the  length  of  time  required  for  a  cure  of  hip-joint  disease  without 
operation,  from  one  to  two  years  being  no  exaggerated  estimate  of  the 
time  for  which  these  cases  require  to  be  kept  under  skilled  observation, 


EXCISION    OF   THE   HIP.  889 

and  the  first  six  to  nine  months  of  this  heing  an  average  period  in 
which  the  patient  requires  to  be  kept  recumbent,  even  when,  what  is 
rarely  the  case,  such  treatment  is  enforced  continuously  from  the  first. 
The  difficulty  of  finding  the  needful  accommodation  in  general  hospitals, 
and,  it  must  be  added,  the  lack  of  interest  in  these  cases,  when,  after 
the  first  few  weeks,  the  disease  is  rendered  quiescent,  and  the  process  of 
repair  begins  ;  the  diificulty  of  finding  teaching  material  in  patients 
efficiently  treated  by  fixed  apparatus,  the  frequent  change  in  the 
personnel  of  our  medical  schools,  and  the  preference  for  cases  of  more 
decided  interest  and  involving  operations  with  more  speedy  results  ;  all 
these  facts  admit  of  no  denial. 

With  reference  to  operative  interference,  the  advocates  of  earlier 
excision  have  much  reason  in  their  claims.  While,  theoretically,  the 
disease  can  be  cured  by  sufficient  efficient  rest,  in  practice  such  rest 
is  rarely  secured.  Tuberculous  disease  here  runs  the  same  course  as 
elsewhere,  and  early  complete  removal,  care  being  taken  that  the  first 
operation  is  so  complete  as  to  be  the  last,  is  acknowledged  to  be  the 
best  way  of  dealing  with  tubercle. 

Certain  points,  however,  connected  with  the  hip-joint  prevent  the 
results  of  such  advocac}r  being  as  successful  here  as  elsewhere.  In 
cases  where  excision  is  performed  early,  before  suppuration  is  a 
marked  feature,  complete  extirpation  of  the  synovial  membrane, 
especially  its  posterior  portion,  often  not  an  easy  matter  in  the  case 
of  the  knee-joint,  is  rendered  far  more  difficult  here,  thus  explaining 
the  reappearance  of  the  disease.  And  when  this  difficulty  has  been 
overcome  and  rapid  healing  of  the  wound  has  been  secured,  the  patient, 
if  examined  later,  is  often  found  to  have  an  unsatisfactory  flail-like, 
unstable  limb,  liable  to  flexion  and  other  deformities.  With  regard  to 
this  second  objection  to  early  excision  of  the  hip-joint,  it  may  be 
admitted  that  it  would  be  partly  met  by  more  prolonged  efficient  rest. 
The  difficulties  of  securing  this  have  already  been  alluded  to. 

When  excision  is  performed  later  and  abscesses  are  present,  satis- 
factory dealing  with  these  is  usually  rendered  extremely  difficult  by 
their  devious  tracks,  the  risk  of  leaving  a  tuberculous  sinus,  and  of 
this  becoming,  later,  the  seat  of  mixed  infection.  Then  follow  one 
or  more  curettings,  and  the  child  is  sent  out  in  a  Thomas's  splint,  or 
perhaps  to  a  convalescent  home,  or  otherwise  lost  sight  of;  the 
dislike  to  having  even  mild  cases  of  suppuration  in  the  wards  of  a 
general  hospital  playing  a  large  part  in  the  interruption  in  the 
treatment. 

The  truth  is  that  the  only  satisfactory  treatment  of  hip-joint  disease 
is  the  preventive  one  by  strict  adequately  prolonged  rest.  This  will 
not  be  obtained  while  these  cases  are  treated  in  general  hospitals. 
Institutions  on  a  large  scale,  especially  adapted  to  this  class  of  case, 
are  what  is  needed. 

The  unsatisfactory  results  met  with  after  excision  of  the  hip  have 
led  surgeons  to  be  more  chary  in  its  performance,  and  to  the 
employment  of  other,  more  conservative,  steps. 

Where  the  surgeon's  surroundings  admit  of  his  securing  skilled 
aftev-attention,  especially  as  to  the  dressings,  he  will,  in  nrv  opinion, 
do  wisely  to  interfere  early  with  the  view  of  eradicating  as  far  as 
possible  the  disease,  short  of  an  actual  removal  of  the  upper  end  of  the 


S90  OPERATIONS    o\    THE    LOWER   EXTREMITY. 

femur.  The  cases  referred  to  are  of  course  those  in  which  either  rest 
and  fixity  have  not  been  adequately  employed,  or  where  these  fail  as 
shown  by  continued  pain,  increasing  swelling  and  tenderness.  If  any 
abscess  be  present,  this  should  be  cut  down  upon  by  a  free  incision, 
but  not,  if  possible,  opened  at  once.  All  the  superficial  part  of  the 
abscess  bring  isolated,  and  the  adjacent  parts  protected  by  gauze,  the 
abscess  is  then  emptied  and  the  wall  clipped  away  with  scissors.  The 
curette  (p.  899)  should  be  used  cautiously  for  fear  of  further  infect- 
ing tissues  whose  vitality  is  greatly  lowered,  and  chiefly  for  the  less 
accessible  part  of  the  abscess  tracks.  Any  such  tracks  being  then 
plugged  with  gauze  and  pure  carbolic  acid  or  zinc  chloride  (gr.  20 — 1  oz.) 
the  capsule  is  opened  by  an  anterior  incision  sufficiently  free  to  give 
adequate  access  to  the  whole  upper  extremity  of  the  femur.  Any 
escaping  fluid,  whether  sero-pus  or  curdy  and  flaky,  is  most  care- 
fully mopped  away  and  the  bone  examined  for  foci  of  disease,  either 
patches  of  caries  or  spots  of  tuberculous  osteitis.  To  enable  this  to 
be  done  with  any  chance  of  success,  it  is  absolutely  necessary  that 
the  dense  fixed  capsule  be  freely  opened.  The  finger  may  now  detect 
caries  on  the  head  of  the  femur,  where  the  cartilage  has  been  raised, 
blister-like,  by  deeper  tuberculous  osteitis.  Another  common  region 
for  such  osteitis  is  on  the  under  aspect  of  the  neck.  To  expose  these 
sufficiently  for  an  adequate  use  of  the  gouge  or  curette,  and  to  find 
other  disease  in  the  femur,  it  will  often  be  needful  to  dislocate  the 
head,  aided  by  an  elevator.  This  must  be-  done  carefully  owing  to 
the  presence  of  delicate  epiphysial  tissues  and  the  probably  wasted 
condition  of  the  small  femur.  Though  at  first  sight  severe,  this  step 
will  often  alone  suffice  for  the  finding  and  satisfactory  dealing  with 
bone  disease.  Moreover,  displacement  of  the  head,  in  my  opinion, 
alone  enables  the  surgeon  to  eradicate  the  synovial  membrane  especially 
at  the  back  of  the  capsule  ;  the  difficulties  of  dealing  with  this  have 
been  already  alluded  to  (p.  889).  If  the  surgeon  fails  to  find  foci  of 
bone  disease,  of  the  existence  of  which  he  is  assured  by  the  per- 
sistence of  pain,  the  increase  of  swelling,  &c,  after  displacing  the 
head,  and  if  he  proceeds  to  open  up  the  different  epiphysial  lines,  he 
must  be  prepared  to  convert  his  conservative  operation  into  an 
excision.  While  the  head  is  still  displaced  the  acetabulum  is  carefully 
examined  with  a  finger  and  dealt  with  according  to  its  needs  with 
gouge  and  curette.  The  less  accessible  parts  of  any  abscess  tracks 
are  now  explored  with  probes  and  extirpated  as  far  as  is  possible. 
The  joint  is  next  washed  out  with  sterile  saline  or  dilute  sublimate 
solution,  carefully  dried,  and  swabbed  over  with  iodoform  and  glycerine 
(10  per  cent.).  The  head  is  then  replaced.  The  anterior  incision  is 
only,  in  my  opinion,  to  be  sutured  when  the  operator  is  able  to  feel 
assured  that  he  has  succeeded  in  eradicating  the  disease,  and  is  leaving 
a  dry  wound.  The  same  remark  applies  to  drainage.  Where  one 
or  more  abscess  tracks  are  present  gauze  wrung  out  of  pure  carbolic 
acid  or  zinc  chloride  solution  will  ensure  this.  In  any  case  gauze  is 
to  be  preferred  to  tubes. 

If  the  above  conservative  treatment — the  object  of  which  is  to  secure 
as  radical  dealing  with  the  disease  as  excision,  without  the  resulting 
flail-like  limb — is  to  succeed,  absolute  fixity  and  sufficiently  prolonged 
rest  are  essential.     In  hospital  practice,  where  expense  is  an  object 


EXCISION   OF   THE   HIP.  891 

and  skilled  anaesthesia  readily  secured,  plaster  of  Paris  strengthened 
with  metal  strips  is  the  simplest  and  most  efficient.  Any  windows 
required  must  be  large  enough  to  allow  of  resterilisation  of  the 
adjacent  skin,  a  point  of  great  importance  and  often  forgotten.  The 
plaster  should  reach  from  helow  the  ribs  to  below  the  knee.  It  is 
obvious  that  attention  to  the  above  details  requires  time.  This  method 
is  not  to  be  employed  at  the  end  of  a  day's  work,  after  other  operations. 
To  be  successful,  every  step  must  pass  under  the  eye  of  the  surgeon 
responsible  for  the  case. 

Where  the  surgeon's  surroundings  are  different — and  one  of  the 
objects  of  this  book  is  to  help  in  widely  differing  cases — he  is  justified 
in  resorting  to  a  milder  conservative  method,  viz.,  the  injection  of 
iodoform  emulsion  into  abscesses  and  the  joint  itself,  as  advocated  by 
the  late  v.  Mickulicz  of  Breslau  and  other  authorities.  The  weak 
points  of  this  treatment  are  obvious.  In  the  case  of  abscesses  thick- 
ness of  the  pus  may  prevent  anything  like  complete  evacuation.  The 
method  makes  no  attempt  to  eradicate  the  bone  lesions  usually 
present. 

In  dealing  with  an  abscess  strict  asepsis  as  to  the  skin,  &c,  is  need- 
ful. A  syringe  holding  2 — 3  ounces  should  be  employed,  so  as  to  allow 
of  aspiration  of  the  pus.  The  emulsion  is  then  injected,  the  syringe 
being  resterilised.  A  spray  of  ethyl-chloride  may  be  used.  The 
aspiration  is  repeated  according  to  the  rate  at  which  the  abscess  re-fills 
Where  the  process  has  to  be  repeated,  fresh  spots  should  be  selected. 
If  the  re-collection  takes  place  slowly  and  is  found  to  contain  only 
blood-stained  or  brownish-green  fluid,  the  outlook  is  good.  I  need  not 
enforce  the  necessity  of  watching  these  cases.  Where  the  abscess  is 
multiple,  this  method  rarely  succeeds,  in  my  experience. 

The  joint  itself  may  be  injected  by  taking  the  line  for  opening  the 
joint  anteriorly  (p.  897),  and  introducing  the  needle  two  to  three  inches 
below  the  anterior  superior  spine,  in  a  direction  backwards,  upwards, 
and  inwards,  so  that  it  enters  the  joint  just  above  the  anterior  inter-tro- 
chanteric  line.  From  4  to  30  c.c.  of  the  emulsion  are  injected  at 
intervals  of  from  one  to  two  weeks,  according  to  the  reaction  pro- 
duced.    Any  pyrexia  and  pain  are,  usually,  quite  temporary. 

Reference  may  here  be  made  to  an  important  contribution  to  the 
study  of  the  treatment  of  hip  disease  by  Drs.  Gibney,  Waterman,  and 
Reynolds,  of  New  York  (Ann.  of  Surg.,  vol.  ii.  1897,  p.  435).  An 
analysis  is  given  of  150  cases  treated  at  the  New  York  Hospital  for  the 
Ruptured  and  Crippled.  Of  these  25  were  still  under  treatment,  and 
need  not  be  further  considered;  7  were  advised  readmission  for  defor- 
mity, 11  died,  and  107  were  cured.  The  107  cured  cases  were  finally 
examined  at  an  interval  of  five  to  twenty  years  after  leaving  the  hospital. 
The  excellence  of  the  final  result  in  the  cured  cases,  all  of  which 
recovered  with  sound  and  useful  limbs,  will  be  gathered  from  the 
following  facts.  As  regards  motion,  this  was  perfect  in  15,  good  in  22, 
limited  in  41,  and  absent  in  only  9  cases.  Shortening  averaged  an 
inch  and  three-fifths  in  all  the  cases,  but  was  absent  in  21  cases ; 
under  one  inch  in  71,  and  over  one  inch  in  36.  The  record  as  regards 
flexion  is  also  extremely  satisfactory,  as  47  cases  had  none  at  all, 
and  in  JJ  it  was  under  io°;  in  the  remaining  30  cases  it  was  under  300. 
The  treatment  employed  consisted   essentially  in   rest   and  extension; 


892  OPERATIONS   ON   THE   LOWER   EXTREMITY. 

abscesses  being  either  aspirated,  or  opened  and  curetted.  Osteotomy 
of  the  femur  was  performed  19  times  to  correct  deformity,  but  excision 
\v;ts  done  in  4  cases  only. 

Briefly  stated,  of  114  cases  examined  five  years  and  upwards  after 
leaving  the  hospital,  107  "  were  cured  and  able  to  follow  an  occupation 
without  the  slightest  trouble,"  and  the  remaining  7  cases  were  cured 
but  suffering  from  considerable  deformity.  As  excision  was  performed 
in  only  4  of  these  cases,  it  must  be  admitted  that  these  excellent 
results  constitute  very  strong  evidence  in  favour  of  treatment  other 
than  that  by  actual  excision. 

In  my  opinion  excision,  while  justifiable  in  the  earlier  stages  because 
we  are  dealing  with  a  tuberculous  affection,  gives  after  results  inferior 
to  those  of  the  first  of  the  conservative  methods  which  have  been  de- 
scribed. Because  of  the  condition  of  the  limb  which  often  follows  later 
it  is  only  to  be  employed  when  the  surroundings  of  the  surgeon  ensure 
his  keeping  the  resected  joint  fixed  for  a  period  of  upwards  of  nine 
months  and  under  his  own  eye  in  order  to  secure  satisfactory  consoli- 
dation of  the  parts.  Otherwise  I  should  reserve  excision  for  those 
cases  where  the  first  of  the  conservative  methods  above  given  fails,  or 
where  the  mischief  found  is  considered  too  great  for  its  success,  for 
the  rare  cases  where  the  acetabulum  is  chiefly  diseased,  or  those,  rarer 
still,  where  it  is  perforated.  Examination  per  rectum  or  the  presence  of 
thickening  or  sinuses  above  Poupart's  ligament  may  cause  suspicion 
of  the  presence  of  these  conditions.  Finally,  excision  on  one  side  is 
justifiable,  at  a  later  date,  to  remedy  the  deformity  known  as  "  scissors- 
leg,"  which  occurs  in  bilateral  hip-joint  disease  where  the  position  has 
been  neglected  and  the  limbs  allowed  to  cross  one  another  in  the 
adducted  position. 

Having  given  the  results  of  my  own  experience,  I  shall  now  take 
those  of  two  of  the  chief  writers  on  hip  disease  and  the  subject  of 
excision,  Prof.  Howard  Marsh,*  with  his  experience  gained  from  Great 
Ormond  Street  and  the  Alexandra  Hospital  for  Hip  Disease  in  Child- 
hood, and  Mr.  G.  A.  Wright,!  of  the  Manchester  and  the  Pendlebury 
Hospital  for  Sick  Children.  Prof.  Marsh  is  strongly  against  excision, 
for  these  reasons :  He  considers  the  results  obtained  by  continued  rest 
to  be  such  as  to  render  excision  totally  uncalled  for.  "  The  estimate 
that  I  have  been  led  to  form  is,  (a)  that,  in  the  early  stage  of  the  disease, 
although  matter  is  developed,  the  operation  is  as  unjustifiable  as  it  is 
to  remove  a  testis,  an  eye,  or  a  tooth  for  incipient  but  still  curable 
disease  ;  (b)  that  the  operation  is  generally  uncalled  for,  even  when 
sinuses  have  formed;  (c)  that  if  hip  disease  has  been  allowed  to  reach 
the  stage  in  which  the  bones  have  become  extensively  carious,  in  which 
matter  has  burrowed  widely,  and  in  which  the  general  health  has 
become  seriously  affected,  excision  will  be  of  very  doubtful  benefit. 

On  the  other  hand,  my  old  friend,  G.  A.  Wright,  speaking  from  the 
very  large  experience  of  over  a  hundred  cases  of  excision,  of  which 
only  three,  at  most,  died  of  the  direct  results  of  the  operation,  strongly 
urges  that  the  hip  should  be  excised  "  as  soon  as  there  is  any  evidence 
of  external  abscess,  .  .  .  and  still  better  results  would,  I  believe,  be 
obtained  by  operating  before  the  pus  has  escaped  from  the  articulation. 

*  Diseases  of  the  Joints,  p.  317.  \  Ilij/  Disease  in  Childhood,  p.  93. 


EXCISION    OF   THE    HIP.  893 

The  operation  is  discredited  because  it  is  put  off  until  disease  is  so  far 
advanced  that  no  treatment  can  have  more  than  a  fraction  of  good 
results  ;  while  timely  excision  cuts  short  the  disease,  saves  pain,  lessens 
the  time  of  treatment,  and  gives  a  better  limb."  And  again,  at  p.  97 
of  his  book,  Mr.  Wright  says  :  "  While  fully  aware  that  abscesses 
disappear  and  tuberculous  lesions  cicatrise  under  favourable  circum- 
stances, I  think  that,  in  the  case  of  the  hip,  delay  is  unwise  amongst 
the  hospital  class,  with  whom  it  is  as  yet  impossible  to  deal  on  the 
same  lines  as  with  the  well-to-do.  In  almost  every  instance  I  have 
found  much  more  extensive  disease  than  might  be  expected  from  the 
external  evidence,  unless  the  pathology  of  the  affection  is  borne  in 
mind  ;  and  I  believe  that,  once  this  chronic  osteo-myelitis  is  estab- 
lished, nothing  short  of  excision  can,  in  hospital  cases,  prevent  the 
ultimate  progress  of  the  disease  to  abscess,  and  too  often  to  gradual 
exhaustion  of  the  patient  by  pain  and  discharge.  Nature,  of  course, 
in  many  cases  will,  unaided,  get  rid  of  the  dead  bone  by  slow  and 
tedious  processes,  but  the  number  of  children  who  can  survive  the 
process  of  elimination  is  very  small,  while  the  mortality  after  early 
excision  is  not  great,  and  the  failures  are  mainly  in  those  instances 
where  the  operation  has  been  put  off  till  too  late.  Where  actual 
necrosis,  or  caries  of  the  head  of  the  femur,  with  destruction  of  bone 
and  cartilage,  and  often  sequestra  of  varying  size  in  the  acetabulum,  or 
at  least  caries  of  it,  are  known  to  exist,  I  think  few  advocates  of  non- 
operative  treatment  will  be  found."  With  reference  to  so  wide  a 
divergence  of  opinion  between  two  authorities  on  the  subject,  it  may 
be  pointed  out  that  both  have  worked  under  conditions  more  favourable 
than  those  which  fall  to  the  lot  of  most  hospital  surgeons.  Thus,  at 
the  Alexandra  Hospital,  cases  are  kept  under  treatment  as  long  as  rest 
and  extension  are  required ;  if  an  operation  is  called  for,  the  case  is 
transferred  elsewhere.  Mr.  G.  A.  Wright  gained  especial  experience 
from  his  long  connection  with  the  hospital  at  Pendlebury,  one  of  the 
best  children's  hospitals  in  the  kingdom. 

The  following  are  the  conditions  given  by  a  committee  of  the  Clinical 
Societ}'  as  calling  for  excision,  viz. : — 

i.  "  Necrosis,  and  separation  of  the  entire  head  of  the  femur,  and  its 
conversion  into  a  loose  sequestrum."* 

ii.  "  The  presence  of  firm  sequestra  either  in  the  head  or  neck  of  the 
femur,  or  in  the  acetabulum."  This  question  is  a  most  important  one, 
for,  as  Prof.  Marsh  (p.  318)  writes,  "  much  difference  of  opinion  exists 
as  to  the  frequency  with  which  hard  sequestra  of  any  material  size  are 
present  in  suppurative  hip  disease."  He  himself  thinks  that,  when 
present,  sequestra  usually  consist  of  porous,  friable  bone.  Their 
structure  is  such  that,  should  excision  not  be  performed,  they  will 
crumble  away  and  disappear,  and  will  not  prevent  repair.  |     A  distinctly 


*  Prof.  Marsh  (lor.  supra  cit.,  Fig.  50,  p.  383)  thinks  that  these  cases  are  not  rare. 
Mr.  Hilton  (Rest  and  Pain,  Fig.  63,  p.  341)  shows  a  similar  specimen.  I  should  have 
thought  the  condition  a  very  uncommon  one. 

t  "  This  seems  to  be  proved  by  the  fact  that  in  numerous  cases  in  which  profuse 
suppuration  has  been  going  on,  so  that  there  can  be  no  reasonable  doubt  that  extensive 
bone  disease  has  been  present,  all  the  sinuses  will  close,  although  either  no  bone  has 
worked  out  or  been  extracted.     In  these  instances  we  must  conclude  either  that  no 


894  OPERATIONS   ON    THE   LOWEK    EXTREMITY. 

different  opinion  is  held  by  Mr.  Wright  (loc.  supra  cil.,  p.  118)  :  "  Here 
opening  of  abscesses,  and,  still  less,  expectant  treatment,  can  hardly  be 
considered  ;i  satisfactory  mode  of  getting  rid  of  sequestra,  yet  in  no  less 
than  in  39  (out  of  100)  were  there  actual  loose  sequestra,  while  in  many 
others  there  were  patches  of  bone  which  was  practically  dead,  though 
not  loose.  The  possibility  of  removing  sequestra  without  a  formal 
excision  is  worth  trying  in  some  cases,  but  it  is  often  impossible  to 
discover  the  presence  of  the  sequestra  until  the  end  of  the  bone  has 
been  removed,*  or  to  extract  them  if  found.  Moreover,  even  after  the 
removal  of  sequestra,  others  may  exist  and  not  be  found,  and  in  other 
instances  the  disease  progresses  in  the  surrounding  bone  and  necessi- 
tates subsequent  excision.  There  are  often,  too,  other  foci  of  disease 
in  the  medulla,  which  are  as  great  bars  to  recovery  as  the  sequestra 
themselves." 

iii.  "  Extensive  caries  of  the  femur,  or  the  pelvis,  leading  to  prolonged 
suppuration  and  the  formation  of  sinuses." 

iv.  "  Intra-pelvic  abscess  following  disease  of  the  acetabulum." 

With  reference  to  the  two  last  conclusions  I  should  doubt  myself 
whether  excision  can  be  often  justifiable,  especially  in  the  latter.  Even 
if  it  gave  the  desired  drainage  the  patient's  condition  with  disease  of 
the  acetabulum  is  not  one  usually  to  give  the  required  repair  after 
excision.  "Extensive  caries"  of  the  pelvis  certainly,  and  in  many 
cases  of  the  femur,  will  require  amputation,  especially  after  childhood. 

v.  "  Extensive  and  old-standing  synovial  disease  and  ulceration  of 
the  articular  cartilages,  with  persistent  suppuration."  This  condition 
is  rarely  seen  in  the  hip-joint,  where  the  disease,  as  usually  met  with, 
starts  not  in  the  synovial  membrane,  as  in  the  knee-joint,  but  as  a 
chronic  osteo-myelitis  in  the  neighbourhood  of  the  epiphyses,  especially 
the  upper  one. 

vi.  "  Displacement  of  the  head  of  the  femur  on  the  dorsum  ilii,  with 
chronic  sinuses  and  deformity." 

I  have  performed  excision  seven  times  for  such  cases ;  of  these  six 
recovered  with  sound  and  useful  limbs.  These  patients  seem  to  me  to 
bear  excision  well,  this  being  probably  due  to  their  having  good  vitality, 
as  shown  by  their  survival,  and  the  amount  of  repair.  Further,  in 
running  successfully  the  gauntlet  of  the  disease,  they  have  escaped 
the  dangers  of  lardaceous  and  general  tuberculous  trouble.  But  as  a 
rule,  especially  if  the  sinuses  are  few  or  closed,  osteotomy,  either 
cuneiform  of  the  neck  or  by  Gant's  method,  together  with  division  of 
the  contracted  sartorius,  tensor  fascise,  and  adductor  longus  is  much 
to  be  preferred.  Excision  does  away  with  much  of  the  stability  of  the 
limb,  already  secured.  The  surgeon  here  must,  if  he  excise,  be  prepared 
for  a  good  deal  of  trouble  in  dislodging  the  displaced  head,  after  sawing 
through  its  neck,  owing  to  its  being  firmly  matted  down  by  old 
adhesions. 


sequestra  were  present, and  in  (li.it  case  it  would  appear  that  Bequestra  are  not  so  common 
as  some  believe,  or  that  they  often  crumble  away  and  are  discharged,  BO  that  operative 
interference  is  by  no  means  essential  for  their  removal"  (Marsh,  lor.  tupra  cil..  p.  319). 

*  For  the  word  "removed"  I  should  substitute  "displaced,"  a  step  which  I  consider 
quite  justifiable  at  the  present  day,  to  prevent  the  need  of  a  complete  excision  and  the 
flail-like  limb  which  usually  follows  (p.  890). 


EXCISION    OF   THE    HIP.  895 

.  The  Condition  of  the  Limb.  Is  this  a  better  one  after  Excision 
or  after  a  Cure  by  Rest  ? 

Here,  again,  there  is  marked  divergence  of  opinion.  Prof.  Marsh  (loc. 
supra  cit.,  p.  308)  is  of  opinion  that  "the  limb  after  excision  of  either 
the  hip  or  the  knee  is  usually  very  inferior  to  the  average  limb  that  is 
obtained  after  recovery  has  followed  the  treatment  by  rest."  The 
Clinical  Society's  Committee  reported  on  this  subject  that,  after  excision, 
"  movement  is  more  frequently  present,  and  is  also  more  extensive, 
but  that  patients  often  walk  more  insecurely  and  with  a  considerable 
limp,  while  the  limb,  after  treatment  by  rest  and  extension,  though 
frequently  more  or  less  fixed,  is  more  firm  and  useful  for  the  purposes 
of  progression."  While  feeling  assured  that  the  resulting  usefulness 
in  some  cases  treated  by  excision  far  surpasses  the  best  results  obtained 
by  rest,  I  consider  that  the  average  result  obtained  by  rest  is  superior 
to  that  following  excision,  and  that  this  is  increasingly  marked  after 
childhood,  the  limb,  especially  in  adolescents  recovering  after  excision, 
being  very  often  flail-like  and  useless.  * 

On  the  other  hand,  Mr.  Wright,  whose  large  experience  on  this 
subject  has  already  been  referred  to,  has  come  to  the  conclusion  (loc. 
supra  cit.,  p.  126)  that  "  excision  gives  a  better  limb  than  the  average 
result  obtained  without  operation  ;  "  and  again  (p.  114)  :  "In  my  own 
experience,  useless,  flail-like  joints  are  exceedingly  rare,  and  limited  to 
those  cases  where  the  excision  was  performed  in  very  late  stages  of  the 
disease  ;  the  powerless  condition  is,  I  take  it,  the  result  of  the  disease, 
not  of  the  operation."  With  regard  to  the  shortening  of  the  limb,  he 
considers  (p.  108),  that  "  though  some  shortening  must  necessarily 
result,  this  arises  mainly  from  the  weight  being  borne  upon  the  limb 
prematurely.  .  .  .  Growth  in  length  of  the  femur  takes  place  almost 
entirely  at  its  lower  epiphysial  line,  hence  the  loss  of  length  or  true 
shortening  is  only  the  distance  from  the  line  of  section  to  the  top  of 
the  head,  coupled  with  such  arrest  of  growth  as  may  result  from 
impaired  nutrition,  this  last  being,  of  course,  a  very  inconstant 
quantity."  t 

Conditions  of  Success  in  Excision  of  the  Hip. — Amongst  these 
are :  1.  Age.  I  consider  the  best  six  to  fourteen.  After  eighteen 
excision  should  rarely  be  performed,  amputation  by  the  methods  of 
Furneaux  Jordan  and  Sir  H.  Howse  (p.  884)  taking  its  place.  Mr. 
Wright  (p.  126)  thinks  that  after  fifteen  excision  should  be  rejected  in 
favour  of  amputation.  2.  Absence  of  lardaceous  disease.  Excision 
should  be  performed,  in  my  opinion,  only  before  the  appearance  of 
lardaceous  disease.  When  there  is  evidence  of  this  condition  having 
set  in,  especially  in  the  kidneys  or  intestine,  amputation  is  to  be  pre- 
ferred. 3.  Absence  of  advancing  mischief  in  other  joints,  or  of 
tuberculous  lesions  in  the  viscera — e.g.,  the  lungs.  4.  The  disease 
must  be  removed  as  entirely  as  possible.     Thus,  in  the  femur  at  least, 

*  Prof.  Bruns,  of  Tubingen  (loc.  infra  cit."),  is  of  opinion  that  in  the  preservation  of 
function  the  balance  is  greatly  in  favour  of  the  conservative  treatment  as  opposed  to 
resection. 

f  On  this  matter  Mr.  Wright  quotes  Prof.  Ollier's  (Rev.de  Chi?:,  1881  ;  Ann.  of  Surg., 
Jan.,  1886)  estimate  that,  up  to  five  years  of  age,  the  growth  of  the  femur  takes 
place  about  equally  at  its  two  ends  ;  that,  after  five,  the  rate  of  growth  of  the  lower  end 
increases  rapidly  till  it  becomes  three  times  that  of  the  upper. 


s,/>     OPERATIONS  ON  THE  LOWEB  EXTREMITY. 

the  section  must  pass  below  all  foci  of  disease  (p.  902).  All  sinuses 
should  also  be  scraped  out.  5.  Adequate  drainage.  6.  Careful  after- 
treatment,  the  wound,  including  the  adjacent  skin,  being  kept  aseptic. 
7.  The  patient:  must  not  be  kept  too  long  on  his  back  in  ordinary 
hospital  air.  These  words  must  not  be  taken  to  encourage  getting  the 
patient  up,  still  less  allowing  him  to  bear  any  weight  on  the  limb,  even 
if  primary  union  has  been  secured,  eight  weeks  or  so  after  the  opera- 
tion. This  liberty  is  not  to  be  given  for  nine  months  or  more,  if  the 
limb  is  to  be  a  stable  and  satisfactory  one. 
B.  Gunshot  Injuries. 

Excision  of  the  Hip-joint  for  Gunshot  Injuries,  contrasted  with  Conservative 
Treatment,  and  Amputation  at  the  Hip-joint. — For  the  sake  of  convenience  it  will 
be  well  tn  take  the  above  three  plans  of  treatment  of  gunshot  injuries  of  the  hip  together. 
As  before,  I  shall  avail  myself  of  the  laborious  researches  and  the  unrivalled  authority  on 
this  subject  of  Dr.  Otis.  He  writes  {Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion, 
pt.  iii.  p.  165)  that  the  evidence  collected  during  the  American  war  shows  that  "expectant 
treatment  is  to  be  condemned  in  all  cases  in  which  the  diagnosis  of  direct  injury  to  the 
articulation  can  be  clearly  established,"  that  "  primary  excisions  of  the  head  or  upper 
extremity  of  the  femur  should  be  performed  in  all  uncomplicated  cases  of  shot  fracture  of 
the  head  or  neck  ;"  that  "intermediary  excisions  are  indicated  in  similar  cases  where 
the  diagnosis  is  not  made  out  till  late;"  that  "secondary  excisions  are  demanded  by 
caries  of  the  head  of  the  femur  or  secondary  involvement  of  the  joint  ;"  that  amputation 
should  be  performed — "  1.  When  the  thigh  is  torn  off,  or  the  upper  extremity  of  the  femur 
comminuted  with  great  laceration  of  the  soft  parts,  in  such  proximity  to  the  trunk  that 
amputation  in  continuity  is  impracticable.  2.  When  a  fracture  of  the  head,  neck,  or 
trochanters  of  the  femur  is  complicated  with  a  wound  of  the  femoral  vessels.  3.  When  a 
gunshot  fracture  involving  the  hip-joint  is  complicated  by  a  severe  compound  fracture  of 
the  limb  lower  down,  or  by  a  wound  of  the  knee-joint." 

( >ther  authorities  have  differed  from  Dr.  Otis' s opinion  as  to  the  uselessness  of  expectant 
treatment  in  gunshot  injuries  of  the  hip-joint.  Prof.  Langenbeck,*  from  his  experience 
in  the  Franco-German  war,  considered  that  the  expectant  treatment  gave  a  larger 
proportion  of  recoveries  than  excision,  and  still  more  than  amputation,  and  advised  that 
the  expectant  method  should  always  be  resorted  to  save  when  disarticulation  is  rendered 
inevitable  by  the  destruction  and  shattering  of  the  limb.  BirT.  Longmore  (Syst.  of  Surg., 
vol.  i.  p.  561),  thought  that  this  question  must  be  held  to  be  still  "  subjudice,  and  Burg 
must  wait  for  still  more  extended  experience  under  modern  improved  methods  of  treat- 
ment, before  any  rule  can  be  accepted  as  having  yet  been  established  on  this  grave 
question." 

Dr.  Otis  shows  that  "  intermediary  operations  offer  the  least  chance  of  recovery." 

The  experience  of  the  Boer  campaign,  one  where  the  proportion  of 
shell  wounds  was  very  small,  has  been  widely  different. 

Mr.  G.  H.  Makins,  C.B.  (loc.  supra  cit.,  pp.  193  and  238)  saw  no  case 
of  perforation  of  the  head  or  neck  of  the  femur,  nor  of  injury  to  the 
hip-joint. 

Operation. — Two  will  be  described  here  :  A.  By  Anterior  Incision  ; 
B.  By  Posterior  Incision. 

A.  Mr.  A.  E.  Barker,!  in  his  Hunterian  Lectures  {Brit.  Med. 
Journ.,  1888,  vol.  i.  p.  1326)  advocated  the  use  of  the  anterior  method 

*  Arch.f.  Klin.  C/iir.,  1874,  lid.  xvi.  S.  309-316.  The  recoveries  seem  to  have  been 
twenty-five  out  of  eighty-eight  cases  so  treated. 

f  Mr.  R.  W.  Parker  (Clin.  800.  Trans.,  vol.  viii.  p,  108)  recommended  this  method  as 
interfering  less  with  the  muscles  and  the  blood-supply  of  the  joint,  lliiter  was,  1 
believe,  really  the  first  to  use  this  incision,  draining  the  joint  by  a  counter-puncture 
at  the  back. 


EXCISION   OF   THE    HIP.  897 

in  the  early  stage  of  hip  disease.  In  later  papers  (ibid.,  1888,  vol.  ii. 
p.  1337,  and  1890,  vol.  ii.  p.  1009)  he  published  some  most  successful 
cases  thus  treated  in  later  stages,  where  other  means  had  failed,  and 
ahscesses  were  threatening  to  hurst.  The  following  are  the  chief 
advantages:  (1)  the  interference  with  the  muscles  is  practically  nil ; 
(2)  the  patient  can  thus  he  treated  and  his  wound  dressed  much  more 
conveniently — e.g.,  with  a  Thomas's  splint;  (3)  primary  union  will 
follow  if  the  following  most  essential  points  can  he  secured  :  (a)  the 
whole  of  the  diseased  structures  must  be  removed;  (l>)  perfect  asepsis 
must  be  secured  ;  (c)  all  oozing  must  be  checked,  and  the  wound  kept 
dry  by  well-applied  dressings ;  (d)  absolute  rest  must  be  maintained 
during  healing.  With  regard  to  the  objection  which  has  usually  been 
considered  to  be  fatal  to  the  anterior  incision — viz.,  the  insufficient 
drainage  which  it  gives — Mr.  Barker  replies  that  the  incision,  though 
anterior,  is  perfectly  adequate  for  drainage,  (1)  because  the  dis- 
charges are,  if  the  above  given  precautions  are  duly  followed,  very 
small  in  quantity,  "little  more  than  odourless  serum,  which  ought 
never  to  become  truly  purulent";  (2)  "if  all  the  tubercular  tissue  is 
removed,  a  clean- walled  cavity  is  left,  most  of  which  is  quite  capable 
of  healing  by  first  intention,  when  its  different  surfaces  are  brought 
into  close  contact  by  firm  pressure.  And,  in  these  cases,  the  head  of 
the  bone  being  removed,  and  the  acetabulum  quite  clean,  the  cut 
surface  of  the  neck  of  the  femur  can  be  brought  close  up  to  the  latter, 
so  that  although  there  is  potentially  a  large  space  in  the  field  of 
operation,  there  ought  to  be  actually  little  or  no  cavity  left,  if  pressure 
has  been  properly  applied  from  the  first." 

Of  the  conditions  which  it  is  absolutely  necessary  to  secure  for  the 
obtaining  of  primary  union,  and  the  success  of  the  anterior  incision, 
the  first — that  the  whole  of  the  diseased  structures  must  be  removed — is 
by  far  the  most  important.  It  is  also,  from  my  experience,  the  most 
difficult  to  secure.  G.  A.  Wright  (Brit.  Med.  Journ.,  1888,  vol.  ii. 
p.  1338),  speaking  at  the  discussion  on  one  of  Mr.  Barker's  papers, 
said  that  he  had  found  the  entire  removal  of  the  morbid  tissues 
practically  impossible  either  by  the  anterior  incision  which  he  used 
occasionally,  or  by  the  posterior.  Only  little  foci  of  disease  might 
be  left,  but  they  were  apt  to  suppurate  when  some  fall  or  accident 
gave  them  the  opportunity.  And  this  will  be  the  experience  of  most, 
particularly  with  regard  to  the  acetabulum,  and  synovial  membrane 
at  the  back  of  the  capsule. 

Operation. — The  patient  being  on  his  back,  with  the  limb  extended, 
and  the  parts  duly  sterilised,  the  surgeon  standing,  in  the  case  of 
either  limb,  on  the  right  side,  makes  an  incision  three  to  four  inches 
long,  starting  half  an  inch  below  the  anterior  superior  spine,  down- 
wards and  slightly  inwards,  between  the  tensor  vaginas  and  glutrei 
externally  and  the  sartorius  and  rectus  internally.  The  upper  part  of 
tbis  incision  should  pass  down  to  the  capsule  at  once,  the  lower  third 
should  divide  skin  only.  The  interval  between  the  above-named 
muscles  is  next  thoroughly  opened  up  and  the  wound  retracted,  so  that 
the  anterior  surface  of  the  capsule  is  exposed.  A  branch  of  the  external 
circumflex  artery  will  now,  probably,  be  divided.  The  capsule  now  being 
freely  opened,  and  the  limb  flexed,  the  left  index  finger  is  passed  into 
the  joint.      As    the    difficulty   which    is    sometimes   experienced    in 

s. — vol.  ir.  57 


898 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


removing  the  head  is  usually  due  to  an  insufficient  division  of  the 
capsule,  this  is  now  further  incised  with  scissors,  the  left  index  finger 
being  used  as  a  guide.  An  aseptic  finger  now  examines  the  condition 
of  the  joint.  The  wound  being  opened  by  retractors,  a  narrow-bladed 
saw,  guided  by  a  finger,  is  introduced  into  the  upper  part  of  the  wound 
in  the  direction  of  this,  and  with  as  little  damage  to  the  soft  parts  as 


Fig.  370. 


(1)  R.  Jones's  line  of  section  through  trochanter.  By  this  transtrochanteric  osteotomy, 
followed  by  traction  and  abduction,  Mr.  It.  Jones  has  been  able  to  obliterate  or  very  greatly 
lessen  the  shortening  in  a  very  large  number  of  cases  of  bony  ankylosis.  (2)  Cuneiform 
osteotomy  for  coxa  vara.     (3)  Anterior  incision  for  excision  of  the  hip  (MacCormac). 

possible,  and  the  femur  sawn  through  the  neck,  or  across  the  top  of 
the  great  trochanter. 

The  advantages  and  disadvantages  of  these  sections  are  given 
below  at  p.  902.  In  a  case  at  all  advanced  there  will  always  be  a 
risk  that  a  section  through  the  neck  will  expose  diseased  bone. 
The  head  of  the  femur  is  now  extracted  and  the  acetabulum  treated 
by  the  means  given  at  p.  902.  Owing  to  the  depth  at  which  it  lies 
there  is  usually  difficulty  in  dislodging  the  head  of  the  femur.  Its 
direction  must  be  remembered,  and  the  narrow  interval  between  its 


KXCLSION    OF   THE    HIP.  899 

articular  surface  and  the  acetabulum  detected.  A  free  opening  in  the 
capsule  will  facilitate  its  extraction.  In  the  use  of  elevator  or  forceps 
care  must  be  taken  not  to  damage  the  sawn  edge  of  the  femur  (p.  902). 
Every  atom  of  diseased  structure,  including  all  the  synovial  membrane 
that  is  accessible,  must  now  be  removed,  especial  care  being  taken 
to  clear  out  any  caseating  abscesses  communicating  with  the  joint. 
All  this  should  be  done  with  as  little  violence  as  possible  to  the 
surrounding  tissues,  the  lowered  vitality  of  these  being  remembered, 
so  that  none  of  the  tuberculous  debris  be  forced  into  the  fresh-cut 
surfaces.  The  best  instrument  for  removing  the  disease  thoroughly  is 
Mr.  Barker's  "  flushing  gouge  "  (Fig.  371).  This  has  a  cutting  scoop- 
like edge,  is  perforated,  and  to  its  belt  is  attached  tubing  which  com- 
municates with  an  irrigating  can.  By  this  means  boiled  water  (F.  1050) 
is  kept  flowing  through  the  area  of  operation,  carrying  away  the  debris 
of  disease  whether  from  abscess  cavities,  the  joint,  or  the  surface  of  the 
acetabulum,  if  diseased,  and  with  it  all  blood,  while  at  the  same  time 
it  arrests  haemorrhage.  When  every  part  of  the  field  of  operation  has 
been  gouged  and  scraped  clear  of  all  tuberculous  material,  and  the  water 
runs  clear,  the  cavity  is  dried  out  with  sterilised  pads,  one  or  two  of 
which  are  left  in  it  until  all  the  sutures  are  in  situ,  if  the   surgeon 

Fig.  371. 


Barker's  flushing  gouge.     (Down's  Catalogue.) 

decide  to  close  the  wound,  a  step,  in  my  opinion,  very  rarely  advisable 
(p.  897).  These  should  dip  deeply,  and  be  placed  close  together. 
Just  before  they  are  tied,  the  sponges  are  removed,  and  with  them  the 
last  trace  of  moisture.  The  wound  is  then  filled  up  with  iodoform 
emulsion,  and  the  sutures  are  tied,  as  much  of  the  emulsion  as  will 
come  away  being  squeezed  out  at  the  last  moment.  Graduated  even 
pressure  is  then  applied  by  the  dressing  and  bandages,  so  that  the 
walls  of  the  cavity  are  brought  into  apposition,  and  the  remainder  of 
the  neck  of  the  femur  secured  in  the  acetabulum.  The  patient  is  then 
placed  in  a  double  Thomas's  splint.  If  sinuses  are  present,  and  the 
joint  infected,  the  wound  must  not  be  closed,  but  drainage  must  be 
provided.  All  sinuses,  having  been  thoroughly  opened  up  and  curetted, 
must  be  plugged  by  means  of  strips  of  iodoform  gauze  passing  down 
to  the  bottom. 

With  regard  to  the  after-treatment  I  would  urge  that  cases  of  hip 
excision  should  be  got  up  as  early  as  possible — i.e.,  at  the  end  of  six 
or  eight  weeks.  A  double  Thomas's  splint,  with  foot-pieces,  should  be 
applied  immediately  after  the  operation,  and  worn  for  a  period  of  from 
six  to  eight  months.  After  this  the  child  should  get  about  on  a 
patten  and  crutches,  swinging  the  affected  limb.  He  should  not  be 
allowed  to  bear  any  weight  on  this  for  a  year  after  the  operation.  If 
weight  is  borne  on  the  limb  earlier,  the  end  of  the  femur  is  pushed 
upwards  on   to  the  dorsum  ilii,   and  much  shortening  is  the  result. 

57—2 


goo 


OPERATIONS    ON    THE    EOWER    EXTREMITY. 


Mr.  Barker  has  allowed  some  of  his  cases  to  pet  up  and  dispense 
with  a  splint  at  a  much  earlier  period.  I  think  the  above-given  dates 
better  suited  to  these  cases  of  excision  of  the  hip,  when  we  remember 
the  risks  to  which  they  are  exposed  by  their  rough-and-tumble  life 
when  they  leave  the  hospital. 

B.  Posterior  Incision  (Figs.  372,  373). — The  chief  advantage  of  this 
is  its  better  drainage,  a  point  which  is  of  less  importance  nowadays, 
and  which  no  longer  outweighs,  in  my  opinion,  the  smaller  interference 
witli  muscles  entailed  by  the  incision  in  front  (p.  897). 

Fig.  372. 


Resection  of  the  head  of  the  femur  by  the  posterior  incision.  The  thigh  is 
flexed  to  an  angle  of  45°.  The  gluteus  maxinms  has  been  divided,  allowing  the 
great  trochanter  to  come  into  view.  The  retractor  draws  aside  the  skin,  the 
upper  part  of  the  glutseus  maximus,  and  the  medius.  Below  it  is  the  pyriformis. 
(Farabeuf.) 

Whilcthe  patientis  being  brought  under  ether,  a  stirrup  is  applied  il  weight-extension  is 
to  be  made.     The  child  being  rolled  over  on  to  bis  sound  side,  and  the  parts  thoroughly 

cleansed,  the  surgeon  stands  usually  outside  the  limb,  the  patient's  body  being  in  cither  case 
placed  conveniently  at  the  edge  of  the  table,  one  assistant  supporting  the  limb,  while  another 
is  opposite  to  the  surgeon.  An  incision,  about  three  inches  and  a  half  long,*  is  now  made  over 
the  middlef  of  the  great  trochanter,  commencing  about  midway  between  the  top  of  this 
bone  and  the  posterior  superior  spine,  and  ending  over  the  shaft,  just  below  the  trochanter. 


*  It  must  be  always  remembered  that  a  small  wound,  by  giving  insufficient  room,  leads 
to  bruising  and  difficulty. 

t  The  advantage  of  going  so  far  forward  as  this  is,  that  the  fleshy  and  vascular  parts 
of  the  muscles  attached  to  t he  great  trochanter  are  better  avoided. 


EXCISION    OF    TIIK    HIP. 


901 


The  incision  should  curve  slightly  forwards  and  pass  down  to  bone  or  cartilage,  as  the  case 
may  be,  at  once.  Any  bleeding  vessels  having  been  seemed,  the  exact  position  of  the 
head  and  neck  is  now  made  out  by  the  finger,  aided  by  an  assistant  rotating  the  limb.  A 
second  incision  opens  the  capsule  freely.  With  a  periosteal  elevator,  aided  by  a  knife,  the 
muscles  attached  to  the  great  trochanter  are  detached,  the  cartilage  in  young  subjects 
peeling  off  with  them  in  one  or  more  pieces.  The  linger  is  now  passed  round  the  neck  of 
the  femur  and  the  soft  parts,  including  the  periosteum,  detached  as  much  as  possible  on 
the  inner  side.  The  linger  now  feeling  that  the  upper  part  of  the  trochanter  and  the 
neck  of  the  bone  are  free,  and  protecting  the  soft  parts  on  the  inner  side,  the  bone  is  sawn 
through  just  below  the  top  of  the  trochanter  with  an  osteotomy,  metacarpal,  or  keyhole 

Fig.  373- 


"•»&. 


Excision  of  the  head  of  the  right  femur.  Separation  of  the  capsule  and  peri- 
osteum has  been  thoroughly  performed.  G,  Glutasus  maximus.  M,  Medius. 
C,  The  capsule  opened.  P,  Pyramidalis.  T,  Great  trochanter.  The  upper 
retractor  raises  the  upper  lip  of  the  glutseus  maximus,  the  medius,  the  minimus 
which  is  hidden,  and  the  capsule.  The  lower  retractor  depresses  the  pyramidalis 
and  the  capsule.     (Farabeuf .) 


saw.*  This  division  should  be  thoroughly  and  cleanly  effected  without  splintering.  If  it 
be  preferred,  in  addition  to  the  protection  of  the  finger  on  the  inner  side,  a  blunt  dissector 
may  be  passed  behind  the  bone,  but  this  is  not  essential :  retraction  will  protect  the  lips 

*  It  is  usually  advised  that  the  section  of  the  femur  be  made  while  the  bone  is  in  situ, 
owing  to  the  risks  of  fracturing  a  wasted  shaft,  inflicting  damage  on  weak  epiphysial 
lines  and  stripping  off  the  periosteum.  But  these  accidents  will  be  very  exceptional  in 
careful  hands,  and  there  is  no  doubt  that  displacement  of  the  head  (b}r  adducting  the 
limb)  facilitates  complete  removal  of  the  synovial  membrane,  especially  its  posterior  and 
less  accessible  portion.  Finally,  careful  dislocation  of  the  head  does  away  with  the 
difficulty,  often  present,  of  turning  it  out  of  its  socket  after  the  bone  section  has  been 
made  in  situ,  and  the  resulting  damage  so  easily  inflicted  on  the  upper  end  of  the  shaft  of 
the  femur  (vide  infra'). 


902  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

of  the  wound  from  the  -aw.  With  the  aid  of  the  finger  and  an  elevator,  or  with  a  lion- 
ps,  the  head  and  neck  of  tfa  levered  nut  of  the  acetabulum,  this  being  often 

attended  with  difficulty.  Free  opening  of  tb«  capsule  will  aid  this  Btep.  But  great  care 
is  now  needed  to  avoid  infliction  of  damage  on  the  -awn  femur.  Such  damage  is  very 
likely  indeed  to  lead  to  tuberculous  infection  of  the  bony  section.  This  must  be  left  clean 
cut  ami  uninjured.  Any  instrument  used  must  be  directed  to  the  head  it>elf.  The  liga- 
mentnm  teres  is  probably  destroyed  ;  if  not,  it  must  be  divided.  The  acetabulum  is  then 
examined,  and,  if  merely  roughened,  lefl  alone:  if  pitting  or  erosion  be]  s   ngingmust 

be  resorted  to.  Any  sequestra  present  must  be  removed.  If  the  acetabulum  is  perforated, 
and  pus  present  on  its  pelvic  aspect,  free  exit  must  be  provided  by  means  of  a  gouge  or 
small  trephine,  and  a  drainage-tube  passed  through. 

The  inner  surface  of  the  capsule  and  all  abscess  cavities  must  now  be  thoroughly 
curetted  and  irrigated  by  means  of  a  flushing  spoon,  as  described  above,  until  all  granula- 
tion tissue  and  caseous  debris  have  been  removed.  If  sinuses  are  present,  these  must  be 
carefully  curetted  and  treated  with  pure  carbolic  acid  (p.  S90).  Haemorrhage  is  usually 
very  slight,  ami  with  the  exception  of  a  few  vessels,  which  may  be  caught  with  forceps, 
usually  consists  of  a  general  oozing.  This  will  usually  be  stopped  by  the  hot  irrigating 
fluid  :  if.  however,  it  is  troublesome,  tie'  cavity  may  be  packed  with  gauze. 

Drainage,  either  by  mean-  of  iodoform  gauze  or  a  tube,  will  be  necessary  in  nearly  all 
cases.  In  a  very  few.  however,  where  no  sinuses  exist,  where  all  disease  in  bone  and  soft 
parts  alike  has  been  removed,  and  where  all  oozing  has  been  arrested,  a  little  sterilised 
iodoform  emulsion  may  be  rubbed  in  and  the  wound  partially  closed  with  sutures.  The 
die-sings  must  be  carefully  applied  and  firm  pressure  used  to  prevent  oozing. 

Site  of  Section  of  the  Femur. — Section  through  the  root  of  the 
neck  of  the  femur  has  the  great  advantage*  of  disturhing  and 
damaging  the  attachments  of  muscles  much  less,  and  thus  leads 
to  more  rapid  healing  and  far  greater  mobility  of  the  limb.  These, 
however,  are  outweighed  by  the  disadvantage  which  leaving  such  a  large 
piece  of  bone  as  the  trochanter  entails — viz.,  that,  after  healing,  this 
process  gets  drawn  up  against  the  scar  and  may  constantly  fret  it.* 
It  is  also  said  to  check  the  escape  of  discharges,  and  to  render  the 
patient  liable  to  persistence  or  recurrence  of  the  disease.  I  am 
doubtful  as  to  the  last  two,  but  the  first  is  absolutely  certain,  unless 
prolonged  rest  is  enforced.  AVhere  the  section  is  made  through  the 
neck,  the  surface  must  be  carefully  scrutinised. 

Usual  Causes  of  Failure  after  Excision  of  the  Hip. 

1.  Persistent  pelvic  disease.  2.  Chronic  osteomyelitis  of  sawn  end 
of  femur  (vide  siij>ra).  3.  Suppuration  and  hectic.  4.  Lardaceous 
disease.  5.  Tuberculous  conditions  elsewhere.  General  outbreak  of 
tuberculosis.     6.  Disease  of  the  opposite  femur. 

Operations  for  Rectifying  Deformities  in  the  Later  Stages  of 
Hip-Joint  Disease,  such  as  a  cuneiform  osteotomy  of  the  neck,  or 
Gant's  sub-trochanteric  operation,  tire  described  below  in  the  chapter 
on  <  Isteotomy. 

The  anterior  incision  should  be  used  to  open  the  joint  in  <ases  of 
infective  arthritis  and  epiphysitis  occasionally  met  with  here.     Owing  to 

*  About  eighteen  years  ago  I  made  use  of  this  method  in  one  case,  -awing  the  bone 
through  the  neck  and  leaving  the  trochanter  entire.  A  rapid  recovery  took  place,  and 
the  boy  was  allowed  to  begin  to  use  his  limb  seven  weeks  after  the  excision.  He  quickly 
regained  power  over  the  limb,  becoming  able  to  run  and  climb  like  other  Lads,  the  move- 
ments of  tlexion.  extension,  abduction,  and  adduction  being  extraordinarily  perfect.  He 
came,  however,  under  my  care  on  several  occasions  for  superficial  ulceration  of  the  scar, 
which  was  fretted  by  the  very  prominent  upper  margin  of  the  immediately  subjacent 
trochanter. 


EXCISION   OF   THE   HIP. 


903 


the  gravity  of  these  cases,  and  the  difficulty  of  flushing  out  the  joint 
thoroughly  with  sterile  saline  or  weak  sublimate  solutions,  the  head 
and  neck  of  the  femur  should  usually  be  removed,  attention  being  paid 
only  to  the  patient's  life,  and  not  to  the  after  condition  of  the  limb. 
Drainage  should,  in  every  case,  be  provided  behind  by  a  counter- 
puncture  in  the  buttock,  made  with  a  pair  of  stout  forceps  thrust  through 
the  back  of  the  capsule  from  the  wound  in  front. 

I  only  mention  the  subject  of  excision  in  osteoarthritis  to  condemn 
it,  owing  to  its  severity  in  patients  of  the  usual  age  at  which  this 
disease  appears,  and  the  impossibility  of  preventing  re-appearance  of 
osteophytes.  I  can  imagine  the  operation  being  justified  in  patients 
who  are  crippled  at  an  unusually  early  age,  in  whom  both  joints  are 
affected,  the  operation  being  performed  in  the  hope  of  enabling  them 
to  bend  one  hip-joint. 


CHAPTER   II. 

OPERATIVE   INTERFERENCE    IN    DISLOCATION    OF 
THE   HIP.      COXA   VARA. 

Here  three  varieties  of  cases  have  to  be  considered  :  I.  Traumatic 
Dislocations.  II.  Dislocation  from  Disease  (this  is  rather  a  partial 
dislocation,  or  a  subluxation).     III.  Congenital  Dislocations. 

I.  Traumatic  Dislocation. — The  great  deformity,  permanent  crippling,  and  often 
great  suffering  resulting  occasionally  from  old  unreduced  dislocations  of  the  hip,  abun- 
dantly justify  resort  to  operation,  nowadays,  as  long  as  it  is  understood  that  the  operation 
will  be  a  severe  one,  and  the  after-treatment  one  requiring  great  vigilance  on  the  part  of 
the  surgeon. 

In  an  excellent  paper  {Ann.  of  Surg.,  Sept.  1S94,  p.  319)  Dr.  M.  L.  Harris,  of  Chicago, 
publishes  an  instructive  case  of  his  own  and  twenty-four  others  which  be  has  collected. 
From  these  he  draws  the  following  conclusions  :  (1)  Owing  to  the  danger  of  fracturing 
the  neck  of  the  femur  (Arch.f.  hint.  Chir.,  1885,  Bd.  xxxii.  S.  440)  ;  of  laceration  of  the 
great  vessels  of  the  thigh  {Aim.  of  Surg.,  June  1892,  p.  425), — here,  in  an  attempt  to 
reduce  by  manipulation  an  obturator  dislocation  of  thirteen  weeks'  duration  in  an  adult, 
a  fatal  tear  was  produced  at  the  junction  of  the  superficial  and  deep  femoral  veins  ;  or  of 
shock  and  death  {Rev.  d'Orthoj).,  Sept.  1890),  the  application  of  great  force  to  reduce  old 
dislocations  of  the  hip  should  be  discontinued  in  favour  of  freely  opening  the  joint  and 
reducing  the  head  of  the  bone,  after  the  method  used  by  Dr.  Harris  (vide  infra).  (2)  Sub- 
cutaneous operations  in  old  dislocations  are  without  benefit.  (3)  As  osteotomy  below  the 
great  trochanter  leaves  the  head  in  its  abnormal  position,  and  thus  fails  to  relieve  the  pain 
which  so  frequently  accompanies  these  old  dislocations,  and  as  it  cannot  improve  the 
limited  mobility  which  is  always  present,  it  is  not  to  be  considered  in  any  way  an 
operation  of  choice.  (4)  Resection  is  only  to  be  thought  of  when  reduction  after  free 
arthrotomy  fails. 

The  following  are  the  steps  of  the  operation  performed  by  Dr.  Harris  in  his  case  of 
dorsal  dislocation  of  nearly  four  months'  standing,  in  which  repeated  and  prolonged 
attempts  at  reduction  had  been  made  : 

A  free  incision  was  made  between  the  tensor  vagina?  femoris  and  the  glutams  medius, 
thus  leading  directly  down  to  the  acetabulum  and  anterior  surface  of  the  head  and  neck 
of  the  femur.  As  was  expected,  the  acetabulum  was  found  filled  with  a  tough,  adherent 
connective  tissue  proliferation*  from  the  anterior  portion  of  the  capsular  ligament,  which, 
in  falling  over  the  cavity,  completely  closed  it.  On  cutting  through  the  capsular  liga- 
ment, the  head  of  the  bone  was  found  resting  on  the  posterior  and  superior  edge  of  the 
acetabulum  in  a  shallow  depression,  the  lining  of  which  had  a  smooth  cartilaginous 
feel.  Immediately  in  front  of  the  head  and  helping  to  fill  the  cotyloid  cavity  was  a 
small  piece  of  bone,  curved  in  shape,  which  had  been  detached  from  the  posterior  wall 
of  the  acetabulum.     This  may  have  been  an  obstacle  to  the  early  reduction  of  the  case. 

*  In  a  case  of  traumatic  dorsal  dislocation  in  a  boy,  aged  7,  reduced  after  live  months 
by  the  open  method,  and  brought  by  Mr.  Spencer  before  the  Clinical  Society.  Feb.  8,  1895, 
a  long  anterior  incision  showed  the  acetabulum  to  be  filled  with  dense  fibrous  tissue.  It  is 
stated  that  the  acetabulum  could  not  have  been  reached  by  a  posterior  incision  without 
resecting  the  head  of  the  bone. 


DISLOCATIONS   OF   THE    HIP.  905 

The  head  of  the  bone  was  still   covered  with   smooth   cartilage,  while   the   neck   had 
acquired  new  firm  adhesion  to  all  the  surrounding  parts,  thus  producing  a  new  capsular 

ligament. 

Only  a  small  portion  of  the  ligamentum  teres  was  present  in  the  depression  in  the  head 
when  this  was  turned  out  of  its  new  joint.  The  adhesions  to  the  neck  were  divided,  and 
all  the  muscular  attachments  to  the  great  trochanter  and  shaft  as  far  down  as  the 
trochanter  were  separated  sub-periostcally  from  the  bone,  thus  liberating  the  entire  upper 
end  of  the  femur.  Attention  was  then  directed  to  the  acetabulum,  which,  by  means  of 
the  gouge  and  sharp  spoon,  was  freed  of  capsular  ligament  and  the  new  connective  tissue 
formation.  The  cartilage  lining  the  bottom  of  the  cavity  was  found  to  be  still  smooth. 
The  head  of  the  bone,  however,  could  not  be  made  to  enter  the  acetabulum,  which  seemed 
too  small.  The  cavity  was  consequently  enlarged  somewhat  posteriorly  with  the  gouge 
and  mallet,  after  which,  by  considerable  exertion  and  manipulation,  the  head  was  finally 
returned  to  its  place,  and  the  leg  assumed  its  normal  position.  The  wound  was  partly 
stitched,  and  the  rest  packed  with  iodoform  gauze.  The  limb  was  placed  in  the  extended 
position,  plaster  of  Paris  put  on,  and  extension  applied.  The  operation  was  a  very  severe 
one,  occupying  fully  two  hours.  The  patient  suffered  considerably  from  shock,  although 
the  loss  of  blood  was  not  great.  Reaction  came  on  promptly,  and  the  progress  of  the  case 
was  favourable  from  the  start.  There  was  considerable  serous  drainage  from  the  wound 
during  the  first  few  days,  necessitating  rather  frequent  renewals  of  the  dressings.  In 
three  weeks  the  wound  was  closed,  but  in  another  week  a  small  collection  of  sero-pus 
required  evacuation  by  a  counter-puncture.  The  extension  was  continued  three  weeks. 
Six  weeks  from  the  time  of  the  operation  the  patient  was  allowed  up  on  crutches.  In 
three  months  he  could  walk  with  a  cane  without  pain  in  the  hip.  Active  motion  was 
possible  in  all  directions — flexion,  abduction,  adduction,  and  rotation  ;  these,  though 
limited,  were  daily  increasing. 

II.  Dislocation  from  Disease. — This  has  been  referred  to  at  p.  894. 

III.  Congenital  Dislocations. — Operative  interference  in  this  con- 
dition should  not  be  undertaken  unless  the  bloodless  method  of 
reposition  by  manipulation  has  been  given  a  fair  trial,  and  has  failed. 
Even  then  the  advisability  of  operative  interference  here  is  still  much 
disputed.  When  we  consider  the  condition  of  the  parts  affected, 
especially  the  shallow,  ill-developed  acetabulum,  and  the  altered 
flattened  head,  we  can  easily  understand  the  difficulty  which  has 
been  met  with  in  getting  the  head  into,  and  retaining  it  in,  a 
satisfactory  position. 

Mr.  Jackson  Clarke,  whose  book  on  "Congenital  Dislocation  of  the 
Hip,"  2nd  ed.,  1905,  contains  the  clearest  account  of  Lorenz's  manipu- 
lative method  with  which  I  am  acquainted,  and  one  based  on  much 
personal  experience,  goes  farther  than  the  above  statement  and  sums  up 
the  position  of  the  open  operation  as  follows  (p.  x.)  : — "  It  should  not 
be  performed  in  any  case  in  which  manipulative  reposition  is  impossible, 
and,  where  the  latter  can  be  done,  it  is  safer,  and  alone  gives  far  better 
functional  results  than  the  open  operation.  Therefore  the  open  opera- 
tion is  no  longer  a  legitimate  surgical  procedure."  Later  in  his  work 
Mr.  J.  Clarke  is  inclined  to  allow  a  little  more  latitude,  implying  that 
there  may  be  a  few  cases  in  which  an  open  operation  is  justifiable. 
Thus  he  writes  at  p.  21:  "Lorenz's  manipulative  method  in  a  con- 
siderable proportion  of  cases  gives  a  perfect  anatomical  and  physio- 
logical result  (i.e.,  it  cures  a  condition  hitherto  deemed  incurable) ;  in 
a  still  greater  number  of  cases  it  affords  a  permanent  functional 
improvement  that  relieves  the  patient  of  the  grievous  disabilities  which 
the  deformity  entails  if  untreated.  In  the  remaining  cases  in  which 
this    method  fails  to   give   a  firm   articulation  placed  anteriorly,  the 


go6  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

manipulative  operation  of  Lorenz  is  a  necessary  preliminary  to  any 
subsequent  treatment  by  open  operation  that  may  he  undertaken." 

In  his  characteristic  endeavour  after  accuracy  Mr.  J.  Clarke  prefers 
the  term  "  manipulative  "  to  bloodless  because  (i)  some  effusion  of 
blood  must  lake  place  during  the  subcutaneous  division  of  the  adductor 
longus  and  it  may  be  the  deeper  adductors  by  careful  repeated  "  hack- 
ing "  strokes  made  with  the  ulnar  border  of  the  hand;  (2)  when  these 
muscles  are  unusually  resistant,  it  is  wise  to  divide  them  subcutaneously 
with  a  tenotome. 

Indications  for  Operation. — No  one  who  studies  the  results  which 
have  been  progressively  attained  during  the  last  few  years  will  feel  any 
doubt  that  with  increasing  experience  and  careful  attention  to  the 
details  of  Lorenz's  technique,  not  only  at  the  time,  but  during  the  nine 
or  twelve  months  which  follow,  the  number  of  perfect  results  will 
increase.*  Where  a  perfect  result,  i.e.,  an  actual  replacement  of  the 
head  within  the  acetabulum  and  its  retention  there,  as  proved  by 
skiagraphy,  six  months  after  the  removal  of  all  casing,  is  not  secured, 
but  merely  an  improved  position,  e.g.,  an  anterior  transposition,  not  a 
true  reposition,  if  this  transposition  has  brought  the  head  of  the  femur 
near  the  acetabulum,  and  if  this  new  resting  place  is  made  secure  by 
attention  to  the  after-treatment  insisted  upon  by  Lorenz  so  as  to 
secure  sound  healing  of  the  torn  structures  and  to  prevent  a  relapse, 
either  anterior  or  supra-cotyloid,  or  still  more  a  posterior  or  dorsal 
one,  the  result  will  be  a  great  improvement.!  Thus  many  of  the  chief 
deformities  characteristic  of  congenital  dislocation,  viz.,  the  shortening, 
the  lordosis,  and  the  insecurity  will  be  largely  removed,  and  a  good 
functional  result  will  be  secured. 

Operation. — In  those  cases  where  it  has  been  found  impossible  to 
secure  or  to  maintain  a  sufficiently  improved  position,  where  the  child 
is  over  five  or  six  years  and  therefore  more  easily  kept  clean,  but  not 
of  such  an  age  that  the  structures  have  become  so  rigid  that  the  head 
cannot  be  brought  near  the  acetabulum,  the  following  method  may  be 
emplo}Ted ;  the  chief  changes  in  the  structures  and  the  difficulties  that 
may  be  met  with  will  be  manifest.  If  the  adductors  and  hamstrings 
are  very  rigid  these  must  be  dealt  with  at  a  preliminary  stage.  By 
extension  the  head  is  drawn  down  to  the  level  of  the  hip-joint.  The 
incision  given  at  p.  897  is  made  and  its  upper  part  prolonged  along  the 
crest  of  the  ilium  in  order  to  detach  the  origin  of  the  tensor  fascise  and 
the  deep  fascia  (Burghard,  Brit.  Med.  Journ.,  Oct.  19,  1901,  p.  1157). 
The  tensor  is  retracted  and  the  extended  limb  rotated  outwards.  The 
capsule  is  next  freely  incised  parallel  with  the  anterior  inter-trochanteric 
line  and  the  head  protruded.  If  the  ligamentum  teres  interfere  with 
this,  it  should  be  divided.     With  a  sterile  finger  the  condition  of  the 

*  Mr.  J.  Clarke  is  of  opinion  that  those  who  speak  of  the  perfect  results  attained  by 
Lorenz's  method  being  few  and  isolated  have  no!  really  mastered  the  details  of  his 
technique. 

t  The  different  results  which  may  be  attained  short  of  a  perfect  one  and  the  necessary 
treatment,  exercises,  &c,  to  secure  further  improvement  arc  given  in  detail  by  Mr.  J. 
Clarke  (loc.  supra  <•//.).  On  this  subject  my  readers  should  also  refer  to  a  paper  by#Dr.  J. 
Ridlon,  of  Chicago  (Journ.  Amrr.  Mid.  Assoc,  1904,  pp.  ion  and  1063).  The  paper  is  a 
very  helpful  one  from  its  straightforward  candour,  and  from  the  fact  that  Dr.  Kidlon,  like 
Mr.  Clarke,  has  been  associated  with  Lorenz. 


DISLOCATIONS   OF   THE   HIP.  907 

acetabulum  is  investigated.  I  shall  suppose  that  one  exists  though 
small,  and  I  would  here  point  out  that  the  safety  of  the  operation 
largely  turns  on  the  degree  to  which  the  acetabulum  and  head  of  the 
femur  are  developed ;  the  difficulties  and  dangers  of  the  operation 
increase  greatly  when  this  is  not  the  case.  The  obstacles  to  the 
re-entrance  of  the  head  may  now  be  found  to  require  division  of  the 
ilio-psoas  at  its  insertion  (Burghard),  the  straight  head  of  the  rectus  at 
its  origin  (Keetley,  Ortlurpcedic  Suir/cri/,  p.  297),  or  to  be  due  to  resist- 
ance of  the  capsule  and  a  narrow  slit-like  condition  of  the  cotyloid 
ligament.  With  regard  to  the  capsule,  any  unnecessary  division  must 
be  avoided,  as  it  is  one  of  the  chief  means  of  restraining  and  steadying 
the  head  later,  and  the  introduction  of  sutures  is  a  possible  source  of 
infection.  If  it  be  a  slit-like  condition  of  the  cotyloid  ligament  which 
cannot  be  sufficiently  dilated  by  the  pressure  of  the  head,  this  structure, 
with  the  anterior  attachment  of  the  capsule  to  the  acetabulum,  together 
with  the  straight  head  of  the  rectus,  must  be  carefully  detached  with 
a  periosteal  elevator.  The  head  can  usually  now  be  placed  in  its 
proper  position  by  the  manipulations  of  Lorenz.  It  remains  to  replace 
the  separated  capsule  and  to  tighten  this  by  sutures  of  sterilised  catgut 
or  silk.  The  question  of  drainage  must  depend  upon  the  extent  to 
which  the  parts  have  been  disturbed,  and  the  dryness  of  the  wound. 
The  limb  is  then  put  up  in  plaster  of  Paris  in  the  abducted,  outwardly 
rotated,  and  slightly  flexed  position.  To  provide  inspection  of  the 
wound,  Mr.  Burghard  employs  a  form  of  Croft's  splint,  consisting  of  a 
posterior  portion  embracing  the  posterior  two-thirds  of  the  buttocks, 
pelvis,  thigh,  and  leg ;  the  other  half  embraces  the  anterior  portions, 
and  can  be  taken  off  for  inspection  of  the  wound.  The  knee,  in  the 
flexed  position,  is  included  in  the  plaster.  At  the  end  of  a  month  a 
large  plaster  spica  is  substituted,  and  the  abduction  slightly  diminished. 
An  X-ray  photograph  is  taken  at  the  same  time. 

Up  to  this  point  the  conditions  met  with  have  been  comparatively 
simple  and  easy  to  deal  with.  But  there  are  other  cases  which  present 
an  entirely  different  aspect.  To  take  those  where  the  acetabulum  and 
head  of  the  femur  are  totally  inadequate.  With  regard  to  the  first,  and 
deepening  or  making  a  new  acetabulum,  it  should  be  superfluous  to 
point  out  how  the  difficulties  and  dangers  of  the  operation,  especially 
shock,  haemorrhage,  and  infection,  are  increased.  And  if  these  are 
satisfactorily  met,  the  ultimate  after-result  is  liable  to  be  very  dis- 
appointing. On  this  point  Mr.  Burghard's  opinion  on  the  results  of 
Mr.  Lane's  operation,  the  object  of  which  is  to  make  a  secure  joint 
below  the  anterior  inferior  spine,  deserves  careful  attention.  "  I  have 
tried  it  in  five  cases  and  have  been  invariably  disappointed  with  the 
results.  The  space  available  for  the  formation  of  a  new  acetabulum  is 
extremely  small,  and  in  order  to  get  a  stable  joint  it  is  necessary  to  so 
whittle  down  the  head  of  the  bone  that  it  becomes  a  mere  point  and  firm 
ankylosis  is  likely  to  result.  If  not,  the  joint  becomes  gradually  unstable, 
and  the  final  condition  is  no  better  than  before  operation."  Every 
surgeon  of  experience  will  confirm  Mr.  Burghard's  opinion.  Hoffa 
himself,  in  his  article  in  v.  Bergmann's  Surgery  (Amer.  Trans.,  vol.  iii. 
p.  413),  dismisses  the  formation  of  a  new  acetabulum  in  four  and  a 
half  lines,  as  if  it  were  a  simple  and  easy  matter.  It  is  a  matter  of 
great  difficulty  to  ensure  that  "  the  new  cavity  be  deep  and  broad  and 


go8  ol'K NATIONS   ON    THE    LOWER    EXTREMITY. 

the  walls  fairly  steep,  especially  above,  to  give  good  support  to  the 
head."  It  requires  most  careful  and  arduous  work  with  gouge  and 
burrs  to  form  a  new  cavity  even  large  enough  to  bury  the  Last  joint 
of  an  adult  thumb.  One  operator  lias  been  candid  enough  to  record  a 
case  in  which  perforation  of  the  hone  took  place  at  this  Btage  with  fatal 
peritonitis.  AYhen  the  head  and  neck  of  the  femur  are  faulty  in  direc- 
tion rather  than  in  development,  i.e.,  directed  forwards  instead  of 
inwards,  this  may  he  first  corrected  and  the  dislocation  reduced  later. 
When  the  head  and  neck  are  practically  absent  it  is  extremely  doubtful 
if  any  operation  will  be  of  real  permanent  value.  Our  experience  up 
to  the  present  time  justifies  the  following  conclusions.  Between  the 
ages  of  about  two  and  six — I  repeat  that  the  amount  of  rigidity  present 
is  a  more  important  factor  than  the  number  of  years — one  or  more 
attempts  should  always  be  made  to  secure  a  perfect  or  much  improved 
result  by  the  manipulative  method  perfected  by  Lorenz.  If  the  details 
insisted  upon  by  this  authority  are  followed  at  the  time  and  during  the 
needful  after-treatment,  good  results  will  be  increasingly  secured.  It' 
the  surgeon  fail,  and  also  in  the  case  of  rather  older  children,  i.e.,  from 
the  ages  of  six  to  about  eight,  it  will  be  justifiable  to  operate  on  the 
lines  given  above.  AVhen  the  acetabulum  and  upper  extremity  of  the 
femur  are  sufficiently  developed  and  normal  in  direction  and  position 
to  admit  of  their  being  refitted,  the  result  will  often  be  good.  In  other 
eases,  it  is  very  doubtful  if  the  results  ultimately  attained  are  worth 
the  risks  which  are  necessarily  run. 

Risks  and  Causes  of  Failure — The  chief  of  these  are:  I.  Shock. 
2.  Hemorrhage.  3  and  4.  In  children  the  effects  of  a  prolonged 
anaesthetic  and  of  iodoform  intoxication  must  also  be  remembered. 
5.  Infection.  6.  Prolonged  suppuration  increasing  the  risk  of 
7.  ankylosis.  8.  Relapse  into  a  faulty  position.  Other  rarer  but 
possible  accidents,  such  as  that  of  peritonitis,  have  been  already 
mentioned.  Finally,  in  cases  where  much  difficulty  is  present,  it  is 
obvious  that  the  dangers  which  have  been  met  with  in  the  manipulative 
method  must  be  remembered  here  also.  I  refer,  especially,  to  injury 
to  the  delicate  epiphyses  and  shaft  and  neck  of  the  femur.  These, 
and  many  others,  are  mentioned  by  Dr.  llidlon  and  Mr.  -I.  Clarke, 
especially  the  former  (loc.  supra  cit.). 

CURVATURES  OF  THE  NECK  OF  THE  FEMUR.   COXA 

VARA.* 

Indications  for  Operation. — These  are,  chiefly,  a  degree  of  deformity 
in  which  such  shortening,  fatigue  after  walking,  stiffness  in  stooping 
and  sitting  are  present  that  rest  will  not  permanently  relieve  the  pain, 
or  exercises,  active  and  passive,  increase  the  range  of  movement.  No 
operation  should  be  undertaken  in  children  or  adolescents  while  there 
is  any  reason  to  believe  that  the  bones  are  still  soft,]  and  if  the  patient 

Mini  is  convenient,  but  only  correct  when  one  curve  is  Bpoken  of.     More  than 
one  curve  may  be  met  with. 

1   Mr.  Keetley,  to  whom  belongs  the  credit  of  first  performing  osteotomy  (snb-trochan- 

.  in  a  case  due  to  rachitis  adolescentium  and  proving  this  by  examination  of  the 

wedge  removed  (Illut.  Med.  News,  Sept  29,  1SS8),  gives  the  following  important  hint 


CURVATURES   OF   THE   NECK    OF   THE    FEMUR  gog 

operated  on  1"'  rapidly  growing  with  poor  development  of  muscles  and 
joints,  prolonged  rest  and  general  treatment  will  be  required  if  a  satis- 
factory result  is  to  be  attained.  An  occupation  involving  hard  work, 
or  carrying  heavy  weights  is,  in  my  opinion,  an  indication  for  operation, 
it'  the  above-mentioned  condition  can  be  secured. 

Operation. — Two  groups  may  be  made  here:  A.  On  the  neck. 
B.  Sub -trochanteric.  Owing  to  the  healthy  condition  of  the  joint, 
excision  may  be  set  aside,  though  still  highly  thought  of  by  some 
German  authorities.*  Contrasting  these  two  methods  briefly,  I 
consider  that  the  younger  the  patient  the  more  is  a  sub-trochanteric 
operation  indicated.  In  children  the  parts  are  too  small  to  admit  of 
easily  meeting  the  necessity  of  so  arranging  the  wedge  that  when  the 
gap  is  brought  together  the  proper  position  of  the  femur  is  restored. 
In  older  patients,  where  the  parts  are  larger  and  the  elongation  of  the 
upper  margin  of  the  neck  more  pronounced,  it  is  easier  to  secure  the 
above  object,  but  in  these  patients  opening  the  joint,  which  it  is  difficult 
to  avoid,  is  more  likely  to  be  followed  by  stiffness.  In  my  opinion  a 
sub-trochanteric  operation  is  always  to  be  preferred.  Certainly 
osteotomy  of  the  neck  should  never  be  employed  unless  a  skiagram 
shows  that  the  lengthening  of  the  neck  is  enough  pronounced  to  render 
removal  of  a  wedge  likely  to  be  sufficient.  Linear  osteotomy  alone  is 
not  likely  to  be  satisfactory  in  cases  of  sufficient  severity  to  call  for 
operation. 

A.  Cuneiform  osteotomy  of  the  neck  (Fig.  370). — The  parts  are 
exposed  by  the  anterior  incision  already  described  (p.  897).  The  upper 
margin  of  the  neck  is  the  spot  to  which  attention  must  be  directed,  and 
in  separation  of  the  periosteum  and  other  structures  care  must  be  taken 
not  to  inflict  needless  damage  on  the  epiphysial  structures  or  the  joint. 
It  will  be  remembered  that  the  epiphyses  here  are  late  in  joining,  and 
that  rachitic  changes  may  be  more  or  less  active  up  to  certainly  as  late 
as  eighteen  years.  The  base  of  the  wedge  should  be  upwards  and 
usually  forwards ;  according  to  the  degree  of  the  deformity  it  will 
measure  from  one  to  two  inches.  The  wedge  must  be  cut  cleanly 
with  a  chisel,  and  through  to  the  inner  border,  which  is  always  short. 
In  removing  it  the  above  given  precautions  as  to  injury  to  adjacent 
parts  must  be  remembered. 

{jOrthopadic  Surgery,  p.  312):  "Adolescents  attacked  with  rickets  do  not  present  the 
same  clinical  picture  as  infants.  .  .  .  The  older  a  person  is  when  attacked  with  rickets, 
the  more  limited  and  localised  are  his  deformities  likely  to  be." 

*  Prof.  Hoffa  (v.  Bergmann's  Surgery,  Amer.  Trans.,  vol.  iii.  p.  517)  writes  :  "Resection 
of  the  joint  is  be<t  for  the  severe  cases.  The  improvement  in  the  gait  and  general 
condition  in  the  majority  of  cases  of  resection  verify  its  value  (Miiller,  Hoffa,  Kocher, 
Maydl,  Sprenger.  and  others).  In  the  case  which  the  author  resected  the  shortening  was 
reduced  from  2 J  to  if  inches.  The  importance  of  gymnastics  and  massage  after  the 
extension  is  removed  is  self-understood.''  It  is  difficult  to  understand  the  above  statement 
with  regard  to  the  shortening  if  the  case  had  been  watched  for  any  length  of  time.  With 
regard  to  the  adoption  of  this  step,  Mr.  Keetley  writes  in  his  usual  terse  and  vigorous 
style  :  "  What  is  to  be  thought  of  reports  like  the  following  (reference  to  one  of  Schneider's 
cases)  :  '  Patient  limps,  but  has  no  pain.  Treatment  :  Resection  of  the  hip-joint.  The 
patient  was  discharged  cured.'  Cured  !  What  of  ?  Not  of  the  limp,  we  may  be  sure  ; 
not  of  the  adduction  either,  unless  bony  ankylosis  ensued  ;  nor  of  the  shortening. 
Increased  mobility  may  have  been  obtained,  but  at  the  expense  of  increased  weakness 
and  diminished  length." 


gio 


OPERATIONS    ON    TIIR    LOWKR    EXTREMITY. 


Before  the  necessary  correction  into  the  abducted,  everted  and 
rotated  inwards  position  can  be  satisfactorily  secured,  division  of  the 
adductors  and  hamstrings  may  be  needful,  now,  or  as  a  preliminary 
measure. 

B.  Sub-trochanteric  osteotomy  (Fig.  374). — Here  the  osteotomy  has 
been  linear,  transverse,  oblique  from  without  inwards,  or  cuneiform. 
Theoretically,  as  the  neck  is  the  part  primarily  affected,  interference 

Fig.  374. 


A.  A  normal  femur.  T5.  A  femur  with  coxa  vara.  a.  A  sub-trochanteric 
wedge  has  been  removed.  C.  Abduction  first  fixes  the  upper  segment  by  contact 
with  the  acetabulum,  and  then  closes  the  opening  in  the  bone.  1).  Replacement 
of  the  limb  after  union  is  completed  elevates  the  neck  to  its  former  position. 
(Whitman.) 


here  is  the  more  scientific  course,  but  on  account  of  its  greater 
simplicity,  and  for  the  reasons  given  above,  I  recommend  sub- 
trochanteric osteotomy.  I  shall  mention  two  methods,  both  of  which 
give  good  results.     I  prefer  the  first  as  rather  the  simpler. 

I.  Cuneiform  Sub-trochanteric  Osteotomy.  Here  a  wedge  is 
removed  below  the  great  trochanter,  the  apex  being  inwards  and 
forming  a  hinge  ;  on  this,  when  the  cut  surfaces  of  the  bone  are 
brought   into  contact    by  abducting  the  limb,  not  only  is  the  position 


CURVATURKS    OF    THE    NECK    OF    THE    FEMUR.  911 

of  the  limb  rectified  but  the  restoration  of  a  more  normal  angle  and 
direction  of  the  neck  is  commenced,  the  after-treatment  continuing 
this  object. 

R.  Whitman's  method  (Ann.  of  Sun/.,  1900,  vol.  i.  p.  145,  and 
Med.  Rec,  Mar.  19,  1904)  will  be  found  comparatively  easy  and 
efficient  (Fig.  374).  It  is  especially  indicated  in  adolescents  (about 
twelve  to  seventeen  years  of  age).*  In  Dr.  Whitman's  words  :  "  The 
base  of  the  wedge  should  be  about  three-quarters  of  an  inch  in  breadth, 
directly  opposite  to  the  trochanter  minor  ;  the  upper  section  should  be 
practically  at  a  right  angle  with  the  shaft,  the  lower  one  being  more 
oblique.  The  cortical  substance  on  the  inner  aspect  of  the  bone  should 
not  be  divided,  but,  reinforced  by  the  cartilaginous  trochanter  minor, 
should  serve  as  a  hinge  on  which  the  shaft  of  the  femur  is  gently 
forced  out  until  the  opening  is  closed  by  the  apposition  of  the  fragments 
after  the  upper  segment  has  been  fixed  by  contact  with  the  margin  of 
the  acetabulum  ;  thus  the  continuity  of  the  bone  is  preserved.  The 
leg  is  then  held  in  the  attitude  of  extreme  abduction  by  a  plaster  spica 
bandage,  which  should  include  the  foot  also,  until  the  union  is  firm." 

Here  also  any  contracted  adductors  or  hamstrings  must  be  rectified, 
either  at  the  time,  or  beforehand  by  manipulation  or  tenotomy. 

II.  Mr.  Watson  Cheyne,  C.B.,  divides  the  femur  below  the 
trochanters,  and,  having  rotated  the  limb  inwards  until  in  the  position  of 
extreme  internal  rotation,  holds  the  fragments  together  by  perforated 
aluminium  plates  secured  with  tin-tacks. 

When  both  limbs  require  operation,  they  should,  if  possible,  be  dealt 
with  at  the  same  time.  In  a  young  adult  the  time  required  for  adequate 
rest  and  after  exercises,  if  the  result  is  to  be  satisfactory,  is  consider- 
able. Mr.  Watson  Cheyne  gives  another  reason  which  affects  younger 
patients.  In  a  case  seen  some  years  after  the  operation,  the  limb 
operated  on  was  found  to  be  a  good  deal  longer  than  its  fellow,  which, 
not  rectified  and  still  incapacitated,  had  not  grown  so  well. 

*  In  children  Mr.  Barnard  finds  it  possible  to  produce  a  subcutaneous  rectification  of 
the  neck  of  the  femur  by  simply  abducting  the  femur  under  an  anaesthetic,  to  a  similar 
degree  to  the  normal  side  and  then  putting  the  limb  up  in  plaster  (Clin.  Journ.,  Jan.  6, 
1904). 


CHAPTER  III. 
OPERATIONS  ON  THE  THIGH. 

LIGATURE  OF  THE  COMMON  FEMORAL.— TREATMENT 
OF  WOUNDS  OF  THE  FEMORAL  OR  OTHER  LARGE 
VESSELS  BY  SUTURE  AND  RESECTION.— LIGATURE 
OF  THE  SUPERFICIAL  FEMORAL  IN  SCARPA'S 
TRIANGLE.— LIGATURE  OF         THE  SUPERFICIAL 

FEMORAL         IN         HUNTER'S  CANAL.— PUNCTURED 

AND  STAB  WOUND  IN  MID-THIGH. — AMPUTATION 
THROUGH  THE  THIGH.— AMPUTATION  IMMEDIATELY 
ABOVE  THE  KNEE-JOINT.— REMOVAL  OF  EXOSTOSIS 
FROM  NEAR  THE  ADDUCTOR  TUBERCLE. — FRACTURES 
OF  THE  FEMUR. 

LIGATURE   OF  THE   COMMON   FEMORAL. 

Though  this  operation  is  not  regarded  with  much  favour,  especially  for 
aneurysm,  it  will  be  described  here,  as  the  question  of  tying  it  arises 
from  time  to  time,  and  as  it  should  always  be  performed,  for  the  sake 
of  practice,  on  the  dead  body. 

Indications. 

I.  Wounds. — These  are  rare,  here,  compared  with  those  affecting  the 
vessels  lower  down.  The  wound  must  always  be  explored  and  the 
bleeding-point  sought,  for  two  reasons — (a)  Ligature  of  the  external 
iliac  will  usually  fail  to  arrest  bleeding  from  the  common  femoral. 
(6)  The  source  of  the  bleeding  may  easily  be  mistaken  here;  thus, 
Mr.  Liston,*  in  a  case  of  pistol-shot  wound  of  the  groin,  tied  the 
external  iliac  for  what  was  proved,  at  the  necropsy,  to  be  a  wound  of 
"one  of  the  superficial  branches  of  the  common  femoral,  about  half  an 
inch  below  Poupart's  ligament." 

The  very  important  subject  of  ligature  of  the  femoral  artery  or 
vein,  or  both,  in  cases  of  wounds,  will  be  referred  to  here,  though 
briefly.  Such  cases  will  arise  most  frequently  in  removal  of  growths — 
e.g.,   epitheliomata,   lvmphomata,   sarcomata — less    often    in    cases    of 

*  Med.-Chir.  Tremg.,  vol.  xxix.,  p.  107.  The  flow  of  the  blood  here  is  said  to  have 
been  "  most  impetuous  and  profuse."  In  Mr.  Listen's  words :  '-The  division  of  even  a 
small  branch  close  to  the  principal  vessel,  it  is  well  known,  pours  out  blood  furiously,  as 
much  <o.  in  fact, a3  if  an  opening  in  the  coats  of  the  artery  itself  were,  so  to  [  say,  punched 
out,  corresponding  in  size  to  the  area  of  the  branch." 


LIGATURE    OF   THE    COMMON    FEMORAL.  913 

stabs.  Much  interesting  information  on  these  subjects  will  be  found 
in  papers  by  M.  Kirmisson*  (Rev.  de  Chir.,  May  10,  1886),  and  Dr.  L. 
Pilcher  (Ann.  of  Surg.,  Feb.  1886). 

2.  Removal  of  Growths  from  Scarpa's  Triangle  and  Injury  to 
Femoral  Vessels. — M.  Kirmisson  has  drawn  attention  to  the  following 
points :  In  the  course  of  the  deeper  dissection  the  pulsation  of  the 
femoral  artery  should  be  frequently  felt  for  with  the  finger.  As  this 
vessel  may  have  been  displaced,  it  is  not  enough  to  trust  to  anatomical 
knowledge  alone.  Where  the  adhesions  are  very  firm,  and  where  a 
large  growth  surrounds  the  sheath,  it  is  useful  to  divide  the  growth 
and  to  remove  large  parts  of  it,  only  preserving  that  part  in  intimate 
connection  with  the  vessels,  this  being  finally  separated  most  carefully. 
In  the  case  of  growths  in  intimate  connection  with  the  sheath  the 
vein  is  particularly  in  danger,  because  (a)  the  vein-walls  are  much 
more  quickly  invaded  than  the  arterial,  and  (b)  the  vein  is  in  closer 
connection  with  the  glands.  Two  conditions  are  likely  to  be  met  with 
bjr  the  surgeon :  1.  Denudation  of  the  vessels.  Here  the  adhesions 
are  sufficiently  loose  to  be  separated,  and  the  sheath  is  either  left 
intact  or  opened.  Every  effort  must  be  taken  to  keep  the  wound  here 
aseptic.  2.  Resection  and  ligature  of  one  or  other  of  the  femoral 
vessels.  If  the  vein  alone  has  been  injured  in  an  operation  or  by  a 
stab,  it  should  be  secured  if  possible  by  a  laterally  applied  suture,  by 
resection  and  end-to-end  suture  by  Murphy's  method  (p.  917),  or  by 
the  application  of  Spencer  Wells's  forceps  left  in  situ  for  two  or  three 
days.t  All  of  these  formerly  hazardous  procedures  have  been  rendered 
much  safer  by  the  precautions  of  aseptic  surgery.  Maubrac  (Arch. 
Gen.  de  Med.,  1889)  strongly  advocates  lateral  suture,  especially  when 
the  lesion  is  small.  Kammerer  (New  York  Med.  Joum.,  1890,  vol.  i. 
p.  511)  points  out  that  suture  of  the  wall  has  undoubted  advantages, 
and  that  it  has  been  used  successfully  in  the  case  of  the  femoral  vein 
by  Schede  (Arch.  f.  klin.  Chir.,  Bd.  xxviii.  S.  671),  and  (Lange  (New 
York  Med.  Jour.,  vol.  xliv.  p.  720).  If  these  steps  are  impossible,  or 
fail,  the  femoral  vein  must  be  ligatured.  Dr.  Pilcher,  quoting  from  a 
paper  of  Braun's  (Arch.  f.  klin.  Chir.,  Bd.  xxviii.  Heft.  3,  S.  610), 
shows  that  of  eighteen  cases  in  which  ligature  of  the  femoral  vein 
alone  was  practised  at  the  level  of  Poupart's  ligament,  thirteen  occurred 
as  the  result  of  wounds  inflicted  during  the  removal  of  growths.  In 
none  of  these  thirteen  cases  did  gangrene  ensue.  Dr.  Pilcher  points 
out  that  this  is  due  to  the  gradual  enlargement  of  the  collateral  venous 
circulation  which  takes  place  during  the  increase  of  the  growth.  This 
constitutes  a  most  important  difference  between  wounds  of  the  vein 
during  operation  and  by  a  stab.  Thus,  in  five  cases  in  which,  as  the 
result  of  acute  injuries,  the  femoral  vein  was  tied  high  up,  recovery 
without  disturbance  took  place  in  only  one.     In  two,  death  took  place 


*  I  am  indebted  for  my  knowledge  of  this  paper  to  an  abstract  by  Mr.  T.  Jones,  of 
Manchester  (Med.  Chron.,  September  1886,  p.  514). 

t  Pilcher  mentions  a  case  of  Kiister's,  in  which  a  wound  in  the  vein  was  secured  with 
haemostatic  forceps  ;  the  removal  of  these  after  only  twenty-four  hours  was  followed  by 
renewed  bleeding,  ligature  of  the  femoral  artery,  and  fatal  gangrene.  A  case  under  the 
care  of  Mr.  Taylor,  of  Dublin,  in  which  forceps  were  successfully  employed  to  command 
the  subclavian  artery  will  be  found  referred  to  (vol.  i.  p.  784). 

S. — VOL.  II.  58 


914  OPERATIONS    o.\    THE    LOWER    EXTREMITY. 

from  septicaemia  and  pyemia;  in  the  remaining  two,  gangrene  rapidly 

supervened.  Niebergall  found  that  in  sixteen  cases  when  both  common 
femoral  vessels  were  tied  dining  the  removal  of  growths  about  62  per 
cent  developed  gangrene,  and  that  in  eight  cases  in  which  both  were  tied 
for  injury  gangrene  followed  in  50  per  cent.  On  the  other  hand,  in 
none  of  twenty-five  cases  in  which  the  common  femoral  vein  was  tied 
during  removal  of  growths  did  gangrene  occur,  and  in  ten  cases  of 
injury  in  which  the  vein  only  was  ligatured  one  only  was  followed  by 
gangrene.  In  the  case  of  stab-wounds  of  the  common  femoral  vessels 
the  complication  of  infection  has  to  be  remembered. 

Thus,  Mr.  Gould  (.!/«/.  Soe.  Proc,  vol.  x.  p.  177)  published  a  case  of  great  interest  in 
which  the  common  femoral  vein  was  wounded  (''the  whole  anterior  segment  of  the 
;  "  being  severed)  with  a  cat's-meat  knife.  A  ligature  tied  round  the  vein  above  and 
below  the  wound  not  arresting  the  bleeding,  the  internal  saphena  which  entered  the 
femoral  just  opposite  the  wound  was  tied  also.  Blood  still  welled  up  from  the  wounded 
'..  and  further  search  showed  that  another  vein  entered  the  femoral  trunk  just  opposite 
the  wound  in  the  trunk  between  the  two  ligatures.  This  vein  was  tied  and  then  all 
haemorrhage  was  found  to  be  arrested.  Though  the  wound  was  very  thoroughly  irrigated 
with  solution  of  hydr.  perch.  (1-2000),  all  the  infective  material  introduced  by  the  knife 
could  not  be  removed.  Phlebitis  followed,  with  inflammation  of  the  coats  of  the  artery 
and  haemorrhage  on  the  ninth  day  necessitating  ligature  of  the  superficial  and  deep 
femoral  arteries.  Meanwhile  the  infective  thrombus  had  been  spreading  up  the  iliac  vein 
until  all  the  chief  channels  for  the  return  of  venous  blood  were  blocked.  This  brought 
about  moist  gangrene,  the  patient  dying  on  the  eleventh  day  with  septicaemia,  accelerated 
by  the  loss  of  arterial  blood. 

The  question  has  been  raised  whether,  when  ligature  of  the  common  femoral  vein  has 
been  found  needful,  the  common  femoral  artery  should  not  be  tied  also,  in  order  to 
diminish  the  risk  of  gangrene.  Dr.  Pilcher,  while  quoting  the  cases  of  Roux,  Linhart, 
and  Langenbeck,  in  which  this  step  was  successful,  shows  that  the  practice  of  ligature  of 
the  common  femoral  artery  as  a  prophylactic  step  after  wound  of  the  common  femoral 
vein  high  up,  whether  in  the  removal  of  tumours  or  injuries — e.g.,  stabs — is  to  be 
discouraged.* 

In  cases  where  both  vein  and  artery  are  wounded  these  must  be 
secured  in  situ  b}'  one  of  the  methods  given  above.  The  risk  of 
gangrene  is  now  enormously  increased,  though  the  risk  will  vary 
somewhat  according  as  the  simultaneous  ligature  or  sutures  are  placed 
above  or  below  the  deep  femoral. 

A  few  other  points  bearing  upon  the  removal  of  growths  here  may 
be  alluded  to.  The  internal  saphena  vein  should  be  carefully  preserved 
intact,  and  where  it  is  really  needful  to  divide  it  this  should  be  done  as 
far  from  the  main  femoral  trunk  as  possible,  otherwise  most  trouble- 
some cedema  may  subsequently  develop. 

In  operating  close  to  Poupart's  ligament,  and  especially  on  the  inner 
side,  the  presence  of  the  peritomeum,  and  the  possible  existence  of  a 
femoral  hernia,  must  be  remembered. 

3.  Ulceration  into  the  Artery  by  Growths. — From  the  frequency  of  growths  here  this 
indication  will  occasionally  arise.  I  have  met  with  one  case.  A  man  was  admitted  under 
my  care  who  had  been  operated  on  elsewhere  for  the  removal  of  sarcomatous  glands  in  the 

*  In  support  of  this,  Dr.  Pilcher  writes  :  li  To  diminish,  to  an  extreme  degree,  the 
arterial  supply  to  a  part  whose  nutrition  is  already  seriously  compromised  by  general 
venous  stasis,  would  certainly  tend  to  precipitate  and  aggravate  the  threatened  nee;   - 
The  cases  collected  by  Niebergall,  alluded  to  above,  emphasise  the  importance  of  arterial 
pressure  in  keeping  up  the  circulation  through  the  collateral  veins. 


LIGATURE   OF   THE   COMMON    FEMORAL.  915 

groin.    The  application  of  zinc  chloride  paste  had  led  to  detachment  of  sloughs  and 

exposure  of  the  coin 1  Femoral,  which  gave  way,  leading  to  profuse  haemorrhage.     I 

tied  the  common  femoral  immediately  above  the  bleeding-poinl  ;  this  was  slowly  followed 
by  typical  dry  gangrene,  necessitating  amputation  through  the  lower  third  of  the  thigh. 

4.  Ulceration  of  the  Femoral  Vessels  in  Inguinal  Bubo. — Mr.  Shield  has  drawn  attention 
to  this  most  dangerous  condition  (Med.  Sue.  Proc,  vol.  x.  p.  261).  Though  in  his  case 
ulceration  occurred  in  the  superficial  femoral  vessels,  I  have  alluded  to  it  here,  in  associa- 
tion with  the  previous  two  headings.  Owing  to  hemorrhage  from  sloughing  sinuses  in 
Scarpa's  triangle,  Mr.  Shield  was  obliged  to  tie  both  artery  and  vein,  using  two  ligatures 
in  each  case.  There  was  no  return  of  haemorrhage,  and  gangrene  did  not  occur,  but  the 
patient  sank  exhausted  on  the  eleventh  day  with  a  large  py;emic  abscess  in  the  opposite 
hip-joint.  Mr.  Shield  points  out  that  in  these  most  dangerous  casesof  spreading  sloughing 
bubo,  preventive  treatment — use  of  the  sharp-spoon,  chloride  of  zinc  paste,  continuous 
warm  baths,  &c. — is  urgently  indicated.  When  once  bleeding  has  occurred  and  recurred, 
as  pressure,*  owing  to  the  condition  of  the  soft  parts,  is  likely  to  fail,  a  free  incision  and 
ligature  of  the  vessels  above  and  below  the  point  of  ulceration  is  the  wisest  course. 

5.  Aneurysm. — There  has  been  much  difference  of  opinion  as  to 
whether  it  is  wiser,  when  dealing  with  an  aneurysm  of  the  superficial 
femoral  high  up,  to  tie  the  common  femoral  or  the  external  iliac. 
English  surgeons,  have  rejected  ligature  of  the  common  femoral  for 
these  reasons — (1)  The  risk  of  gangrene,  as  the  ligature  is  placed 
above  both  the  great  nutrient  arteries  of  the  limb.  (2)  The  probability 
of  firm  clotting  taking  place  after  the  ligature  is  rendered  doubtful, 
owing  to  the  number  of  small  vessels  given  off  here — viz.,  the  super- 
ficial epigastric,  and  circumflex  iliac,  the  superior  and  inferior  external 
pudic,  and  very  commonly  one  of  the  circumflex  arteries,  and  also  by 
the  proximity  of  the  profunda.  (3)  The  uncertainty  of  the  origin  of 
the  profunda,  and  thus  of  the  length  of  the  common  femoral.  (4)  I 
would  add  to  the  above  that  ligature  of  the  common  femoral  for 
aneurysm  approximates  the  treatment  to  that  of  Anel  rather  than  to 
that  of  Hunter.  Sir  J.  E.  Erichsen  (Surgery,  vol.  ii.  p.  244),  went  so 
far  as  to  say,  "  It  may  be  laid  down  as  a  rule  in  surgery,  that  in  all 
those  cases  of  aneurysm  which  are  situated  above  the  middle  of  the 
thigh,  in  which  compression  has  failed  and  sufficient  space  does  not 
intervene  between  the  origin  of  the  deep  femoral  and  the  upper  part  of 
the  sac  for  the  application  of  a  ligature  to  the  superficial  femoral,  the 
external  iliac  should  be  tied." 

The  opposite  opinion  has  been  held  by  some  of  the  Irish  surgeons — 
viz.,  the  two  Porters,  Mr.  Smyly,  Mr.  Butcher,  and  Dr.  Macnamara. 
The  last-mentioned  surgeon  has  published  t  eight  cases,  of  which  six 
were  successful,  two  dying  of  haemorrhage. 

It  is  probable,  however,  that,  for  the  reasons  given  above,  ligature  of 
the  external  iliac  will  be  preferred,  especially  as,  nowadays,  antiseptic 
precautions  and  improved  ligatures  will  have  rendered  this  operation 
increasingly  safe. 

*  At  the  debate  on  Mr.  Shield's  paper,  Mr.  Cripps  supported  pressure  in  these  cases.  It 
should  be  applied  methodically  according  to  Mr.  Cripps's  plan  (vide  infra,  p.  926),  and,  to 
secure  asepsis  in  these  most  persistently  foul  cases,  it  would  be  well  to  try  the  application 
of  pure  carbolic  acid,  formalin,  and,  where  these  are  not  at  hand,  that  powerful  styptic 
and  disinfectant,  turpentine  (vol.  i.  p.  745). 

f  Brit.  Med.  Jour  11.,  October  5,  1867.  Mr.  G.  H.  Porter  (Dub.  Jottrn.  Med.  Sei.,  vol.xxx. 
N.  S.  i860,  p.  302)  reports  three  cases,  and  alludes  to  two  under  'his  father's  care.  All 
were  successful,  though  secondary  haemorrhage  occurred  in  two. 

58-2 


gi6  OPERATIONS    ON    THE    LOWEB    EXTREMITY 

6.  As  a  Preparatory  Step  to  Amputation  at  the  Hip-joint. — The 
need  of  this  lias  heen  largely  done  away  with  by  the  adoption  of  other 
preferable  steps  (p.  875). 

Link  and  Guide. — From  a  point  mid  way  between  the  anterior 
superior  spine  of  the  ilium  and  symphysis  pubis  to  the  adductor 
tubercle,  and  the  inner  margin  of*  the  internal  condyle. 

Relations:  In  Front. 

Skin;  fascial ;  lymphatic  glands. 

Crural  branch  of  genito-crural.     Sheath. 

Outside.  Inside. 

Anterior  crural.  Common  femoral.  Septum  of  sheath. 

Femoral  vein. 
Behind. 
Sheath. 
Psoas. 
It  is  important  to  note  that  the  common  femoral  is  usually  only  an 
inch  and  a  half  long,  and  that  from  it  come  off  not  only  the  superficial 
epigastric,  circumflex  iliac,   and  superior  and  inferior  external  pudic, 
hut  occasionally  one  of  the  circumflex  arteries  as  well. 
Collateral  Circulation  (Fig.  378). 

Above.  Below. 

Glutseal  and  sciatic,  with          Superior  perforating  and  cir- 

cumflex arteries. 

Superficial  circumflex  iliac,  with         Ascending    branch   of   exter- 

nal circumflex. 

( obturator,  with         Internal  circumflex. 

Comes  nervi  ischiadici,  with         Perforating  of   profunda  and 

articular  of  popliteal. 

Operation. — The  groin  having  heen  shaved  and  cleansed,  the  hip 
and  knee  semiflexed,  and  the  limb  abducted  and  rotated  somewhat 
outwards,  an  incision  about  two  and  a  half  inches  long  is  made  in  the 
line  of  the  artery,  commencing  just  above  Poupart's  ligament.  The 
skin  and  superficial  fascia  having  been  divided,  and  any  overlying 
glands  displaced  or  removed,  any  veins  which  may  be  met  with 
descending  to  join  the  internal  saphena  are  either  drawn  aside  or  tied 
between  double  ligatures.  The  fascia  lata  having  been  opened  just 
below  Poupart's  ligament,  the  artery  or  its  pulsation  is  felt  for,  the 
vessel  exposed  here,  and  the  needle  passed  from  within  outwards, 
care  being  taken  to  avoid  the  crural  branch  of  the  genito-crural  nerve, 
which  lies  superficial  to  the  artery.  The  neighbourhood  of  any  branch 
is,  if  possible,  avoided.  The  wound  is  then  most  carefulhy  dried  out 
and  closed. 

SUTURE    OF    WOUNDS    OF    LARGE    VESSELS. 

This  method,  adapted  to  many  wounds  elsewhere  (e.g.,  vol.  i.  p.  343), 
is  referred  to  here,*  because  it  was  in  this  region  that  the  illustrious 
surgeon  who  has  advocated   it  first  proved  its  feasibility. 

*  While  this  subject  has  been  dealt  with  h<Te  as  it  was  in  the  case  of  the  femoral 
vessels  that  Dr.  Murphy  proved  the  value  of  his  experimental  work,  the  method  of  suture, 


SUTURE   OF    WOUNDS   OF    LARGE   VESSELS.  917 

Dr.  J.  B.  Murphy,  of  Chicago,  drew  attention  to  the  feasibility  of 
resection  and  end-to-end  suture  of  arteries  and  veins  (New  York  Med. 
!!<<•.,  Jan.  16,  1897).  Technique. — The  points  to  be  considered  are  : 
(1)  Complete  asepsis;  (2,)  exposure  of  the  vessel  with  as  Little  injury 
as  possible;  (3)  temporary  suppression  of  the  blood  current ;  (4)  con- 
trol of  the  vessel  while  the  suture  is  applied;  (5)  accurate  approxima- 
tion of  the  walls;  (6)  perfect  hse  mo  stasis  by  pressure  after  the  clamps 
are  taken  off;  and  (7)  "toilet"  of  the  wound.  Some  of  the  above  are 
considered  in  detail.  Thus  for  control  of  the  haemorrhage  forceps 
with  broad  blades,  covered  with  tubing  and  a  graduated  catch,  are 
preferred.  They  are  closed  just  sufficiently  to  control  the  hemor- 
rhage, and  hold  the  vessel  in  the  correct  position  for  approximation.* 
If  such  an  instrument  is  not  at  hand,  a  stout  silk  ligature  may  be  used  ; 
it  must  not  be  tied  so  tightly  as  to  injure  the  intima,  and  is  best 
secured  with  a  loop-knot,  so  as  to  be  readily  removed. 

Ordinary  fixation-forceps  should  never  be  applied  to  the  vessel  itself, 

Fig.  375. 


Murphy's  method  of  invagination  of  artery.     Insertion  of  sutures. 

only  to  the  adventitia.  The  intima  should  be  especially  avoided.  The 
most  useful  needles  are  the  fully-curved  sharp  and  round  conjunctiva 
needles,  but  ordinary  fine  cambric  needles,  if  with  a  large  eye,  may  be 
employed.  The  most  serviceable  suture  is  silk.  The  sutures,  inter- 
rupted, should  be  inserted  about  every  one-twentieth  of  an  inch,  entering 
one-sixteenth  of  an  inch  from  the  edge  of  the  wound,  and  should  not 

with  or  without  resection,  of  large  blood  vessels  will  arise  elsewhere,  e.g.,  in  the  case  of 
wounds  of  the  axillary  vessels  in  operations  for  carcinoma,  especially  where  much  scar 
tissue  is  present,  and  sufficient  exposure  is  difficult  and  inadequate.  Injuries  to  the 
common  femoral  vessels  already  alluded  to  (p.  913)  are  another  instance  ;  in  fact  Dr. 
Murphy's  results  and  method  must  now  be  followed  in  every  case  of  injury  to  large  vessels 
where  the  surgeon's  surroundings  are  favourable,  and  where  the  injured  vessel  can  be 
commanded.  The  following  papers  should  be  referred  to  :  "  Injuries  to  the  Axillary 
Vessels  during  Operations,"  by  Dr.  R.  R.  Smith,  of  Michigan  (Ann.  0/ Surg.,  May,  1904, 
P-  757)i  ancl  Dr.  Halstead  (Med.  Bee,  1901,  p.  81)  ;  and  "An  Experimental  Study  of 
Suture  of  Arteries"  by  Dr.  G.  M.  Dorrance,  of  Philadelphia  [Ann.  of  Surg.,  Sept.,  1906. 
p.  409),  a  carefully  detailed  and  candid  record  of  valuable  experimental  work.  In  the 
same  periodical  for  July,  1904,  p.  107,  Dr.  G.  Torrance  records  a  case  of  secondary 
haemorrhage  from  the  brachial  artery,  a  week  after  an  injury  successfully  dealt  with  by  a 
purse-string  suture  of  the  vessel,  protected  by  a  muscle-graft. 
*  Such  forceps  have  been  introduced  by  Crile  (vol.  i.  p.  763). 


gi8 


ol'KUATIONS   ON   TIIK    LOWEB    EXTREMITY. 


include  the  intima,  on  account  of  the  risk  of  endarteritis  and  throm- 
bosis. If  one-half  or  more  of  the  artery  be  wounded,  the  first  suture 
should  be  placed  in  the  middle,  then  one  at  each  angle.  When  all  the 
sutures  have  been  tied — the  tying  should  not  be  too  tight — the  com- 
pression forceps  are  removed,  and  first  from  the  distal  end.  If  there 
should  he  haemorrhage  from  the  needle  punctures  compression  with 
the  fingers  or  gauze  will  be  sufficient  to  control  it,  as  a  small  thrombus 
forms  in  each  puncture.*  When  it  is  possible,  support  should  be  given 
by  suturing  over  the  line  of  approximation  the  sheath  of  the  vessel, 
or  some  muscular  or  fascial  tissue.  The  field  of  the  operation  should  be 
thoroughly  cleansed  and  drained  by  gauze,  this  being  removed  in  forty- 
eight  hours.  In  bullet  wounds  the  bullet  should  be  removed,  as  it  might 
be  a  source  of  infection.     Dr.  Murphy  has  found  that  when  more  than 


Fig.  376. 


Murphy's  method  of  invagination  of  artery.     Insertion  of  external  sutures. 
Completion  of  invagination. 

half  the  vessel  is  destroyed,  it  was  not  advisable  to  suture  the  vessel  end- 
to-end,  but  to  make  a  resection  of  the  injured  portion  and  to  produce 
an  end-to-end  union  by  invagination.  The  sutures  are  introduced  as 
shown  in  Fig.  375 ;  two  or  three  double-needled  threads  are  inserted 
into  the  end  of  the  proximal  portion,  including  only  the  two  outer 
coats  ;  these  are  reinserted  at  regular  intervals  one-third  to  one-half  inch 
above  the  end  into  the  distal  part  from  within  outwards  ;  the  threads 

*  Dr.  Brewer,  of  New  York  (  Ann.  of  Surg.,  1904,  ii.  p.  857),  mentions  two  cases  of  suture 
of  large  vessels,  one  of  which  bears  on  (he  point  just  mentioned.  Here  the  external  iliac 
artery  had  been  injured  l.y  a  large  Hagedorn's  needle.  The  wound  was  about  one  quarter 
of  an  inch  in  length.  The  hemorrhage  being  arrested  by  proximal  pressure  and  the 
wound  freely  exposed,  the  edges  of  the  wound  were  satisfactorily  brought'together  by  two 
or  three  sutures  of  fine  silk  including  all  the  coats  save  the  intima.  As  soon  asithe  full 
force  of  the  circulation  was  restored  the  stitches  began  to  cut  through,  and,  in  a  few 
moments,  the  wound  was  entirely  reopened.  A  second  attempt  was  made  with  sutures 
inrluding  more  of  the  wall,  reinforced  by  drawing  some  areolar  tissue  over  them,  but  the 
result  was  the  same.  The  artery  was  accordingly  tied  and  no  untoward  results  followed. 
In  the  second  case,  where  the  axillary  artery  had  been  injured  by  another  surgeon,  Dr 
Brewer  successfully  sutured  the  wound,  which  was  nearly  half  an  inch  long. 


SUTURE   OK   WOUNDS   OF    LARGE    VESSELS.  919 

are  then  tied,  and  this  invaginates  the  artery.  In  order  to  facilitate 
the  invagination,  a  small  incision  is  made  parallel  to  its  long  axis,  ex- 
tending from  one-fourth  to  one-third  of  an  inch.  Next  four  or  five  inter- 
rupted sutures  are  inserted  into  the  intussuscipiens,  binding  it  to  the 
surface  of  the  intussuseeptum,  the  sutures  in  the  latter  entering  only  the 
tunica  adventitia  and  media.  By  this  method  (Fig.  376)  a  large  surface 
contact  of  vessel  is  secured,  the  proximal  portion  being  inserted  into 
the  distal.  Dr.  Murphy  considers  that  this  method  of  suturing  vessels  is 
indicated  not  only  in  injuries  but  also  in  aneurysms*  of  large  vessels. 

In  the  first  class  of  cases,  i.e.,  injuries  to  large  vessels  in  operation, 
the  injury,  if  less  than  two-thirds  of  the  circumference  be  involved, 
should  be  immediately  repaired  by  suture.  If  more  than  two-thirds  be 
injured,  the  division  should  be  made  complete,  and  the  invagination 
method  used,  with  the  precautions  already  given.  The  edges  of  the 
wound  should,  if  necessaiy,  be  cut  clean  before  the  sutures  are  inserted. 

In  traumatic  aneurysms,  recent  and  old,  the  opening  in  the 
artery  is  usually  small  and  a  sufficient  quantity  of  aneurysmal  stump 
may  be  retained  to  produce  a  firm  line  of  approximation.  The 
aneurysmal  sac  should  be  freely  opened  and  enucleated  down  to  the 
position  of  the  opening.  The  edges  of  this  should  be  refreshed  and 
closed,  the  same  technique  being  observed  as  in  primary  suture. 

In  the  fourth  class  of  cases,  i.e.,  sacculated,  fusiform  and  arterio- 
venous aneurysms,  the  aneurysmal  sac  should  be  exposed  and  dissected 
down  to  the  position  of  the  healthy  coats  of  the  artery,  where  it  should 
be  amputated,  leaving  sufficient  of  the  aneurysmal  coat  and  arterial 
wall  to  allow  a  row  of  sutures  involving  one-sixteenth  of  an  inch  of  the 
margin  on  either  side. 

The  paper  is  accompanied  by  the  account  of  numerous  experiments, 
and  two  brilliantly  successful  cases.  The  evidence  thus  acquired  has 
led  Dr.  Murphy  to  believe  that  the  risk  of  thrombosis  is  greatly 
exaggerated,  and  that  as  the  resisting  power  of  the  walls  at  the  point 
of  invagination  is  above  normal,  the  danger  of  rupture  and  dilatation 
as  well  as  that  of  thrombosis  is  lessened,  as  while  the  diameter  of  the 
vessel  at  that  point  is  smaller,  the  current  is  more  rapid.  He  admits 
that  after  suture  there  is  a  tendency  to  endarteritis  obliterans.  But 
this  process  is  a  slow  one,  and  while  it  is  occluding  the  vessel, 
collateral  circulation  is  being  established. 

The  following  are  abstracts  of  the  two  cases  : — 

Case  1. — A  man.  set.  33,  was  wounded  by  a  bullet  in  the  left  Scarpa's  triangle.  From  the 
profuse  haemorrhage,  the  presence  of  a  large  swelling  without  pulsation  or  bruit,  and  the 

*  Dr.  Matas  (Tram.  Amer.  Surg.  Assoc,  vol.  xx.  p.  416)  thus  criticises  Dr.  Murphy's 
proposals  for  dealing  with  aneurysms  and  compares  them  with  his  own,  the  details  of 
which  are  given  below  (p.  981).  "  Murphy's  suggested  operation  is  practically  an 
extirpation  of  the  sac,  and  as  such  is  fraught  with  all  the  difficulties  of  this  operation 
with  the  added  difficulty  of  suturing  the  openings  in  the  vessel  itself.  He  has  also  over- 
looked the  fact  that  in  fusiform  aneurysms  the  continuity  of  the  main  artery  is  lost  for  a 
considerable  distance  in  the  sac,  where  it  merges  completely  with  the  aneurysmal  walls  ; 
hence  the  impracticability  of  resecting  the  sac  by  the  method  he  suggests.  In  the 
sacciform  and  arterio-venous  aneurysm  his  procedure  is  perfectly  feasible,  but  the  same 
result  can  be  accomplished  by  the  much  easier  and  safer  plan  described  in  this  contribu- 
tion." Dr.  Bicknell,  of  New  York,  discusses  the  application  of  the  Matas  method  to 
arterio-venous  aneurysms  (Ann.  of  Surg.,  May,  1904,  p.  767). 


920  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

fact  that  the  left  posterior  tibial  artery  pulsated  naturally  it  was  believed  that  the  femoral 
vein,  and  not  the  artery,  was  injured.  A  free  incision  parallel  with  the  artery  showed 
that  the  bullet  had  first  passed  through  the  internal  saphenous  vein.  The  two  openings 
on  its  anterior  and  posterior  surfaces  were  closed  with  continuous  silk  sutures.  The 
tion  being  continued,  a  similar  perforation  was  found  in  the  femoral  vein  a  little 
above  the  junction  of  the  profunda.  Much  difficulty  was  met  with  in  controlling  the 
haemorrhage,  as  the  blood  returned  through  the  profunda  vein  when  the  clamps  were 
placed  upon  the  femoral  vein  above  and  below  the  opening.  As  it  was  found  impossible 
to  close  the  posterior  opening  without  dividing  the  profunda  vein,  this  was  done  between 
two  ligatures.  It  now  being  possible  to  turn  the  posterior  opening  forward,  this,  like  the 
anterior  opening,  was  closed  with  a  continuous  silk  suture.  After  the  removal  of  the 
clamps  a  little  blood  escaped  from  the  postero-inferior  angle  of  the  wound  in  the  vein  ; 
this  was  arrested  by  an  additional  suture.  The  femoral  artery  had  a  fragment  of  tissue 
torn  off  from  the  side  of  its  sheath,  but  the  vessel  wall  was  not  injured.  The  wound  was 
sponged  out  with  a  5  per  cent,  solution  of  carbolic  acid  and  closed  without  drainage. 
Owing  to  infection  by  the  bullet,  the  wound  suppurated.  It  was  opened  and  a  gauze 
drain  inserted.  Suppuration  continued  about  a  month  after  the  first  operation,  and  con- 
siderable haemorrhage  occurred  through  a  small  opening  which  remained.  A  large  and 
very  tense  haeniatoma  formed  without  pulsation.    About  a  month  after  the  first  operation, 


--" FT~ 

Degree  of  destruction  of  artery  ;  portion  removed  and  appearance  after 
invagination  in  Dr.  Murphy's  second  case. 

Dr.  Murphy  Laid  the  swelling  open  and  turned  the  clots  out ;  smart  arterial  haemorrhage 
followed,  arrested  by  digital  pressure.  The  inner  side  of  the  artery  was  eroded  for  one 
inch,  and  showed  a  number  of  perforations.  About  one  and  a  half  inches  of  the  vessel  were 
resected  and  a  single  ligature  placed  on  the  distal  and  a  double  one  on  the  proximal  end. 
Some  fragments  of  the  femur  broken  off  by  the  bullet  were  removed.  The  femoral  vein 
could  not  be  located.     The  patient  made  a  complete  recovery. 

Que  2. — A  man,  act.  29,  received  a  bullet  wound  about  one  and  a  half  inches  below 
Poupart's  ligament.  About  a  fortnight  later  a  loud  bruit  and  thrill  were  apparent  at  this  spot. 
No  mention  is  made  of  primary  haemorrhage.  The  artery  was  exposed  by  a  five-inch  incision, 
and  a  provisional  ligature  thrown  round  it.  Compression-clamps  were  carefully  applied 
above  and  below  the  point  of  injury  to  the  artery  ;  on  elevating  the  artery  profuse 
haemorrhage  took  place  from  the  opening  in  the  vein.  A  cavity  about  the  size  of  a  filbert 
f'jund  posterior  to  the  artery  communicating  with  its  calibre,  forming  an  aneurysmal 
pocket.  A  small  aneurysmal  sac,  about  the  same  size,  was  found  on  the  anterior  surface 
of  the  artery  over  the  point  of  perforation.  The  bullet  had  passed  through  the  artery 
leaving  only  one-eighth  of  an  inch  of  the  wall  on  the  outer  side  and  one-sixteenth  on  the 
inner  :  it  had  then  passed  downwards  and  backwards,  making  a  large  hole  in  the  femoral 
vein  in  its  posterior  and  outer  aspect  just  above  the  junction  of  the  profunda  vein.  The 
hemorrhage  from  the  vein  was  profuse,  and  controlled  rir~t  by  digital  compression,  and 
later  by  dissecting  the  vein  free  above  and  below  the  point  of  injury  and  placing  a 
temporary  ligature  on  the  profunda  vein.  The  opening  in  the  femoral  vein  was  then 
sutured,  but  the  method  employed  is  not  specified.  When  the  clamps  were  removed,  the 
vein,  which  had  been  greatly  narrowed  at  the  point  of  suture,  dilated  one-third.    Attention 


LICATl'KK    OK    TIIK    SUPERFICIAL    FEMORAL.  921 

was  next  turned  to  the  artery.    Two  inches  of  this  were  freed  from  its  surroundings  ;  the 
opening  in  the  artery  was  threi  1  an  inch  in  length,  one  half-inch  was  resected 

(Fig.  377).  and  the  proximal  end  was  invaginated  into  the  distal  end  Eor  one-third  of  an 
inch  with  four  double-needled  threads,  which  penetrated  all  the  coats  of  the  artery  as 
shown  in  Pig.  375.  The  adventitia  was  peeled  off  the  invaginated  portion  for  a  distance 
of  one-third  of  an  inch,  a  row  of  sutures  were  placed  around  the  edge  of  the  overlapping 
distal  end.  the  sutures  penetrating  only  the  media  of  the  proximal  portion  ;  the  adventitia 
was  then  drawn  over  the  line  of  union  and  sutured.  Not  a  drop  of  blood  escaped  at  the 
line  of  suture.  Pulsation  was  immediately  restored  in  the  artery  below.  The  .sheath  and 
connective  tissue  around  the  artery  were  then  approximated  at  the  point  of  suture  with 
catgut  so  as  to  support  the  wall  of  the  vessel.  The  wound  was  closed  without  drainage. 
'  The  duration  of  the  operation  was  about  two  and  a  half  hours,  most  of  this  time  being 
spent  in  securing  the  vein.  Though  the  wound  suppurated  and  required  drainage,  a 
complete  recovery  followed. 

LIGATURE     OF    THE    SUPERFICIAL    FEMORAL    IN 
SCARPA'S    TRIANGLE   (Figs.  379  and  380). 

Indications. 

1.  Certain  Cases  of  Aneurysm  of  the  Popliteal  Artery  or  the  Femoral 
low  down. — Thus  the  ligature  will  probably  be  indicated — (a)  where  a 
popliteal  aneurysm  is  rapidly  growing,  especially  when  (b)  it  is  on  the 
anterior  aspect  of  the  artery  instead  of  behind  or  at  one  side  of  it,  as 
in  the  former  case  the  knee-joint  may  become  involved  after  very 
obscure  symptoms  ;  (c)  when  the  aneurysm  is  fusiform  rather  than 
saccular ;  (d)  when  it  has  veiy  thin  walls ;  (e)  when  it  threatens  to 
burst,  or  when  this  has  already  happened,  unless  other  symptoms — 
e.g.,  gangrene — call  for  amputation ;  (/)  if  visceral  disease — cardiac, 
renal,  hepatic — or  an  atheromatous  condition  of  the  vessels  is  present, 
the  surgeon  must  weigh  carefully  the  question  of  operative  interference  : 
I  should  prefer  in  most  cases  a  trial  of  the  ligature  as  likely,  with  the 
aid  of  antiseptic  precautions,  a  modern  ligature  and  primary  union,  to 
entail  less  taxing  of  the  patient's  powers.  On  this  point,  so  difficult 
of  wise  decision,  I  may  say  that  of  the  seven  cases  in  which  I  have 
ligatured  the  superficial  femoral  for  popliteal  aneurysm  the  only  one 
that  ended  in  failure  was  that  of  a  man  a3t.  65,  with  diseased  arteries 
and  interstitial  nephritis.  Owing  to  the  restlessness  and  want  of 
amenability  of  the  patient  I  decided  against  a  trial  of  pressure.  The 
greatest  difficulty  was  met  with  in  keeping  the  patient  still,  and 
gangrene  followed,  fatal  on  the  fifth  day ;  {g)  where  a  trial  of  pressure 
has  failed,  or  is  certain  to  fail  from  the  irritability  of  the  patient. 
Matas's  operation  is  given  at  p.  981,  and  his  method  and  that  of 
Antyllus  are  compared  at  p.  988. 

2.  Wounds. — Nothing  need  be  added  here  to  what  is  said  on  the 
subject  at  pp.  913  and  917. 

3.  For  Haemorrhage  low  down — e.g.,  after  amputation  in  the  middle 
of  the  thigh,  when  other  means  fail  and  the  wound  is  nearly  united 
(p.  927).  Two  other  instances  are  given  by  Mr.  Bryant  {Surgery, 
vol.  ii.  p.  417). 

One  was  "  a  case  of  Mr.  Bransby  Cooper's  in  which  a  compound  fracture  of  the  leg  was 
complicated  with  a  laceration  of  the  femoral  artery.  The  artery  was  secured  at  the  seat 
of  injury,  and  repair  went  on  well  in  all  respects.  Mr.  Bransby  Cooper  has  also  recorded 
in  his  Surgical  Essays  a  ease  of  fracture  of  the  femur  in  which  the  femoral  artery  was 
ligatured  for  a  ruptured  popliteal  artery,  and  in  which  recovery  took  place  in  six  weeks." 


922  OPERATIONS   ON   THE    LOWEB    EXTREMITY, 

Each  of  such  cases  must  be  considered  on  its  own  merits,  but  the 
above  shows  what  ligature  of  the  femoral  artery  will  do  in  appropriate 
cases. 

4.  For  Elephantiasis. — Cases  in  which  the  superficial  femoral  has 
been  tied  will  be  found  in  the  Lancet  for  1879,  vol.  i.  p.  44 ;  and 
Ranking's  Abstract  for  i860,  vol.  ii.  p.  193.  The  subject  of  ligature 
of  the  main  artery  of  a  limb  for  this  affection  has  been  considered  at 
P-  3- 

Link. — That  above  given,  p.  916. 

Guide. — The  above  line  and  the  inner  border  of  the  sartorius  at  the 
apex  of  the  triangle. 

Relations. — 

In  Front. 

Skin  ;  superficial  fascia  ;  glands  ;  crural 
branch  of  genito-crural  nerve  ;  middle 
cutaneous  and  branch  of  internal  cu- 
taneous ;  fascia  lata  ;  sartorius. 

Outside.  Inside. 

Femoral  vein   (below).     Ante-  Femoral  vein  (above), 

rior  crural  nerve,  and  some 
of  its  branches — viz.,  the 
nerve  to  the  vastus  internus, 
and  long  saphenous  nerve. 

Behind. 

Psoas  ;  pectineus ;  adductor  longus  ;  fe- 
moral vein  (below)  ;  profunda  artery 
and  vein  ;  nerves  to  pectineus. 

Collateral  Circulation. 

Above.  Below. 

Perforating  of  profunda,  with     Lower  muscular  and  anastomotic 

of  femoral,  articular  of  popli- 
teal, and  anterior  tibial  recur- 
rent. 

External    circumflex    of 

profunda,  with     Ditto  ditto. 

Comes  nervi   ischiadici,  with     Perforating    of     profunda    and 

articular  of  popliteal. 

Operation. — (Figs.  379,  380). — The  parts  having  been  sterilised, 
the  knee  and  hip  slightly  flexed,  the  thigh  abducted  and  somewhat 
everted,  and  the  leg  resting  on  a  pillow,  the  surgeon,  seated  or  standing 
to  the  right  of  the  affected  limb,  makes  an  incision  three  inches  long 
in  the  line  of  the  artery  (p.  916).  This  should  begin  about  two  inches 
and  a  half  below  Poupart's  ligament,  and  run  down  to,  and  somewhat 
below,  the  apex  of  Scarpa's  triangle,  which  lies  usually  four  to  five 
inches  below  Poupart's  ligament.  The  skin  and  superficial  fascia 
having  been  divided,  any  small  vessels  are  secured,  and  branches  of 
the  saphena  vein  drawn  aside  with  a  strabismus  hook  or  secured  with 
double  ligatures.     The  deep  fascia  is  now  slit  up  for  the  whole  length 


LIGATURE   OF   THE   SUPERFICIAL    FEMORAL. 


923 


Fig.  378. 
Ilio-lumbar  branch  of  internal  iliac, 


Deep  circumflex  iliac, 


Profunda 

External  circumflex. 


Superior  extenial  arti 
cular 


Inferior  external  arti- 
cular   

Posterior  1  ibial  recur- 
rent    .. 

Anterior  tibial  recur- 
rent    

Superior  fibular 


( lommon  iliac. 


[ntemal  iliac. 
Deep  epigasl  tic. 

External  iliac. 
( (bturator. 

Common  femoral. 
Sciatic. 

Internal  pudic. 
Internal  circumflex. 
Superficial  femoral. 


Perforati  1 1  g    bra  ncb.es 

of  profunda. 


Anastomotica  magna. 
Popliteal. 

Superior  muscular 
branches  of  pop- 
liteal. 


Superior  internal  arti- 
cular. 


[nferior  internal  arti- 
cular. 
Posterior  tibial. 

Anterior  tibial. 


Anastomotic  circulation  of  the  iliac  and  femoral  arteries.      (MacCormac.) 


of  the   wound,  and   the   inner   margin  of  the  sartorius,  which   crosses 
the  lower  part  of  the  incision,  identified.     This  is  then  held  outwards, 


924 


OPERATIONS   ON   THE   LOWER    EXTREMITY. 


while  the  artery  or  its  pulsation  is  felt  for.  The  wound  being  now 
well  opened  out  with  retractors  and  carefully  wiped  out,  the  sheath  is 
opened  to  the  outer  side,  care  being  taken  to  avoid  the  nerves  in 
contact  with  it — viz.,  the  long  saphenous,  and  the  nerve  to  the  vastus 
interims.  The  artery  having  been  cleaned,  thoroughly  but  most  care- 
fully, ou  either  side'  and  behind,  the  needle  is  passed  from  within 
outwards,  being  kept  very  close  to  the  vessel  so  as  to  avoid  the  vein 
which  lies  behind  and  internally.*  The  artery  having  been  tied,  the 
ligature  is  cut  short,  drainage  provided  according  to  the  amount  of 
disturbance  of  the  parts,  &c.  and  the  wound  closed.  The  precautions 
given  at  p.  7  for  the  prevention  of  gangrene  must  be  taken. 

Fig.  379. 


Ligature  of  the  common  femoral,  and  the  superficial  femoral  at  the  apex  of 
Scarpa's  triangle.     The  ligature  in  each  case  has  been  passed  from  within  outwards. 

(Sedillot.) 

Difficulties  and  Mistakes. 

I.  Wounding  the  Saphena  Vein.  — This  may  occur  if  the  incision  is 
made  too  internal.     It  is  always  to  be  avoided  if  possible,  owing  to  the 


*  The  vein  is  so  frequently  damaged  here,  especially  on  the  dead  subject,  that  a  few 
precautions  may  be  given  as  to  the  best  way  of  avoiding  it.  First,  the  sheath  must  be 
identified  exactly,  and  sufficiently  opened  at  its  outer  part.  It  will  be  found  of  much 
help  in  cleaning  the  vessel  if  one  edge  of  the  cut  sheath  is  held  by  an  assistant,  while  the 
Burgeon  lias  hold  of  the  other  ;  the  opening  in  the  sheath  is  thus  made  sure  of  and  retained. 
There  must  be  no  needless  disturbance,  or  lifting  up  of  the  vessel  upon  the  needle,  which, 
with  the  director,  must  be  used  with  the  utmost  carefulness.  As  soon  as  the  eye  (and  this 
should  be  at  the  very  end  of  the  needle)  is  seen  to  have  passed  round  the  vessel  the  ligature 
should  be  at  once  seized,  and  the  needle  withdrawn.  On  the  dead  body  the  apparent 
thickness  due  to  the  solid  thrombosis  in  the  vein,  in  subjects  prepared  with  formalin,  must 
not  lead,  here  or  elsewhere,  to  this  vessel  being  mistaken  for  the  artery. 


LIGATURE    OF    THE   SUPERFICIAL    FEMORAL.  925 

troublesome  oedema  which  may  follow.  2.  A  very  broad  Sartorius. 
3.  Injury  to  the  Femoral  Vein. — This  may  easily  take  place  if  force  is 
used  in  pushing  the  needle  round  an  imperfectly  cleaned  artery,  or  if 
the  needle  is  not  kept  close  to  the  vessel.  If  the  accident  occur,  the 
surgeon  must  not  persist  in  his  attempt  to  tie  the  artery  at  this  spot,  a 
course  which  will  only  end  in  his  inflicting  more  injury  in  the  vein,  but 
finger-pressure  being  made  in  the  lower  angle  of  the  wound,  the  artery 
is  tied  either  above  or  below  the  spot  where  the  vein  has  been  injured. 
As  soon  as  the  artery  is  secured,  no  further  haemorrhage  will  take  place, 


Dissection  of  parts  concerned  in  ligature  of  the  femoral  artery  at  the  apex  of 
Scarpa's  triangle.  1.  Fascia?.  2.  Sartorius.  3  and  4.  Superficial  femoral  artery 
and  vein. 

but  pressure  may  be  kept  up  by  means  of  sterilised  dressings  over  the 
wound  for  a  day  or  two.*  The  patient  will  do  well  to  wear  a  Martin's 
bandage  or  an  elastic  stocking  for  some  time  after  getting  up.  4.  In- 
cluding one  of  the  nerves.  5.  A  matted  condition  of  the  parts  due  to 
a  previous  trial  of  compression. 

Abnormalities   of   the    Femoral    Artery. 

1.  A  double  superficial  femoral,  the  two  trunks  uniting  below  to  form  the  popliteal. 
More  than  one  case  of  this  kind  is  recorded.  The  persistence  of  pulsation  in  the  aneurysm 
after  the  first  ligature  would  lead  to  a  suspicion  of  this  condition.  2.  The  vessel  may  run 
down  at  the  back  of  the  limb. 

*  If  venous  haemorrhage  persist,  the  opening  in  the  vessel  should  be  secured  by  suture 
(p.  917),  or  a  pair  of  Spencer  "Wells's  forceps  left  in  situ  (p.  913). 


926 


OPERATIONS    ON    TIIK    LOWER    EXTREMITY. 


LIGATURE  OF  THE  FEMORAL  ARTERY  IN  HUNTER'S 
CANAL  (Fig.  382).— TREATMENT  OF  A  STAB  IN  MID- 
THIGH   (Fig.  381). 

Indications  for  Ligature  of  the  Femoral  Artery  in  Himtor's  Canal. 
I.  Wounds. — These  may  be,  (a)  incised;  (b)  punctured. 
(a)  The    artery  above   is    controlled  by  an  Esmarch's  bandage  or 
the  hands  of  an  assistant    or   provisionally  secured  by  a  loop  of  silk 

immediately  above  the  wound  in  it, 
or  clamps  (p.  917)  if  these  are  at 
hand.  The  wound  is  then  enlarged 
and  the  vessel  dealt  with  according 
to  the  directions  given  at  p.  917, 
if  possible.  Only  if  the  conditions 
do  not  admit  of  this  is  the  artery 
to  be  tied  above  and  below  the  wound 
in  it.  If  the  vein  is  injured  also, 
suture  is  still  more  strongly  indi- 
cated ;  if  ligatures  are  applied,  the 
patient  or  the  friends  must  be  pre- 
pared for  the  possibility  of  imminent 
need  of  amputation.  Here,  as  in  all 
cases,  where,  owing  to  the  hurry, 
sterilisation  of  the  parts  may  have 
been  imperfect,  a  boracic  acid  fomen- 
tation should  be  applied.  The  limb 
should  be  secured  on  a  splint,  and 
the  foot  of  the  bed  raised. 

(b)  If  a  punctured  wound  lies  in 
the  line  of  the  artery  (p.  916),  and 
if  much  blood  has  been  lost,  the 
main  trunk  is  probably  injured,  and 
the  question  will  arise,  if  the  bleed- 
ing has  ceased,  whether  to  cut  down 
upon  the  artery  or  to  trust  to  pres- 
sure. Mr.  Cripps  {Diet,  of  Surg., 
vol.  i.  p.  525)  advises  that,  if  the 
wound  be  in  the  upper  part  of  the 
thigh,  "  the  surgeon  may  enlarge 
the  wound  with  a  good  prospect  of 
finding  the  wounded  vessel  without 
an  extensive  or  prolonged  operation.  If  the  wound  be  in  the  lower 
half  of  the  thigh,  owing  to  the  greater  depth  of  the  artery  and  the 
possibility  of  its  being  the  popliteal  which  is  wounded,  the  search  is 
rendered  far  more  severe  and  hazardous,  and  it  should  not  be  taken 
until  a  thorough  trial  of  pressure  has  proved  ineffectual." 

The  following  mode  of  applying  pressure  is  taken  from  Mr.  Cripps 
(lor.  supra  cit.).*  I  would  also  refer  my  readers  to  tli"  account  of 
punctured  wound  of  the  palm  given  at  p.  36,  Vol.  I.,  of  this  work. 

*  Mr.  < !ripps  draws  attention  i"  the  instructiveness  "f  the  literature  of  this  subji 
it  pruves  not  only  that  many  cases  have  been  successfully  treated  by  pressure  from  the 


[ncised  wound  of  the  thigh  explored  and 
found  to  involve  the  femoral  artery. 


LKJATUllK    OF    TIIF    FKMOI5AL    ARTKRY. 


927 


The  main  vessel  having  been  controlled  above,  the  foot  and  leg  should 
be  carefully  strapped  from  the  toes  to  the  knee,  and  a  bandage  then 
carried  from  the  toes  up  to  the  wound,  and  then,  avoiding  this,  up  to 
the  groin,  where  it  is  secured,  spica-fashion,  over  a  pad  on  the  main 
artery.  The  limb  is  then  laid  on  a  long  back  splint  with  a  foot-piece, 
and  secured  to  this  in  an  elevated  position.  The  wound  having  been 
sterilised,  a  graduated  gauze  compress  is  then  fastened  over  it.  Two 
sterilised  rectal  bougies  are  then  applied  in  the  course  of  the  artery, 
above  and  below  the  wound,  outside  the  bandage  which  surrounds  the 
limb,  so  as  to  keep  these  segments  of  vessel  empty.  Two  well-padded 
lateral  splints  are  then  secured  with  straps  and  buckles  to  the  thigh. 
The  toes  should  be  left  exposed  that  their  condition  may  be  watched. 
Morphia  must  be  given  as  freely  as  is  judicious. 

2.  Haemorrhage  from  a  Stump  after  Amputation  in  the  Lower  Third 
of  Thigh  or  Knee. — If  clearing  away  the  clots  and  disinfecting  the 
stump,  followed  by  well-adjusted  pressure,  and,  this  failing,  trying  to 
find  the  bleeding  point  in  the  flaps,  do  not  suffice,  the  artery  must  be 
tied  above.* 

Line  and  Guide  (p.  916). 

Relations  : 

In  Front. 
Saphena  vein. 

Skin  ;  fasciae  ;  sartorius  ;  aponeurosis  between 
vastus  internus  and  adductors. 

Outside.  Inside. 

Vastus  internus;  vein  (slightly).  Adductor  longus  and  magnus. 

Femoral  artery  in  Hunter's  canal. 

Behind. 
Femoral  vein  (especially  above). 

Operation  (Fig.  382). — The  knee  and  hip  having  been  flexed,  and 
the  limb  abducted  and  rotated  outwards,  the  surgeon,  seated  comfortably 
on  the  inner  side  of  the  limb,  makes  an  incision  three  inches  and  a 
half  long  in  the  line  of  the  artery  in  the  middle  third  of  the  thigh. t 
The  skin,  superficial  and  deep  fasciae,  having  been  divided,  and  the 
saphena  vein,  if  seen,  drawn  to  one  side  with  a  strabismus  hook,  or  an}r 
of  its  branches  divided  between  double  ligatures,  the  sartorius  is 
identified  by  the  direction  of  its  fibres  and  drawn  to  the  inner  side. 
The  canal  is  next  opened  by  dividing  the  aponeurotic  roof,  and  the 
artery    or  its  pulsation  felt  for.     The   vessel  will   be    found    closely 

first,  but  that  both  life  and  limb  have  been  saved  by  pressure  after  the  surgeon  has  failed 
to  find  the  artery  in  the  wound,  or  after  the  iliac  has  been  tied  in  vain. 

*  I  would  again  refer  my  readers  to  Mr.  Cripps's  article  (loo.  §upra  cif.,  p.  526).  He 
points  out  that  a  decision  between  opening  the  flaps  or  ligaturing  the  main  vessel  high 
up  must  depend  on  the  amount  of  union,  and  that  if  the  flaps  must  be  opened  and  the 
vessel  sought  for  before  there  is  much  firm  union,  as  in  the  first  fortnight,  a  director 
should  be  used  rather  than  a  knife,  and  that  if  the  vessel  is  found,  its  soft  condition  will 
require  very  gentle  tying. 

t  This  incision  must  not  be  made  too  low  down.  Its  centre  should  correspond  to  the 
centre  of  the  thigh. 


928  OPERATIONS   <>X    THE    LOWEB    EXTREMITY. 

connected  to  its  vein,  which  lies  behind  it,  while  the  saphenous  nerve 
crosses  it  from  without  inwards.  The  artery  having  been  most  care- 
fully cleaned  all  round,  the  ligature  may  be  passed  from  either  side,  as 
is  found  most  convenient. " 

Causes  of  Failure  after  Ligature  of  the  Femoral. 

I.  Gangrene.  2.  Secondary  Haemorrhage. — If  pressure  fail,  an 
attempt  must  be  made  to  re-tie  the  vessel,  and  this  not  succeeding, 
the  limb  must  be  amputated.  3.  Suppuration  of  the  Sac  of  an 
Aneurysm. — This  is  very  rare.  4.  Recurrent  Pulsation  in  the 
Aneurysm. — The  premature  softening  of  the  ligature,  especially  in  an 
infected  wound,   must  always  be  remembered  as  a  possible  cause  of 

Fig.  382. 


Ligature  of  the  femora]  artery  in  Hunter's canaL  The  Burgeon,  here  standing 
outside,  finds  the  furrow  between  the  adductors  ami  the  quadriceps,  and  then 
makes  an  incision  in  the  line  given  at  p.  916.  The  lower  lip  of  the  wound  having 
been  depressed  with  the  left  thumb,  the  deep  fascia  is  divided  011  a  director. 
( Farabeuf.) 

this.  Pressure  failing,  the  artery  may  be  tied  lower  down.  5.  A 
very  rare  complication  is  the  formation  of  an  aneurysm  at  the  seat  of 
ligature. 

AMPUTATION  THROUGH  THE  THIGH   (Figs.  383-386). 

Practical  Points  in  Amputation  of  the  Thigh. — The  operation 
should  always  be  performed  its  low  down  as  possible,  not  only  to  avoid 
shock  and  to  secure  as  long  a  stump  as  possible  for  the  artificial  limb,  but 
also  to  secure  as  much  as  possible  of  the  rectus  femoris.     This  muscle 


*  Much  difficulty  will  be  met  with  in  tying  the  femoral  artery  in  Hunter's  canal  unless 
the  line  of  the  artery  (p.  910)  is  strictly  followed.  A  common  mistake  is  to  make  the 
incision  too  far  out,  thus  exposing  the  fibres  of  the  vastus  interims,  which  run  downwards 
and  outwards,  instead  of  those  of  the  Bartorius,  which  run  downwards  and  inwards  (Smith 
and  Walsham,  Man.  of  Oper.  Surg.,  p.  83).  Sir  .!.  I-;.  E  icha  n  {Surgery,  v. .1.  ii.  p.  250), 
who  gives  as  the  line  of  the  artery,  one  drawn  from  a  point  exactly  midway  between  the 
anterior  superior  spine  and  the  symphysis  pubis  to  the  most  prominent  part  of  the  internal 
condyle,  in>i~ts  on  the  need  of  making  the  incision  a  finger' s-breadth  internal  to  this. 
The  line  which  I  have  given  above  will  be  found  sufficiently  internal. 


AMPUTATION    THKOI'OH    THE    TIIIOII. 


929 


is  :i  most  important  agent  by  which  the  thigh  is  put  forward  in  stepping. 
Its  division  does  not  preclude  the  retention  of  its  office,  as  it  acquires 
a  sufficient  adhesion  to  the  material  of  the  stump  to  answer  every 
useful  purpose,  as  an  agent  in  the  flexion  of  the  thigh  on  the  pelvis, 
though  that  of  extension  of  the  leg  be  destroyed  (Skey,  Oper.  Surg., 
P-  39*)- 

Different  Methods. — The  following  five,  which  will  give  ample 
choice,  will  alone  he  described  here ;  the  first  is  especially  recom- 
mended : 

T.  Mixed  Antero-posterior  Flaps  and  Circular  Division  of  the 
Muscles.  TT.  Antero-posterior  Flaps  by  Transfixion.  III.  The 
Circular  Method.     IV.     Rectangular  Flaps.      V.     Lateral  Flaps. 

I.  Mixed  Antero-posterior  Flaps  and  Circular  Division  of  the 
Muscles  (big.  383). — By  the  term  mixed  is  meant  an  anterior  flap  of 
skin  and  fasciae  raised  from  without,  and  a  posterior  one  made  by 
transfixion.  The  anterior  is,  wherever  practicable,  made  the  longer  of 
the  two. 

Fig.  383. 


I  The  knife  should  have  been  inserted  here  from  the  inner  side. 

This  method  has  the  following  great  advantages  .'  (1)  The  longer 
anterior  flap  falls  well  over  the  bone,  and  thus  keeps  the  scar  behind  ; 
(2)  being  raised  from  without  inwards,  it  can  be  taken  from  the 
neighbourhood  of  the  knee-joint  and  patella;  (3)  it  is  a  most  ex- 
peditious method,*  almost  as  quick  as  that  by  double  transfixion-flaps; 
(4)  it  is  suited  to  all  cases,  save  perhaps  those  of  very  muscular  thighs, 
where  the  surgeon  should  be  careful  to  take  only  part  of  the  muscles 
behind  as  he  transfixes,  or  else  should  raise  his  posterior  flap  also  from 
without  inwards  ;   (5)  it  gives  good  drainage. 

While  amputation  by  anterior  and  posterior  flaps  is  given  in  detail, 
the  surgeon  will  not  tie  himself  to  this  method,  but  use  such  modifica- 
tions as  that  by  antero-external  and  postero-internal  flaps.  Save  in 
cases  of  malignant  disease,  the  chief  object  is  to  save  as  much  of  the 
femur  as  possible  and  also  of  the  adductors.  The  length  of  the 
leverage  on  the  artificial  limb  is  thus  increased,  and  the  action  of  the 
abductors  better  counter-balanced. 


*  As  in  railway  and  other  accidents. 


-VOL.  II. 


59 


930 


ol'KRATInNS    ON    TIIK    L0WK11    EXTREMITY. 


Operation. — The  It-moral  artery  having  been  controlled  with  an 
Esmarch'8   bandage,*   the    limb,    a   sterile   towel   having   been    firsl 

bandaged  on,  being  brought  over  the  edge  of  the  table,  and  supported 
by  an  assistant  ;  the  opposite  ankle  being  tied  to  the  table,  and  tin-  parts 
duly  cleansed,  the  surgeon  standing  to  the  right  side  of  the  limb  to  be 
removed,  plaees  his  left  index  and  thumb  on  either  side  of  the  limb, 
at  the  level  where  he  intends  to  saw  the  bone,t  and  sinking  the  point 
of  his  knife  through  the  skin  just  below  the  former  and  rather  below 
the  centre  of  the  outer  or  inner  aspect  of  the  limb,  as  the  case  may  be, 
carries  it  rapidly  down  for  about  four  and  a  half  inches,  and  then 
sweeps  it  across  the  limb  with  a  broad,  not  pointed,  convexity,  and 
carries  it  up  along  the  side  nearest  to  him  as  far  as  his  thumb.  A  Map 
of  skin  and  fasciae,  muscle  being  taken  up  increasingly  towards  its  base, 
is  then  quickly  dissected  up,  and  the  knife,  being  sent  across  the  limb, 
behind  the  bone,  cuts  a  posterior  flap,  the  knife  being  used  with  a  rapid 
sawing  movement,  and  driven  at  first  straight  down  parallel  with  the 
bone,  and  then  sharply  brought  out  through  the  skin. 

The  flaps,  covered  with  gauze,  being  held  out  of  the  way  by  the 
surgeon's  left  hand,  I  the  soft  parts  around  the  femur  are  next  severed 
with  circular  sweeps  §  till  the  bone  is  exposed,  when  one  more  firm 
sweep  divides  the  periosteum. |j 

The  saw  is  now  placed  with  its  heel  on  the  bone  and  drawn  towards 
the  operator  once  or  twice  with  firm  pressure  so  as  to  make  one  groove, 
and  one  only.  With  a  few  sharp  sweeps  the  bone  is  next  severed,  care 
being  taken  to  use  the  saw  lightly  for  fear  of  splintering  the  linea 
aspera,  and  to  use  the  whole  length  of  the  instrument.  At  this  time 
the  limb  must  be  kept  steady  and  straight,  the  assistant  neither  raising 
it,  which  will  lock  the  saw,  nor  depressing  it,  which  will  splinter  the 
femur  when  this  is  partly  divided. 

If  the  surgeon  decide  to  make  his  posterior  flap  also  of  skin  and 
fascia?,  he  must  have  the  limb  raised,  and  first  looking  over  and  then 
stooping  down,  he  marks  out  a  skin  flap  about  two- thirds  the  length  of 
the  anterior ;  this  is  then  dissected  up,  and  the  operation  completed 
as  before. 

In  addition  to  the  femoral  vessels,  the  anastomotica,  and  descending 
branch  of  the  external  circumflex,  some  muscular  branches  will  require 
attention  ;  and  one  of  these  last  may  give  some  trouble  from  its  position 
close  to  the  bone,  in  contact  with  the  linea  aspera. 

The  following  points  deserve  attention  in  tying  the  femoral  vessels  : 
(i)  Not  to  include  the  saphenous  nerve  ;  (2)  the  tendency  of  the  vessels 
to  slip  up  if  the  point  of  their  division  passes  through  Hunter's  canal  ; 
(3)  if  the  vessels  are  atheromatous,  they  must  not  be  tied  too  tightly. 


*  If  the  surgeon  is  amputating  very  high  up,  the  metho.l  given  in  the  account  of 
amputation  at  the  hip-joint  (p.  875)  may  be  used. 

f  The  finger  and  thumb  should  not  be  shifted  till  the  anterior  flap  is  marked  out 

%  And  also  pressed  firmly  upwards,  so  as  to  enable  the  saw  to  be  applied  as  high  up  as 
le.     If  the  limb  is  bulky  an  assistant  must  help  here. 

§  This  requires  really  forcible  use  of  the  knife,  the  muscles  behind  the  bone  tending 
to  be  pushed  before  the  knife  rather  than  divided  by  it. 

||  This  final  cut  should  be  a  little  above  the  base  of  the  flaps,  in  order  that  the  sawn 
femur  may  lie  well  buried  in  soft  parts. 


AMPUTATION    THROUGH    THE   THIGH. 


931 


A  sterilised  silk  ligature,  not  too  fine,  should  be  employed  now,  and  care 
should  he  taken  to  include  a  little  of  the  soft  parts  so  as  to  prevent  the 
ligature  cutting  through. 

In  amputations  of  the  thigh  accompanied  by  grave  shock  (p.  883),  no 
time  should  be  lost  in  looking  for  vessels,  save  the  femoral  and  any  other 
large  branch  which  can  be  seen.  Firm  bandaging  and  raising  the  stump 
will  suffice.  It  is  well  to  partially  relieve  the  tightness  of  the  bandages 
in  a  few  hours  by  nicking  them.  Very  few  sutures  should  be  used  in 
these  cases  of  shock,  or  in  those  where  the  soft  parts  are  sinus-riddled. 

II.  Transfixion  Flaps  (Fig.  384). — Advantage. —  Great  rapidity. 
Disadvantages. — Those  given  at  p.  94,  Vol.  I.,  on  a  large  scale.  This 
method  may  be  used  where  much  speed  is  needed,  as  in  a  double 
amputation  after  a  railway  accident,  or  where  many  wounded  require 
attention,  as  after  a  great  battle.  It  is  also  adapted  to  the  wasted 
muscles  of  a  patient  who  has  long  suffered  from  some  chronic  disease  of 
knee  or  leg,  but  even  here  it  is  inferior  to  the  mixed  method. 


Fig.  384. 


Operation. — The  preliminary  steps  given  at  p.  930  being  taken,  the 
surgeon,  standing  to  the  right  side  of  either  limb,  with  his  left  index 
and  thumb  marking  the  site  of  his  intended  bone-section,  raises  with 
his  hand  the  soft  parts  on  the  front  and  sides  of  the  thigh,  and  sends 
his  knife  across  the  limb  in  front  of  the  femur.  The  knife  should  be 
entered  well  below,  so  as  to  get  as  large  an  anterior  flap  as  possible,  and 
at  its  entry  should  be  pushed  a  little  upwards  so  as  to  go  easily  over 
the  bone.  An  anterior  flap  is  then  cut  four  to  four  and  a  half  inches 
long,  with  a  broadly  curving,  almost  square  extremity,  and  not  too  thin 
at  its  edge.  This  being  raised  by  the  surgeon  or  an  assistant,  the  knife 
is  now  passed  behind  the  bone,  and  a  posterior  flap  cut  of  the  same 
length  as  the  anterior,  the  making  of  this  flap  being  somewhat  facilitated 
by  drawing  the  soft  parts  on  the  back  of  the  limb  away  from  the  bone. 

If  the  limb  be  very  bulky,  the  knife  should  be  kept  well  away  from 
the  bone,  especially  behind  it,  and  not  as  in  Fig.  384 ;  thus  the  more 
superficial  muscles  only  will  be  included  in  the  posterior  Hap. 

Both  flaps  having  been  retracted,  the  remaining  soft  parts  are  severed 
with  circular  sweeps,  and  the  rest  of  the  operation  completed,  as  at 

59"2 


932 


OPERATIONS    ON    THK    LOWER    EXTREMITY. 


]>.  (jjo,  but  with  this  difference,  that  here  there  will  he  more  need  of 
trimming  some  of  the  soft  parts  clean  and  square.* 

III.  The  Circular  Method. — I  may  here  state  briefly  why  this  method 
is,  nowadays,  considered  interior,  hoth  in  the  thigh  and  elsewhere,  to 
that  by  flaps.  In  saying  this,  it  is  not  denied  that  in  many  cases  stumps 
hy  the  circular  method  are  fully  equal  to  those  by  flaps  ;  indeed,  in  many 
it  is  impossible  to  tell,  in  later  years,  which  method  has  been  employed. 
On  the  whole,  however,  the  flap-method  has  the  following  advantages  : 
(i)  It  is  most  generally  applicable — e.g.,  in  most  parts  not  circular  and 
at  the  joints.!  (2)  By  it  the  surgeon  can  better  adapt  his  skin  covering 
to  his  needs — e.g.,  when  the  skin  is  less  available  on  one  aspect  of  the 
limb  than  on  another.  (3)  There  is  less  risk  of  a  conical  stump  ;  and 
(4)  of  a  cicatrix  adherent  to  the  bone.  The  great  advantage  of  the 
circular  method — viz.,  that  the  vessels  and  nerves  are  cut  square,  and 
that,  thus,  the  former  retracting  more  easily,  fewer  need  securing,  while 
there  is  less  risk  of  bulbous  ends  forming  on  the  latter — is  attained  by 

Fig.  385. 


Circular  amputation  of  the  thigh  to  show  the  greater  retraction  of  the 

muscles  behind. 

the  mixed  method  of  skin  flaps  and  circular  division  of  the  muscles  as 
advised  at  p.  930.  + 

The  circular  method  is  only  to  be  adopted  here  in  the  case  of  the 
lower  third  of  wasted  thighs,  or  in  those  of  young  subjects.  Even  here 
the  greater  tendency  of  the  posterior  muscles  to  retract  (Fig.  385)  must 
be  met  by  cutting  them  about  three-quarters  of  an  inch  longer  than 
those  in  front. 

While  this  operation  is  for  the  above  reasons  not  recommended  in 
practice,  it  may  be  made  use  of  in  the  lower  third  of  the  thigh  in  the 
cases  mentioned  above.  On  the  dead  subject,  the  student  who  has  not 
had  a  chance  of  performing  it  upon  the  arm,  may  make  use  of  it  here. 

Operation. — As  this  method  has  been  described  in  detail  at  pp.  98, 

*  While  dresser  to  the  late  Mr.  Poland,  I  once  saw  the  femoral  vessels  split  for  al>out 
three  and  a  half  inches  by  his  rapid  hands.  This  amputation  of  the  thigh  by  transfixion 
was  his  hist  operation  at  Guy's  Hospital.  He  was  even  then  facing  with  quiet  hraveness 
the  bronchitis  which,  a  very  few  days  later,  ended  his  life. 

t  To  these  it  maybe  added  thai  the  circular  method  is  not  adapted  to  a  case  where 
the  skin  is  matted  to  the  subjacent  muscles. 

J  <>ue  more  advantage  of  the  flap-method  is  the  greater  rapidity,  especially  when 
transfixion  is  employed,  though  this,  in  these  dayB  of  anaesthetics,  is  only  of  importance 
in  a  few  cases 


IMPUTATION    THKOICII    TIIK    TIIKJII. 


933 


157,  Vol.  I.,*  it  will  be  only  briefly  given  here.  The  preliminaries  are 
those  already  given.  The  surgeon  standing  to  the  right  of  the  limb,  the 
assistant,  who  stands  on  the  opposite  side  to  him,  but  nearer  the  trunk, 
draws  up  the  skin  with  both  hands.  The  surgeon,  stooping  a  little, 
passes  his  knife  first  under  the  limb  then  above,  across,  and  so  around 
it  till  by  dropping  the  knife  vertically  the  back  of  the  instrument  looks 
towards  him,  while  its  heel  rests  on  that  side  nearest  to  him.  He  then 
makes  a  circular  sweep  around  the  thigh,  this  being  aided  by  the  assistant 
who  lias  charge  of  the  limb  rotating  it  so  as  to  make  the  soft  parts 
meet  the  knife.  The  surgeon  then  taking  hold  of  the  edge  of  the 
incision,  dissects  up  a  cuff-like  flap,  about  four  and  a  half  inches  in  length, 
cutting  it  of  even  thickness  all  round  the  limb.  The  flap  is  then  folded 
back,  and  the  remaining  soft  parts  divided  with  circular  sweeps  of  the 
knife.  In  doing  this  the  greater  contraction  of  the  hamstring  muscles 
must  be  remembered  (Fig.  386),  and  these  muscles  cut  rather  longer 

Fig.  386. 


Inner  aspect  of  the  stump  of  a  left  thigh,  amputated  by  the  circular  method. 
The  powerful  tendency  of  the  posterior  muscles  to  retract  has  not  been  allowed 
for,  and  the  stump,  in  consequence,  is  conical.     (Farabeuf.) 

than  those  in  front.  Care  must  be  taken,  if  it  is  thought  needful,  after 
making  the  circular  sweeps,  to  free  the  bone  higher  up,  and  so  to 
secure  its  being  well  buried  in  the  soft  parts,  but  not  to  prick  the 
already  divided  femoral  vessels  which  lie  in  close  proximity  to  the 
femur  in  the  lower  third. 

IV.  Rectangular  Flaps  of  Mr.  Teale. — This  method  is  fully  described  p.  1003.  It 
is  not  recommended  here,  as  it  is  expensive,  involving  division  of  the  bone  nearer  to  the 
trunk  than  other  methods.  (1)  Owing  to  the  bulkiness  of  the  long  anterior  flap,  it  is, 
here,  especially  difficult  to  fold  and  adjust  it  at  the  conclusion  of  the  operation,  and  still 
more  so  to  keep  it  adjusted  if  primary  union  fails.  (2)  Its  chief  advantages — keeping 
the  end  of  the  bone  well  buried,  and  cutting  the  vessels  and  nerves  clean  and  square — are 
also  sufficiently  attained  by  the  other  flap  methods  already  given,  especially  the  mixed 
method  (p.  930). 

V.  Lateral  Flaps. — This  method  has  certain  grave  objections  here.  (1)  The  sawn 
femur,  tilted  upwards  by  the  ilio-psoas,  is  very  liable  to  press  against  the  upper  angle  of 


*  If  it  be  objected  that  the  plan  here  given  of  turning  up  a  cuff-like  flap  is  likely  to 
lead  to  sloughing,  I  would  reply  that  this  is  not  so  in  these  days  of  modern  surgery. 
If  sloughing  is  dreaded,  a  little  more  time  should  be  taken  in  dissecting  up  a  thin  layer  of 
muscle,  so  as  to  secure  the  deep  fascia  and.  tints,  a  better  vascular  supply. 


934  OPERATIONS   ON   THE    LOWER    EXTREMITY. 

tlic  llaps.  and  to  come  through  at  this  spot,  and  necrose.     (2)  If  this  does  not  take  place, 
the  bone  often  adheres  to  the  cicatrix  here,  while  the  flaps  hang  down  and  away  from  it. 
It  should  only  be  made  use  of  when  no  other  method  is  available,  as  in  a  case  where, 
owing  to  the  condition  of  the  soft  parts,  llaps  can  only  be  got  by  making  one  long  external 
and  a  short  internal,  or  vice  versd. 

Operation. — This  method  will  be  found  fully  described  at  p.  1000. 

This  will  be  a  convenient  place  for  making  a  few  remarks  which  may 
he  useful  to  my  juniors  on  certain  grave  conditions  in  which  amputa- 
tion through  the  thigh  may  he  called  for.  I  refer  to — A.  Amputation 
during  shock ;  B.  Multiple  amputations ;  and  C.  Amputation  for 
gangrene. 

I  take  first  A,  the  question  of  the  advisability  of  primary  amputa- 
tion in  severe  injuries,  while  shock  is  present.  Each  case  must  be 
studied  by  itself  according  to  the  conditions  present,  both  as  regards 
the  injury  and  the  patient.  If  a  general  rule  can  be  formulated  it 
would  be  to  run  the  risk,  inevitably  great,  and  operate  as  soon  as 
possible.  Dela}7,  say  for  six  or  twelve  hours,  will  not  remove  the  factor 
of  shock  altogether,  while  it  exposes  the  patient  to  other  dangers. 
H.  Cushing  {Ann.  of  Surg.,  Sept.,  1902)  strongly  advocates  early 
amputation.  "  Here  a  state  of  shock  may  alread}r  be  present,  and  the 
attendant  ordinarily  is  advised  to  wait  for  some  hours,  during  which  time 
a  readjustment  of  conditions  is  expected  to  take  place,  and  the  severity 
of  shock  to  diminish.  As  a  matter  of  fact,  the  very  conditions  are 
present  which  tend  to  perpetuate  or  to  increase  the  already  existent 
degree  of  shock.  Such  an  increase  is  brought  about  by  a  continuation 
of  afferent  sensory  impulses.  The  tourniquet  itself,  which  has  been 
applied  at  the  time  of  the  accident,  although  controlling  the  loss  of 
blood,  constantly  adds,  from  pain,  to  the  shock  of  the  original  injury.  The 
dragging  of  the  mangled  limb  on  the  great  sensory  nerve  trunks,  which 
are  rarely  severed,  gives  impulses  of  pain  with  every  movement  of  the 
often  restless  patient,  impulses  which  in  such  a  state  cause  reflexly  a 
further  lowering  of  blood  pressure.  Strychnia,  intra-venous  infusion, 
and  delay  are  the  usual  measures  advocated  for  such  states.  I  believe 
they  are,  if  not  actually  harmful,  certainly  not  helpful.  The  real 
indication  is  to  rid  the  patient  of  the  centripetal  impulses,  originating 
in  the  crushed  member,  by  cocainisation*  and  division  of  the  large 
nerves,  so  often  exposed  in  a  mangled  limb,  by  ligation  of  vessels,  and 
the  earliest  possible  removal  of  the  painful  tourniquet.  Under  proper 
management,  with  possible  strapping  of  the  abdomen  to  hold  up  the 
blood  pressure,  with  morphia  in  small  amounts  to  control  restlessness, 
and  with  a  proper  avoidance  of  those  conditions  which  during  the 
operation  would  increase  shock,  I  believe  that  it  is  no  heresy  to  advo- 
cate ether  anaesthesia  (never  chloroform)  and  early  operation  for  most 
cases  of  severe  traumatism  of  the  extremities." 

B.  Multiple  amputations. — The  main  points  here  are: — 1.  To 
perform  the  operations  together.  Thus  when  the  services  of  three 
operators  can  be  secured  a  triple  amputation  can  be  completed  in 
thirty-live  minutes.  2.  In  such  a  case  a  large  saline  infusion  should 
be  made  into  one  of  the  main  veins  severed  during  the  amputations. 
3.  As  advised  by  Crile,  eucaine  should  be  injected  into  the  main  nerve 

*  Vol.  I.  p.  226. 


AMPUTATION    THROUGH    THE   THIGH.  935 

trunks  (Vol.  I.  p.  226).  4.  No  time  should  be  lost  in  tying  a  number 
of  smaller  vessels.  The  main  trunks  should  be  secured,  and  Spencer 
Wells's  forceps  applied  toother  bleeding  points,  or  the  wound  packed 
with  gauze  and  firmly  bandaged.  Such  bandages  will  need  nicking  in 
an  hour  or  two.  5.  There  should  be  no  close  or  tight  suturing ;  any 
attempt    to    secure    primary  neatness   will    only  defeat    its   own   end. 

6.  As  sterilisation  will  probably  be  incomplete,  wet  gauze  dressings 
should  be  applied,  to  be  replaced  for  the  first  few  days,  when  the 
danger    of    hemorrhage    has    passed,    by    boracic    acid    fomentations. 

7.  For  the  first  two  days  the  patient  should  have  a  room  to  himself. 

C.  Amputation  in  cases  of  gangrene. — These  may  be  divided  into 
acute  and  chronic.  In  the  former  a  high  amputation  is  the  patient's 
only  chance,  as  in  Mr.  C.  Heath's  case  of  disarticulation  of  the 
shoulder-joint  (Vol.  I.  p.  178).  In  the  lower  extremity  the  resort, 
though  the  only  one,  is  much  more  desperate.  Knott  {Joum.  Amer. 
Med.  Assoc,  April  11,  1903)  recommends  amputation  in  two  stages  in 
acute  traumatic  cases.  A  circular  amputation  is  first  performed  just 
above  the  line  of  apparent  demarcation.  Later,  when  the  patient's 
condition  is  improved,  a  second  operation,  which  consists  in  a  higher 
division  of  the  bone  and  approximation  of  the  soft  parts,  is  done. 
The  reasons  for  advising  this  are  that  the  first  operation  may  remove 
the  source  of  infection,  and  that  the  cutting  of  flaps  and  introduc- 
tion of  sutures  tend  to  produce  gangrene  in  structures  the  circulation 
of  which  is  already  bad.  Knott  has  practised  the  above  method  four 
times — once  in  the  upper  third  of  the  thigh,  once  in  the  middle  third 
of  the  forearm,  and  twice  in  the  upper  third  of  the  leg — with  uniformly 
good  results.* 

Amputation  in  chronic  gangrene. — I  refer  here  to  cases  originating 
in  cardiac  disease,  frost-bite,  typhoid  fever,  pneumonia,  and  the  more 
common  ones,  viz.,  those  simulating  the  senile  form  in  which,  in  an 
elderly  patient  after  an  injury,  e.g.,  to  the  leg,  thrombosis  begins  in  a 
large  muscular  branch,  and  creeps  up  into  the  tibial  arteries,  and 
lastly,  and  more  especially,  to  senile  gangrene.  And  I  use  the  term 
"chronic"  rather  than  "dry"  because  senile  gangrene,  of  which  I 
speak  more  particularly,  is  only  dry  while  it  remains  limited  to  the 
toes,  owing  to  the  small  supply  of  fluid  and  the  readiness  of  evapora- 
tion.    While   in   many  of  the  other  cases  of   chronic  gangrene  the 

*  The  following  case  is  of  some  interest,  as  it  shows  that  sometimes  the  worst  forms  of 
spreading  gangrene  may  be  prevented  by  an  amputation,  though  the  surgeon  may  not  be 
aware  of  this  at  the  time.  Three  years  ago,  a  young  man  who  had  been  run  over  on  the 
South  Eastern  Railway  was  admitted  with  the  lower  part  of  one  leg  so  smashed  as  to  call 
for  amputation  through  the  upper  third.  This  was  done  by  my  house  surgeon,  Dr. 
Norman  Ticehurst,  now  of  St.  Leonards.  When  I  scrutinised  the  condition  of  the 
ligatured  vessels,  I  happened,  by  the  merest  chance,  to  detect  some  bubbles  of  gas  in  the 
connective  tissue  between  some  of  the  intermuscular  septa.  Pointing  this  out  as  an 
instance  of  the  far-reaching  effects  of  a  very  severe  injury,  I  suggested  that  the  tissue 
affected  should  be  cut  out  and  forwarded  in  a  sterile  tube  to  the  Bacteriological  Depart- 
ment, and  further  directed  that  a. drainage- tube  should  be  inserted  and  very  few  sutures 
employed.  The  flaps  sloughed  almost  in  their  entirety,  and,  in  a  few  days,  the  report 
reached  us  that  the  bacillus  of  malignant  oedema  had  been  present.  The  {fcitient  recovered, 
and  the  stump  was,  ultimately,  most  serviceable.  The  soil  at  the  site  of  the  accident  was 
that  of  the  permanent  way  between  London  Bridge  and  Cannon  Street  Stations. 


936  OPERATIONS   ON    THE    LOWEB    EXTREMITY. 

surgeon   will   do  well  to  wait  because  the  progress  is  so  slow,  and 
because,  owing   to    the    completeness    of   the    dryness,  infection    and 
toxaemia  arc  absent,  this  delay  will  thus  allow  of  a  much  less  severe 
amputation  and  a  more  useful  artificial  limb;  this  is  not  the  case  where 
there  is  evidence  of  the  gangrene  being  "  mixed."     Here  evidence  of 
infection  may  show  itself  at  any  moment,  and  owing  to  the  vitality  of 
the   patient,  may  be  rapidly  fatal.     Sooner  or  later,   senile   gangrene 
reaches  the  sole,  and  now  becomes  moist  as  well  as  dry,  and  the  result 
of  infection  will  speedily  follow.     For  this  reason,  and  because  estab- 
lished gangrene  of  the  toes  means  a  bed-ridden  patient  and  a  death  in 
life,  because  the  pain   and  loss  of  sleep  admit  of  no  real  alleviation, 
and,  together  with   the   progressive  impairment  of   damaged  viscera, 
will  but  further  lower  the  depressed  vitality  to  a  point  unable  to  safely 
meet  the  operation  when  this,  often  too  late,  is  consented  to — for  these 
reasons  I  advocate  strongly  amputation  through  the  lower  third  of  the 
thigh  in  senile  gangrene  as  soon  as  this  is  established  in  the  toes.     I 
take  it  for  granted  that  the  other  factors  in  the  question  relating  to  the 
patient's  general  condition  are  sufficiently  favourable.     My  experience 
would   lead   me   to   look  upon  diabetes  and  albuminuria,  especially  in 
stout  patients  with  an  unstable  mental  condition,  as  prohibitive.     If  a 
surgeon,  early  in  his  experience,  be   asked   about  the   value  of  local 
interference,  e.g.,  detachment  of  gangrenous  parts,  incisions,  or  a  low 
amputation,  the  results  are,  as  a  rule,  so  extremely  bad  that  such  ques- 
tions should  not  be  entertained.     Amputation  high  up  in  the  leg  gives 
results  but  little  better,  owing  to  the  condition  of  the  vessels.     Thus 
of  thirteen  cases  recorded  by  Heidenhain   in  only  two  did  the   flaps 
heal,  two  died  of  reappearing  gangrene,  nine  were  reamputated.     In 
amputation  through  the  lower  third  of  the  thigh,  the  results  improve 
owing  to   the  better  nutrition   of  the   parts.     Thus  of  sixteen   cases 
amputated  through  and  above  the  knee-joint  eight  recovered  and  eight 
died  (Heidenhain).     G.  Bellingham  Smith  and  H.  E.  Durham  found 
that  of  eighteen  cases  of  amputation  through  the  thigh  ten  recovered 
(in  four  there  was  some  gangrene  and  infection  of  the  flaps)  ;  eight 
died.     While  the  step  will  always  remain  one  of  great  gravity,  one  in 
which   both   sides  of  the   question   must  be   fairly  placed    before  the 
patients  and  the  decision  left  to  them,  and  while  it  too  often  proves 
only   palliative  owing  to  reappearance,  ultimately,  of  gangrene  in  the 
opposite  limb,  I  consider  it  abundantly  justified  in  suitable  cases  for 
the  reasons  already  given,  and  I  would  lay  stress  on  the  amputation 
being    through   the   lower  third  of  the   thigh,  and    here   only.     The 
greater  distance  from  the  gangrene,  the  better  nutrition  o(  the  parts, 
the  vascular  muscular  tissues,  the  single  large  artery  easy  to  secure,  all 
emphasise   this   point.      The  chief  details  to   bear  in   mind  are  to   see 
that  the  Esmarch's  bandage  or  its  equivalent  is  put  on  with  great  care, 
to  cut  the   flaps   sufficiently  long   and    thick   and   uniform — and   here 
every  cutting  instrument  should  be  of  the  sharpest — not  to  insert  too 
many  or  too  tight  sutures,  and  to  make  use  of  drainage.     It  is  very 
difficult  to  make  out  the  condition  of  the  main   artery  beforehand.     If 
it  be  thrombosed,  an  unusual  number  of  small  vessels   will  probably 
need   securing.     "Where  it   is   rigid   and  calcareous,  the  ligature   must 
not  be  too  small,  and  some  of  the  sheath,  and,  if  needful,  some  fascial 
or  muscular  tissue  as  well,  must  be  included  in  it.      In  two  of  my  cases 


AMPUTATIONS    IMMEDIATELY    ABOVE    THE    KNEE-JOINT.     937 

in  which  this  condition  of  the  femoral  artery  was  present,  uninterrupted 
healing  and  recovery  followed.  In  diabetic  patients,  if  of  sufficient 
hardihood  to  make  the  trial,  local  analgesia  (Vol.  I.  p.  652)  should 
certainly  be  tried. 

AMPUTATIONS    IMMEDIATELY    ABOVE    THE     KNEE-JOINT 

(Figs.  387-395)- 

While  conditions  admitting  of  the  performance  of  these  amputations 
are  not  common,  the  surgeon  should  be  familiar  with  them,  especially 
with  that  of  Carden,  owing  to  the  importance  of  preserving  as  much 
as  possible  of  the  femur  and  adductors. 

Methods. 

i.  Carden's  (Figs.  387,  388,  389).  ii.  G-ritti's  Trans-condyloid 
(Figs.  390,  392,  393).  iii.  Stokes's  Supra-condyloid,  an  important 
modification  of  the  above  (Figs.  391,  394,  395). 

All  the  above,  but  especially  the  two  latter,  possess  the  following 
advantages  (which  they  share  with  amputation  through  the  knee-joint) 
over  amputation  through  the  thigh,  viz. : — 

1.  The  patient  can  bear  his  weight  in  walking  on  the  face  of  his 
stump ;  thus,  he  is  not  compelled  to  take  his  bearing  from  the 
tuberosity  of  the  ischium,  or  to  walk  as  if  he  had  an  ankylosed  hip- 
joint  (Stokes),  as  is  the  case  after  amputation  of  the  thigh.  2.  Very 
good  power  of  adduction  over  the  artificial  limb  remains.  Every 
surgeon  must  have  noticed  how  badly  off  a  patient  is  in  this  respect 
after  an  ordinary  amputation  through  the  thigh.  By  these  methods 
the  adductors  are  left  almost  intact,  even  to  part  of  the  strong  vertical 
tendon  of  the  adductor  magnus,  the  result  being  that  the  balance 
between  the  adductors  and  the  abductors  of  the  thigh  remains  practi- 
cally undisturbed,  and  the  patient  when  walking  has  none  of  that 
difficulty  (which  is  seen  after  thigh  amputations)  of  bringing  the  limb 
which  he  has  swung  forwards  in  again  under  the  centre  of  gravity.* 

3.  The  medullary  canal  is  not  opened  :  on  this  account  there  is  less 
risk   of    necrosis   and   osteo-myelitis   if   the   stump   becomes  infected. 

4.  There  is  less  shock,  because  (a)  the  limb  is  removed  farther  from 
the  trunk,  (b)  the  muscles  are  divided  not  through  their  vascular  bellies, 
but  through  their  tendons. 

i.  Carden's  Amputation  (Figs.  387,  388,  and  389). 

Advantages. — This  valuable  amputation  has  some  points  in  common 
with  Syme's  amputation  at  the  ankle-joint.  In  both  the  bone-section 
is  made  not  through  a  medullary  canal,  but  through  vascular,  quickly- 
healing  cancellous  tissue,  in  both  the  skin  reserved  for  the  face  of  the 
stump  has  been  used  to  pressure,  though  not  equally  so,  for  the  skin 
preserved  in  the  ankle-amputation  is  thick  and  callous,  in  the  other 
thinner  and  more  sensitive. 

Lord  Lister  {System  of  Surgery,  vol.  iii.  p.  705)  thus  recommends 
this  amputation:  "This  operation,  when  contrasted  with  amputation  in 
the  lower  third  of  the  thigh,  presents  a  remarkable  combination  of 
advantages.     It  is  less  serious  in  its  immediate  effects  upon  the  system, 

*  The  importance  of  the  preservation  of  the  quadriceps  extensor,  given  by  the  Stokes- 
Gritti  method,  need  only  be  alluded  to. 


93« 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


because  a  considerably  smaller  quantity  of  the  body  is  removed,  and 
also  because,  the  limb  being  divided  where  it  consists  of  little  else  than 
skin,  bone,  and  tendons,  fewer  blood-vessels  are  cut  than  when  the 
knife  is  carried  through  the  highly  vascular  muscles  of  the  thigh;  the 
popliteal  and  one  or  two  articular  branches  being,  as  a  general  rule,  all 
that  require  attention,  so  that  loss  of  blood  is  much  diminished.  In 
the  further  progress  of  the  case  the  tendency  to  protrusion  of  the  bone, 
which  often  causes  inconvenience  in  an  amputation  through  the  thigh, 
is  rendered  comparatively  slight  by  the  ample  extent  of  the  covering 
provided,  and  also  by  the  circumstance  that  the  divided  hamstrings  slip 
up  in  their  sheaths,  so  that  the  posterior  muscles  have  comparatively 
little  power  to  produce  retraction.  The  superiority  of  the  operation  is 
equally  conspicuous  as  regards  the  ultimate  usefulness  of  the  stump, 
which,  from  its  great  length,  has  full  command  of  the  artificial  limb, 
while  its  extremity  is  well  calculated  for  sustaining  pressure,  both  on 
account  of  the  breadth  of  the  cut  surface  of  the  bone  divided  through 
the  condyles,  and  from  the  character  of  the  skin  habituated  to  similar 
treatment  in  kneeling.     Considering  therefore  that  this  procedure  can 


Fig.  387. 


7/"A 


(Carclen.) 

be  substituted  for  amputation  of  the  thigh  in  the  great  majority  of  cases 
both  of  injury  and  disease  formerly  supposed  to  demand  it,  '  Garden's 
operation'  must  be  regarded  as  a  great  advance  in  surgery."* 

Disadvantages. — The  chief  of  these  is  the  sloughing  of  the  long 
anterior  flap  which  may  occur,  "  in  spite  of  faultless  operating,"  espe- 
cially  if  the  skin,  of  which  it  chiefly  consists,  has  been  damaged  by 
injury  or  disease,  or  if  the  patient  be  old  or  weakly,  thus  leading  to  an 
adherent,  tender  scar,  and  a  useless  stump. 

Operation. — According  to  its  introducer  this  amputation  consists  in  removing  a 
rounded  flap  from  the  front  of  the  joint  (Figs.  387  and  389),  dividing  everything  else 
Btraighl  down  to  the  bone,  and  sawing  this  slightly  above  the  plane  of  the  muscles. 

The  operator,  standing  on  the  right  side  of  the  limb,  takes  it,  between  his  left  fore- 
finger and  thumb,  at  the  spot  selected  for  the  base  of  the  rlap,f  and  enters  the  point  of  his 
knife  close  to  his  finger,  bringing  it  round  through  the  skin  and  fat  below  the  patella  to 
the  spot  pressed  by  his  thumb,  then  turning  the  edge  downwards  at  a  right  angle  with  the 


*  Other  advantages  given  by  Mr.  Carden  are,  the  favourable  position  of  the  stump  for 
Qg  and  drainage  ;  its  painlessness,  the  chief  nerves  being  cut  high  up  and  slipping 
upwards  out  of  the  way  ;  and  the  cicatrix  being  drawn  clear  of  the  point  of  the  bone, 
and  out  of  reach  of  pressure. 

t  This  corresponds  with  the  upper  border  of  the  patella,  the  limb  being  extended. 
The  lower  margin  comes  down  to  the  tubercle  of  the  tibia,  as  in  Fig.  387.  (See  also 
Brit.  Med.  Journ.t  1864,  v°l-  '•  P-  4*6. ) 


AMPUTATIONS    IMMEDIATELY    ABOVE    THE    KNEE-JOINT.    939 

line  of  t he  limb,  he  passes  it  through  to  the  spot  where  it  first  entered,  cutting  outwards 
through  everything  behind  the  bone.  The  flap  is  then  reflected,  and  the  remainder  of  the 
soft  parts  divided  straight  down  to  the  bone  ;  the  muscles  are  then  slightly  cleared 
upwards,  and  the  saw  applied  "  through  the  base  of  the  condyles."  The  projecting  pari 
of  the  femur  may  be  rounded  off.  Where  there  is  any  doubt  about  the  vitality  of  the 
large  anterior  flap,  a  slant  posterior  one  should  be  made,  the  anterior  one  thus  not  needing 
to  be  so  long. 

Owing  to  the  risk  of  sloughing  of  the  long  anterior  flap,  Lord  Lister's  modification,  by 
which  two  shorter  flaps  are  employed,  is  always  to  be  preferred.  "  The  surgeon  first  cuts 
transversely  across  the  front  of  the  limb  from  side  to  side  at  the  level  of  the  anterior 
tuberosity  of  the  tibia,  and  joins  the  horns  of  this  incision  posteriorly  by  carrying  the 
knife  backwards  obliquely  at  an  angle  of  45  degrees  to  the  axis  of  the  leg  through  the  skin 
and  fat.  The  limb  being  elevated,  he  dissects  up  the  posterior  skin  flap,  and  then  proceeds 
to  raise  the  ring  of  integument  as  in  a  circular  operation,  taking  due  care  to  avoid  scoring 
the  subcutaneous  tissue  ;  and  dividing  the  hamstrings  as  soon  as  they  are  exposed,  and 
bending  the  knee,  he  finds  no  difficulty  in  exposing  the  upper  border  of  the  patella.  He 
then  sinks  his  knife  through  the  insertion  of  the  quadriceps,  and  having  cleared  the  bone 
immediately  above  the  articular  cartilage,  and  holding  the  limb  horizontal,  he  applies  the 


Fig.  388. 


Fig.  389. 


(Carden.) 


saw  vertically,  and  at  the  same  time  transversely  to  the  axis  of  the  limb  (not  of  the  bone), 
so  as  to  ensure  a  horizontal  surface  for  the  patient  to  rest  on." 

ii.  Gritti's  Trans-condyloid  (Figs.  390,  392,  and  393).  iii.  Stokes's 
Supra- condyloid  Amputation  (Figs.  391,  394,  and  395). 

For  fuller  information  on  the  above  amputations  I  would  refer  my 
readers  to  a  paper  I  contributed  to  the  Guy's  Hosp.  Reports,  vol.  xxiii. 
p.  211,  1878. 

But  while  this  osteo-plastic  method  shares  with  that  of  Carden  the 
advantages  given  above  (p.  937),  the  difficulty  of  securing  a  satisfactory 
section  of  a  small  mobile  bone  like  the  patella,  and,  later,  of  retaining 
it  accurately  in  situ,  is  usually  very  considerable.  From  an  extended 
experience  of  this  operation,  I  much  prefer  that  of  Stephen  Smith 
when  the  conditions  admit  of  it. 

The  two  methods  are  often  confused.  Between  them  there  is  this  all-important  differ- 
ence :  in  Gritti's  the  section  of  the  femur  is  made  through  the  condyles  ;  in  Stokes's,  at 
least  half  an  inch  above  them.  In  other  words,  the  one  operation  is  trans-,  the  other 
st&pra-condyloid. 

On  this  point  great  stress  has  been  laid,  and  very  rightly,  by  Sir  W.  Stokes,  and  a  com- 
parison of  the  two  operations  will  convince  every  one  that  he  was  correct.  If  the  section 
of  the  femur  be  made  through  the  condyles  (Figs.  390,  393),  the  sawn  patella  will  not  fit 
down  into  place.     It  will  either  be  drawn  up  altogether  on  to  the  front  of  the  femur,  or 


940 


nl-KUATIONS   ON    TIIK    LOWER    EXTREMITY. 


else  will  projeci  forwards,  Bomewhat  Like  the  half-open  li<l  of  a  box  |  Figs.  392,  393),  at  an 
angle  bo  the  broad  sawn  Burface,  which  is  also  ton  large  for  it  to  cover,  and  across,  and  off 
which  it  is  liable  t<>  he  shifted  liy'thc  contraction  of  the  quadriceps,  if  it  lias  been  tumid 
possible  t"  gel  it  into  place.  To  effect  this,  an  amounl  of  force  will  be  required  which  is 
almost  certain  to  result   in  bruising  of  the  cut  periosteum  on  the  edge  of  the  femur,  and 


Fig.  390. 


Fig.  391. 


Gritti's  trans-condyloid  section  of  the 
femur,  leaving  a  surface  much  too  long 
and  large  for  the  sawn  patella  to  lit. 


Stokes's  supra-condyloid  section  of 
the  femur,  leaving  a  surface  much 
more  easily  fitted  by  the  sawn  patella. 


consequent  necrosis.  If,  on  the  other  hand,  the  saw  is  made  to  pass  a  full  inch  above  the 
condyles  (Fig.  391),  the  patella  will  fall  readily  into  place  (Fig.  394),  it  will  cover  more 
completely  the  now  smaller  surface  of  the  femur,  and  will  remain  easily  in  situ  here,  the 
Haps  when  brought  together  presenting  the  appearance  shown  in  Fig.  395. 

Operation. — An   Esmarch's  bandage  having  been  applied,  the  limb  brought  over  the 
edge  of  the  table  and  supported,  and  the  opposite  one  secured  out  of  the  way,  the  surgeon, 


Fig.  392. 


Fig-  393- 


(Farabeuf.) 


FIG.  394. 


( Farabeuf.) 


The  flaps  in  Gritti's  trans-condyloid  amputa- 
tion, showing  the  patella  hitched  and  requiring 
to  adapt  it  to  the  femur,  which  is  now  too 
loni*  as  well  as  too  broad. 


standing  to  the  right  of  the  limb,  with  his  left  index  and  thumb  marking  the  base  of  the 
flap,  makes  an  incision  commencing  (on  the  left  side)  an  inch  above  and  rather  behind 
the  external  condyle,  carried  vertically  downwards  to  a  point  opposite  to  the  tibial 
tubercle,  then  broadly  curved  across  the  leg  and  carried  upwards  to  a  point  opposite  to 
that  from  which  it  staited.  This  flap  having  been  dissected  upwards,  together  with  the 
patella  (after  section  of  the  ligamentum  patellae),  a  posterior  Hap  is  cut  nearly  as  Long  as 
the  anterior.     This  may  be  effected  in  one  of  two  ways,  either  by  the  Burgeon  looking 


REMOVAL    OF    FAOSTOSIS    NKAR    ADI>i:<T<  >|;    TUIIKIJCLK.      941 

over  and  then  stooping  a  little  (the  limb  being  now  raised),  nexi  drawing  the  knife  from 
withoul  inwards  across  the  popliteal  space,  thus  marking  oui  and  then  dissecting  up  a 

skin  flap,  or  by  transfixing  and  cutting  the  flap  from  withii twards.     Of  the  two  r 

prefer  the  first :  the  latter  is  the  speedier,  bul  Less  suited  to  bulky  limbs.  The  flaps  being 
retracted,  the  soft  parts  arc  cut  through  with  a  circular  sweep  a  full  inch  above  the 
articular  surface  of  the  femur  ;  the  bone  is  then  sawn  through  here,  and  the  limb  removed. 
The  posterior  surface  "f  the  patella  is  next  removed  with  a  metacarpal  or  small  Butcher's 
saw.  This  last  step  is  one  of  considerable  difficulty,  owing  to  the  mobility  of  the  bone  ; 
it  will  In-  facilitated  by  an  assistant  with  both  his  hands  everting  and  projecting  the 
under-surface  of  the  anterior  Hap.  so  as  to  make  the  patella  stand  out  from  it. 

The  vessels — popliteal,  one  or  two  articular,  and  the  anastomotic — having  been  secured, 
drainage  is  provided,  and  the  flaps  are  brought  together  with  numerous  points  of  suture, 
save  at  the  angles  (Fig.  395). 

Even  where  the  flaps  arc  cut  of  proper  length  and  the  femur  is  sawn  at  the  proper 
height,  the  patella  may  still  not  remain  accurately  in  situ.  If  there  seem  any  doubt  on  this 
point,  or  if  the  patient  is  very  muscular,  additional  security  maybe  given  bypassing 
sutures  of  sterilised  silk  between  the  tissues  on  the  under-surface  of  the  anterior  flap,  at 

Fig.  395. 


Appearance  of  the  stump  in  a  Stokes-Gritti's  amputation.  The  patella  has 
come  easily  into  place.  The  drainage-tube  shown  might,  in  many  cases,  be  dis- 
pensed with. 

the  edges  of  the  patella,  and  the  soft  parts  in  the  posterior  flap  (avoiding  the  vicinity  of 
the  large  vessels).  Wiring  or  pegging  the  bones  or  division  of  the  rectus  muscle  on  the 
under-surface  of  the  anterior  flap  are  unsatisfactory  complications. 

REMOVAL   OP  AN  EXOSTOSIS  FROM  NEAR  THE 
ADDUCTOR  TUBERCLE.* 

As  these  growths  are  by  no  means  uncommon  in  adolescents,  this 
operation  will  be  briefly  described  here.  Aseptic  excision  has  now 
replaced  any  other  operation,  such  as  subcutaneous  fracture. 

Operation. — The  parts  having  been  thoroughly  sterilised,  the  knee 
is  flexed  so  as  to  bring  down  the  synovial  membrane,  and  the  limb 
placed  on  its  outer  side.  A  free  incision,  about  three  and  a-half  inches 
long,  is  made  over  the  growth,  down  to  the  vastus  interims,  and  any 
superficial  vessels  attended  to.  The  muscular  fibres  are  then  cleanly 
cut  through,  and  the  bluish-grey  cartilage  which  caps  the  swelling  now 
comes  into  view.t     Any  muscular  branches  being  now  carefully  secured, 


*  This  account  will  serve  for  the  removal  of  other  exostoses — e.g.,  those  met  with  at 
the  deltoid  insertion,  the  spine  of  the  scapula,  or  the  pelvis. 

■f  Any  synovia-like  fluid  now  escaping  comes  probably  from  a  bursa  over  the  growth, 
not  from  the  joint. 


942  OPERATIONS   ON    THE   LOWER    EXTREMITY. 

and  the  wound  dried,  the  cut  vastus  is  pulled  aside  with  retractors,  and 
the  base  of  the  growth  being  thoroughly  exposed,  it  is  shaved  off  with 
an  osteotome  or  chisel,  leaving  exposed  cancellous  tissue.  The 
muscular  fibres  are  then  united  with  sterilised  silk,  and  drainage  provided 
if  needful.  Strict  aseptic  precautions  are  taken  throughout  to  secure 
primary  union.  The  limb  should  be  kept  absolutely  quiet  on  a  back 
splint,  and  a  Martin's  bandage  worn,  later,  for  a  short  time. 

FRACTURES   OF  THE  FEMUR. 

The  following  remarks  apply,  chiefly,  to  interference  for  ununited 
fractures:  more  immediate  interference  is  chiefly  called  for  in  injuries 
to  the  lower  end  of  the  bone. 

I.  Ununited  Fractures  about  the  Neck. — Lord  Lister  recorded  as 
long  ago  as  1871  (Brit.  Med.  Journ.,  Aug.  26)  the  case  of  an  ununited 
extra-capsular  fracture  of  the  femur  in  a  man,  aged  45,  where,  eighteen 
months  after  the  injury,  he  cut  down  on  the  fragments,  with  antiseptic 
precautions,  and  gouged  them,  the  fracture  being  then  firmly  put  up. 
Recovery  was  complete,  the  man  walking  well. 

Indications  for  this  rarely  called-for  operation  would  be  a  patient 
before,  or  perhaps  at,  middle  age,  with  good  vitality  and  much  pain  or 
loss  of  function  ;  there  should  be  no  evidence  of  osteoarthritis.  Dr. 
L.  Freeman,  of  Denver,  has  recorded  one  case  of  his  own  and  collected 
thirteen  others  (Ann.  of  Surg.,  1904,  vol.  ii.  p.  561).  Dr.  G.  E.  Davis 
(ibidem,  Aug.  1905,  p.  282)  recorded  a  case  of  intra-capsular  fracture 
successfully  treated  by  a  screw. 

Operation. — The  incision  usually  employed  will  be  the  anterior  one.* 
All  fibrous  tissue  between  the  fragments  must  be  removed  with  scissors, 
gouge,  &c.  As  little  bone  as  possible  is  to  be  taken  away.  Drilling 
and  fixation  of  the  fragments  is  most  difficult,  partly  from  their 
position,  partly  from  their  softened  condition.  Screws,  pegs,  long 
nails,  a  gimlet  left  in  eight  weeks  (Sayre),  have  been  employed. 
They  can  only  be  introduced  through  a  separate  incision  made  over  the 
outer  aspect  of  the  great  trochanter.  This  bone  must  be  well  raised  first 
and  kept  up  by  the  peg,  &c,  owing  to  its  tendency  to  drop  backwards. 
The  drill  and  peg  must  pass  through  the  trochanter  and  neck  well  into 
the  head.  This  requires  much  care.  Whatever  means  of  fixation  is 
used  should  be  left  in  until  there  is  evidence  of  sufficient  consolidation. 
As  is  the  case  elsewhere,  a  sinus  often  forms  at  the  time  that  the 
screw,  &c,  becomes  loose.  The  patient  should  be  kept  in  bed  for  ten 
weeks.  The  results  are  encouraging,  a  satisfactory  degree  of  mobility 
and  good  use  of  the  limb  being  recorded  in  most  cases. 

Some  shortening  remains.  In  a  few  cases  the  fragments  have 
again  become  loose.  In  another  small  series  of  cases  the  head  of  the 
femur  has  been  removed  ;  in  spite  of  the  shortening,  the  result  is  stated 
to  have  been  good. 

II.  Ununited  Fractures  of  the  Shaft. — The  large  number  of  failures 
after  operations  for  this  condition  are  well  known.  The  difficulties 
which  may  be  present  during  and  after  these  operations  are  very  con- 
siderable ;  amongst  them  sufficient  exposure  of  the  fragments,  keeping 

*  The  presence  of  a  skiagram  may  help  the  surgeon  during  the  operation. 


FRACTURES    OF   THE   FEMUR.  943 

the  wound  aseptic,  and  the  parts  in  correct  apposition  afterwards  (vide 
infra),  are  most  prominent. 

Operation. — On  the  whole,  the  introduction  of  pegs  having  been  less 
successful,  suh-periosteal  resection  and  fixation  of  the  fragments  is 
indicated  here.  This  is  especially  so  in  long-standing  cases,  where 
other  methods  have  failed,  where  there  is  very  little  attempt  at  repair, 
where  an  artificial  joint  exists,  or  where,  after  a  severe  injury,  necrosis, 
atrophy  of  the  fragments,  and  fibrous  union  have  followed. 

The  operation  of  resection  should  always  be  performed  with  strict 
aseptic  precautions,  otherwise  the  risks  of  suppuration,  osteo-myelitis, 
and  pyaemia,  owing  to  the  very  free  incision  required,  the  exposure  of 
cancellous  tissue,  and,  perhaps,  of  the  medullary  canal,  are  considerable. 

The  following  most  important  preliminary  points  are  given  by  Sir  P. 
Treves  {Oper.  Surg.,  vol.  i.  p.  588)  :  "  (1)  It  will  be  well  in  some  cases 
to  apply  extension  for  a  week  or  two  before  the  operation ;  this  over- 
comes the  shortening  produced  b}-  contracted  muscles,  and  enables  the 
surgeon  to  make  trial  of  the  splint  he  proposes  to  employ  afterwards. 
(2)  Before  undertaking  this  operation  the  surgeon  should  understand 
that  its  success  depends  more  upon  the  completeness  of  the  arrange- 
ments that  are  made  for  keeping  the  bones  in  position  after  the  opera- 
tion than  upon  the  operation  itself,  provided  the  latter  be  carried  out 

with  due  care Care    in    the    adjusting    of  the  fragments,  and 

infinite  and  continued  care  in  the  after-treatment,  are  the  main  elements 
of  success  in  the  present  class  of  case.  (3)  In  dealing  with  a  fracture 
of  the  femur  in  an  adult,  it  is  well  that  the  operation  be  performed  as 
the  patient  lies  upon  the  bed  he  will  occupy  throughout  the  whole 
treatment.  Much  moving  of  the  patient  after  the  operation  is  very 
undesirable,  and  a  long  thigh -splint  without  extension  apparatus  cannot 
be  conveniently  applied  upon  the  operation  table."  The  limb  having 
been  rendered  bloodless,  if  practicable,  with  Esmarch's  bandages,*  the 
fracture  is  exposed  by  a  free  incision,  five  to  six  inches  long,  on  the 
outer  side  of,  and  going  down  to,  the  bone.  The  incision  should  be 
made  along  the  line  of  the  inter-muscular  septum  between  the  vastus 
externus  and  biceps.  If  it  be  needful  to  expose  the  inner  aspect  of  the 
fragments,  a  second  incision  must  be  made  through  the  vastus  interims 
so  as  to  be  external  to  the  large  vessels.  The  periosteum  is  next  most 
carefully  detached  from  the  ends  of  the  fragments,  and  a  thin  layer  of 
bone,  about  a  quarter  of  an  inch  in  thickness,  removed  from  each. 
The  soft  parts  must  be  protected  with  spatulae  and  retractors.  Only  if 
it  be  absolutely  needful  should  the  fragments  be  thrust  or  dragged  out 
of  the  wound  ;  any  disturbance  of  the  periosteum  should  be  as  restricted 
as  possible.  When  the  ends  of  the  bone  are  cut  square  a  saw  is  prefer- 
able. If  they  can  be  made  to  interlock,  by  shaping  these  in  part  into 
the  form  of  a  >,  or  by  stepping  them  (p.  1021),  a  chisel  will  be  useful  : 
the  ends  of  the  bones  are  first  steadied  with  forceps.  The  fragments 
ai*e  now  brought  into  exact  apposition,  and  to  facilitate  this  it  may  be 
necessary  to  divide  adhesions  or  tendons,  or  to  remove  any  intervening 

*  This  step  is  condemned  by  some,  notably  by  Sir  F.  Treves  (loc.  supra  cit.,  p.  588).  I 
admit  that  it  leads  to  much  oozing  from  the  cut  surfaces,  but.  having  tried  both  ways.  I 
am  of  opinion  that  this  can  be  safely  met  by  applying  ample  well-adjusted  dressings 
before  the  bandage  is  removed,  and  that  the  advantage  of  a  bloodless  wound  during  a  most 
difficult  and  prolonged  operation  is  almost  incalculable. 


"It 


<>im:i;ations  on  tin-:  loweb  extremity. 


fibrous  or  fibrocartilaginous  material,  or  a  sequestrum.  If  the  frag- 
ments are  successfully  adjusted  and  carefully  kept  so  (vide  supra),  the 
use  of  wire,  pegs,  and  screws  may  be  dispensed  with.  Their  use, 
although  it  ensures  correct  apposition  of  the  fragments,  prolongs  and 
complicates  the  operation,  and  may  give  considerable  trouble  later  on. 
If  it  be  determined  to  make  use  of  wire,  the  ends  are  now  to  be  drilled, 
the  drill  being  entered  on  the  superficial  surface  of  each  fragment,  and 
then  made  to  project  in  the  centre  of  the  medullary  canal.  They  are 
next  held  together  by  passing  sufficiently  stout  silver  wire  through  the 
drill-holes,  and  twisting  this  up.  The  ends  are  next  hammered  down, 
in  situ,  three  half-twists  being  made  and  the  ends  cut  short.  See  the 
remarks,  p.  968.  Wire  usually  entails  more  disturbance  of  the  parts  ; 
screws  give  a  firmer  command  over  the  fragments;  pegs  or  steel  pins 
are  the  simplest  if  the  bradawl  used  he  large  enough  to  render  the 
following  of  its  track  easy.  Other  methods  that  may  he  found  superior 
to  wire  are  Mr.  W.  A.  Lane's  screws,  p.  1017  (Clin.  Soc.  Trans.,  1894), 
and  Prof.  Senn's  hollow  perforated  hone  cylinders  or  ferrules.  These 
are  circular  or  triangular,  and  large  enough  to  slip  easily  over  the  frag- 
ments. The  most  accessible  fragment  having  been  sufficiently  isolated, 
the  ferrule  is  slipped  over  it  and  far  enough  away  from  the  line  of 
fracture  to  clear  the  other  fragment.  After  reduction  has  heen  accom- 
plished the  second  fragment  is  engaged  in  the  ring,  which  is  then 
pushed  hack  sufficiently  far  to  grasp  both  fragments  securely.  If  the 
ferrule  rides  too  loosely,  any  space  should  be  packed  with  chips  of  decal- 
cified hone.  The  limb  is  put  up  in  plaster  of  Paris  with  a  sufficient 
interruption  (p.  1013).  If  suppuration  occur,  the  ferrules  are  removed 
by  cutting  through  one  side  with  bone  forceps,  after  enlarging  the  sinus, 
when  the  parts  are  consolidated.  If  there  is  no  suppuration,  the 
ferrule  will  probably  be  absorbed  (Ann.  of  Surg.,  vol.  ii.  1893,  p.  125). 

A  full  account  of  the  clamp  devised  by  Dr.  C.  Parkill  and  its 
various  uses  is  given  in  the  Ann.  of  Surg.,  May,  1898.  Here  will  be 
found  also  the  reports  of  fourteen  cases  in  which  the  clamp  has  been 
used.  The  fact  that  success  was  obtained  in  each  of  these  cases  con- 
stitutes a  strong  claim  for  a  more  extended  trial.  Owing  to  its 
numerous  parts,  it  is  complicated,  and  the  projection  of  a  portion  of  the 
instrument  calls  for  constant  attention  to  keeping  the  skin  sterile.  In 
the  only  case  in  which  I  have  seen  this  clamp  used  it  was  not  successful. 
The  remarks  made  below  on  fractures  of  the  leg  should  also  be 
referred  to. 

III.  Injuries  about  the  lower  end  of  the  Femur. — E.g.,  supra-and 
inter- condyloid  fractures  and  injuries  to  the  epiphysis.  Where,  after  an 
attempt  under  anesthesia,  a  skiagram,  taken  on  the  second  or  third  day, 
shows  that  the  position  of  the  fragments  is  unsatisfactory,  it  is  quite 
justifiable,  especially  in  a  young  and  healthy  patient,  to  resort  to 
operation  if  the  surroundings  of  the  surgeon  are  suitable.  In  the  case 
of  the  shaft  the  dangers  of  the  relations  increase  from  below  upwards; 
here,  in  addition  to  the  importance  of  the  relations,  the  presence  of  the 
knee-joint,  the  possibility  of  injury  to  the  popliteal  vessels,*  the  bulk 
and  fixity  of  the  lower  fragment,  have  all  to  be  remembered.     Adhesions 

*  (Edema  of  the  foot,  persisting  after  alteration  in  the  position  of  the  limb,  will 
indication  for  operation. 


FRACTURES   OF   THE    FEMUR.  945 

here  form  so  quickly  that  interference  should  be  resorted  to  early  in 
the  first  week.     Thefollowing  are  the  chief  points  which  need  attention. 

(1)  The  chief  incision  should  be  on  the  outer  side  along  the  outer 
border  of  the  biceps  tendon,  prolonged  upwards  along  the  line  of  the 
external  intermuscular  septum  already  mentioned  ;  in  any  extension 
of  the  incision  below  care  must  be  taken  of  the  external  popliteal  nerve. 

(2)  If  the  joint  be  uninjured,  the  synovial  membrane  should  be  avoided 
by  keeping  the  incision  low  down.*  (3)  Division  of  the  tendo  Achillis, 
while  variable  in  the  aid  which  it  affords,  should  always  be  resorted  to. 
(4)  The  position  of  the  fragments, t  the  aspect  of  their  surfaces,  the 
amount  of  tilting,  rotation,  &c,  being  determined  by  inspection  and 
a  sterilised  finger,  reduction  must  be  effected  by  manipulations  aided 
by  leverage.  The  wound  and  its  adjacent  area  being  protected  with 
sterile  gauze,  extension  is  made  on  the  leg  in  the  extended  and  flexed 
positions,  while  the  surgeon  makes  counter-extension  on  the  upper 
fragment,  aiding  the  replacement  by  his  fingers  in  the  wound.  The 
difficulties  now  present  are  the  locking  of  the  lower  fragment  between 
the  closeky  adjacent  femur  and  tibia ;  in  the  case  of  a  separated  epiphysis 
this  may  have  carried  with  it  a  portion  of  the  diaphysis  which  may  need 
careful  enucleation,  and,  this  failing,  detachment  with  a  chisel,  or  the 
upper  end  of  the  diaphysis  may  be  held  in  a  buttonhole-like  slit  by 
a  detached  sheath  of  periosteum,  this  requiring  careful  slitting  up.  If 
the  leverage  of  a  periosteal  elevator  is  required,  care  must  be  taken  not 
to  inflict  needless  damage  on  the  delicate  and  softened  epiphysial 
structures.  (5)  When  replacement  has  been  effected  there  is  not,  in 
my  experience,  the  same  difficulty  in  retaining  these  fragments  in 
position  that  is  met  with  in  injuries  about  the  elbow-joint.  If  some 
means  of  retention  is  thought  needful,  pins  or  screws — and  either  must 
be  of  sufficient  length — are  usually  preferable  to  wire.  The  heads 
must  be  left  as  flush  with  the  bone  as  possible.  To  secure  sufficient 
elevation  and  command  over  a  fragment  it  is  always  permissible  to 
make  a  separate  puncture  down  to  the  bone  for  the  preliminary  intro- 
duction of  the  bradawl.  (6)  It  is  needless  to  insist  on  the  need  of  the 
most  rigid  asepsis  throughout.  In  my  opinion,  after  these  most  difficult 
and  complicated  operations,  drainage  is  always  advisable,  and  the 
wounds  should  not  be  completely  closed  at  first.  (7)  The  after- 
position,  whether  flexed  or  extended,  will  mainly  depend  upon  the 
position  in  which  it  has  been  found  easiest  to  replace  and  fix  the 
fragments.  As  I  have  stated,  the  amount  of  mobility  of  the  joint,  even 
where  rapid  healing  has  been  secured,  is  often  disappointing,  and,  in 
separation  of  the  epiphysis  especially,  in  addition  to  some  stiffness  of 
the  joint  and  shortening,  some  degree  of  genu  valgum  or  varum  is 
very  likely  to  follow  if  the  limb  be  used  prematurely. 

*  The  persistent  stiffness  of  the  joint  which  is  so  liable  to  follow  a  successful  reduction 
of  the  fragments  would  make  one  very  chary  of  dividing  the  extensor,  or  opening  the 
knee  joint  so  as  to  insert  a  finger  to  aid  in  the  replacement  as  advised  by  some.  If  the 
joint  be  infected,  it  is  another  matter. 

•f  The  difference  in  the  displacement  in  a  case  of  separated  epiphysis  and  supra- 
condyloid  fracture  will  be  remembered.  In  the  former  case  the  epiphysis  is  displaced 
upwards,  and  the  lower  end  of  the  diaphysis  will  be  felt  in  the  popliteal  space.  In  the 
case  of  the  fracture  the  lower  fragment  is  drawn  backwards,  and  arrested  behind  the 
upper,  with  its  fractured  surface  looking  into  the  space  behind. 

S. VOL.  II.  60 


CHAPTER   IV. 
OPERATIONS   INVOLVING  THE  KNEE-JOINT. 

AMPUTATION  THROUGH  THE  KNEE-JOINT.— ERASION  OF 
THE  KNEE-JOINT.— EXCISION  OF  THE  KNEE-JOINT.— 
ARTHRODESIS.— WIRING  THE  PATELLA. —REMOVAL 
OF  LOOSE  CARTILAGES  FROM  THE  KNEE-JOINT.— 
INJURED  FIBRO-CARTILAGES  AND  OTHER  CAUSES 
OF    INTERNAL    DERANGEMENT. 

AMPUTATION    THROUGH    THE    KNEE-JOINT    (Fig.   396). 

Chief  Methods. 

I.  By  Lateral  Flaps.  II.  By  Long  Anterior  and  Short  Posterior 
Flaps. — Of  these  the  first  is  far  the  superior.  The  great  objection 
to  the  second  is,  that  in  order  to  get  sufficient  covering  to  fall  readily 
over  the  large  condyles,  a  long  anterior  flap  must  be  cut;  as  this  must 
reach  two  inches  below  the  tibial  tubercle,  a  good  deal  of  its  blood- 
supply  which  comes  from  below — e.g.,  from  the  recurrent  tibial — must 
be  cut  off,  and  the  flap  is  thus  liable  to  slough.  This  risk  is  much 
diminished,  and  the  blood-supply  better  equalised,  by  the  method  of 
lateral  flaps. 

I.  Amputation  by  Lateral  Flaps. — This,  the  method  of  Dr.  Stephen 
Smith,*  was  brought  before  English  surgeons  by  Mr.  Bryant. I  The 
femoral  artery  having  been  controlled,  the  limb  supported  over  the 
edge  of  the  table,  and  slightly  flexed,  the  surgeon,  standing  on  the 
right  side  of  either  limb,  marks  out  two  broad  lateral  flaps  as  follows: 
J  lis  left  thumb  and  index  finger  being  placed,  the  former  over  the 
centre  of  the  head  of  the  tibia,  the  latter  at  the  corresponding  point 
behind,  opposite  the  centre  of  the  joint,  he  marks  out  (in  the  case  of 
the  right  limb)  an  inner  flap  by  an  incision  which,  commencing  close 
to  the  index  finger,  is  carried  down  along  the  hack  of  the  limb  for 
about  three  inches  and  a  half,  and  then  curves  upwards  and  forwards 
across  the  inner  aspect  of  the  leg,  till  it  ends  in  front  just  below  the 
thumb.  +      The  knife  not  being  taken  off,  a  similar  flap  is  then  shaped 

*  New  YorkJoum.  of  Med.,  Bept.  1852;  Amer.Jburn.  Med.  Soi.,  Jan.  1870. 

t  Med.-Chir.  '/'run*.,  vol.  lxix.  p.  1G3. 

X  Dr.  S.  Smith  begins  his  incision  about  an  inch  below  the  tubercle  of  the  tibia,  and 
carries  ii  up  rather  higher  behind — viz.,  to  the  centre  of  the  articulation.  It  will  he  found 
r  to  open  the  joint  and  to  detach  the  semilunar  cartilages  from  the  tibia  by  making 
the  incision  as  recommended  above. 


AMPUTATION    TIIItOlMJH    TIIK    K  NKK.JOINT. 


947 


Fig.  396. 


from  the  outer  side,  but  in  the  reverse  direction.  Dr.  Stephen  Smith 
calls  attention  to  the  following  points:  In  making  these  flaps,  they 
should  be  cut  broad  enough  to  secure  ample  covering  for  the  condyles, 
and  the  inner  one  should  be  made  additionally  full  as  the  internal 
condyle  is  longer  than  the  external.  The  flaps  should  be  at  least  three 
inches  and  a  half  long,  if  of  equal  length.  They  consist  of  skin  and 
fasciae.  When  they  have  been  raised  as  far  as  the  line  of  the  articula- 
tion the  ligamentum  patellae  is  severed,  allowing  the  patella  to  go 
upwards.  The  soft  parts  around  the  joint  are  then  cut  through  with 
a  circular  sweep,  and  the  leg  removed.  In  doing  this,  the  limb  being 
flexed  to  relax  the  parts  and  facilitate  opening  the  joint,  the  semilunar 
cartilages  will  very  likely  be  found  closely  encircling  the  condyles  of 
the  femur.  Mr.  Bryant,  in  the  paper  already  quoted,  and  Dr.  Brinton 
(Pit  Had.  M<<1.  Times,  Dec.  28,  1872),  as  long  ago  as  1872,  have  strongly 
advised  that  the  semilunar  cartilages  should  be  left  in  situ  by  severing 
the  coronary  ligaments  which  tie  them  to  the  tibia.  They  thus,  in 
Dr.  Brinton's  words,  form  "  a  cap, 
fitted  on  the  end  of  the  femur,  which 
preserves  all  the  fascial  relations, 
effectually  prevents  retraction,  and 
guards  against  the  projection  of  the 
condyles."  This  precaution  will 
obviate  a  serious  objection  to  ampu- 
tation through  the  knee-joint.  For 
a  time  the  patient  bears  his  weight 
well  on  the  end  of  the  stump.  But 
after  some  months  the  ends  of  the 
condyles  (if  unprotected  by  the 
menisci)  begin  to  fret  the  thin  over- 
lying skin,  and  within  a  year  of  the 
amputation  the  patient,  usually,  has 
to    have    his    artificial    limb    altered.  Amputation    through    knee-joint    by 

lateral  flaps.    The  incision  has  been  begun 

II.  By  a  Long  Anterior    and    a    Short     unusually  low  down.     (Bryant.) 
Posterior  Flap. — The  position  of  the  patient 

and  the  surgeon  being  as  at  p.  946,  the  latter  with  his  left  index  and  thumb  on  either 
side  of  the  interval  between  the  femur  and  tibia,  enters  his  knife  (in  the  case  of  the 
right  limb)  just  below  the  finger  and  internal  condyle,  carries  it  straight  down  along 
the  inner  side  of  the  leg  till  it  reaches  a  spot  two  inches  below  the  tibial  tubercle,*  then 
squarely  across  the  leg  till  it  reaches  a  corresponding  point  well  back  upon  the  outer 
side,  and  thence  up  to  a  point  just  below  his  thumb,  or  to  the  external  condyle.  This 
flap  is  then  dissected  up,  containing  the  patella,  as  thickly  as  possible,  and  almost  rectan- 
gular in  shape,  anything  like  pointing  of  its  lower  end  being  most  carefully  avoided,  as 
certain  to  lead  to  sloughing. 

This  flap  being  raised,  a  posterior  flap  is  made  about  two-thirds  the  length  of  the 
first,  as  at  p.  930,  either  by  dissection  from  without  inwards,  or  by  transfixion  after 
disarticulation. 


*  Mr.  Pollock  (Med.-Chir.  Trans.,  vol.  liii.  p.  20)  advises  that  the  anterior  flap  should 
reach  "quite  five  inches  below  the  patella."  It  is  difficult  to  see  how  sloughing  can  be 
avoided  here,  so  much  of  the  blood  to  this  very  long  flap  coming  from  below  and  being,  of 
necessity,  cut  off. 


60- 


948  OPERATIONS    ON    THE   LOWER   EXTREMITY. 


ERASION*     OF    THE    KNEE-JOINT. 

Definition. — By  this  operation,  which  we  owe  to  G.  A.  Wright,  +  of 
Manchester,  is  meant  a  systematic  removal  of  the  tuberculous  synovial 
membrane ;  the  ligaments,  as  far  as  these  are  diseased,  are  also 
removed,  the  bones  and  cartilage  being  dealt  with  by  paring  with  a 
knife,  or  by  a  gouge  or  sharp  spoon.  The  more  advanced  the  disease 
the  less  typical  will  be  the  erasion.  When  sinuses  are  present,  and 
the  joint  is  the  seat  of  mixed  infection,  the  risks  of  failure  of  any 
attempt  to  save  the  limb  are  hugely  increased.  Where  an  abscess  is 
present,  G.  A.  Wright  {loc.  supra  cit.)  deals  with  this  by  stages.  The 
abscess  should  be  thoroughly  cleared  out  first,  the  wound  closed,  and 
erasion  performed  after  healing  has  taken  place.  This  plan  is  not 
applicable  to  cases  where  the  whole  joint  is  suppurating.  Where 
sinuses  exist  he  has  still  found  it  possible  in  some  cases  to  render  the 
parts  aseptic  by  excision  of  the  walls  of  the  tuberculous  tracts,  and 
the  use  of  powerful  disinfectants,  of  which  he  considers  turpentine  to 
be  one  of  the  best  (Vol.  I.  p.  745).  Thus  while  erasion  is  directed 
chiefly  to  the  soft  structures  which  are  usually  the  primary  seat  of  the 
disease,  it  entails  a  need  of  much  wider  attention  to  other  structures, 
especially  in  hospital  cases  which  have  passed  beyond  the  desired 
early  stage. 

The  old  excision  of  former  days,  with  the  attention  of  the  operator 
directed  to  the  bones  rather  than  to  the  synovial  membrane,  is  an 
operation  of  the  past.  Erasion  is,  when  possible,  always  to  be  pre- 
ferred to  excision.  With  increasing  experience  the  more  will  a 
surgeon's  operation  here  partake  of  an  erasion,  especially  if  he  has 
much  to  do  with  children.  But  in  my  experience,  with  the  advanced 
cases  which  are  still  so  frequent,  the  operation  is  rarely  an  erasion 
alone ;  in  the  great  majority  of  cases  the  ends  of  the  bones  are  affected. 
While  the  gouge  is  invariably,  at  any  age,  to  be  preferred  to  the  saw, 
as  some  surgeons  still  prefer  excision,  and  as  excision  may  be  required 
after  the  failure  of  erasion  in  tuberculous  cases,  and  in  a  few  which 
are  not  tuberculous,  e.g.,  osteo-arthritis,  I  have  described  both 
operations. 

Value  of  Erasion  as  compared  with  Excision;  Suitable  ami  Unsuitable 
Cases. — Where  a  knee-joint,  the  site  of  tuberculous  trouble,  resists,  in 
hospital  patients,  non-operative  treatment  continued  for  three  months; 
where  there  is  but  little  evidence  of  caseation  in  the  joint  (very  difficult 
to  tell,  but  indicated  by  chronic  obstinacy  of  the  disease,  by  spots  where 
the  feel  is  distinctly  doughy,  or  becoming  bluish  in  tint) — in  other 
words,  where  the  disease  is  early,  but,  owing  to  the  patient's  sur- 
roundings, will  go  on  from  bad  to  worse,  erasion  is  indicated  and  far 
preferable  to  excision.  Its  advantages  are,  (1)  There  is  no  removal  of 
bone-slices,  and  still  less  any  interference  with  the  epiphyses.  Thus 
the  only  shortening  which  follows  is  that  due  to  premature  synostosis  of 

*  Arthrectomy  was  a  term  introduced  by  Volkmann  (Cent./  Chir.,  1888)  ;  it 
accurate,  and,  etymologically,  comes  too  near  t<>  excision. 

t  Lancet,  1881,  vol.  ii.  p.  992;  Med.  CUron.,  July  1885;  and  one  together  with 
Mr.  Haslam,  Brit.  Med.  Journ.,  vol.  ii.  1903,  p.  888.  See  also  a  paper  by  Mr.  Shield 
{Ann.  of  Surg.,  Feb.  1888),  and  one  by  Mr.  E.  Owen  QMcd.-Chir.  Trans.,  voL  lxxii.  p.  56). 


ERASION   OF   THE    KNEE-JOINT.  949 

the  epiphysial  line  (W.  Cheyne),  and  disuse  of  the  limb,  too  often 
allowed  to  become  flexed.  This  advantage  will  be  at  once  recognised 
when  it  is  remembered  that  (p.  951)  the  increase  in  length  of  the  femur 
takes  place  chiefly  at  the  junction  of  its  shaft  with  the  lower  epiphysis, 
and  in  the  case  of  the  tibia  at  its  upper  epiphysis.  In  one  of  my  cases, 
a  girl  of  II,  there  was  not  only  no  shortening,  but  repeated  careful 
measurements  showed  half  an  inch  increase  of  length,  perhaps  due 
to  the  increase  of  vascularity  after  the  operation,  about  the  above-men- 
tioned epiphyses.  (2)  With  regard  to  the  retention  of  mobility,  and 
the  advantage  at  first  claimed  for  it,  this,  in  my  opinion,  has  been 
much  exaggerated.  I  have  no  doubt  whatever  that  a  larger  number 
of  carefully  published  cases  will  show  that  where  movement  is  sought 
for,  the  risk  is  run  of  a  certain  degree  of  permanent  flexion,  of  attacks 
of  pain  and  swelling,  and  of  the  formation  of  troublesome  sinuses. 
I  should  strongly  dissuade,  from  any  attempt  to  secure  mobility  in  the 
case  of  the  knee  and  ankle.  (3)  The  ligaments  are  less  interfered 
with,  and  thus,  the  ties  of  the  joint  being  preserved,  firm  union  is 
more  speedy.  This  advantage  is  only  true  of  the  desirable  early  cases, 
and  is  not  to  be  expected  where  the  whole  of  the  interior  of  the  joint 
has  been  interfered  with  to  allow  of  eradication  of  every  diseased 
structure.  (4)  If  performed  earl}',  erasion,  as  excision  does,  but  in 
a  less  expensive  way,  cuts  short  the  disease,  and  thus  gives  a  con- 
siderable saving  of  time  in  children,  at  an  age  when  every  month  is 
of  great  importance.  (5)  It  is  better  suited  to  young  children.  Thus, 
as  it  does  not  arrest  development,  it  may  be  used  very  early.  Wright 
has  operated  "  with  perfect  success  in  a  child  under  two  years 
of  age." 

The  disadvantage  of  erasion — I  am  speaking  only  from  an  experience 
of  twenty-six  cases,  of  which  two  required  excision  later,  and  two 
others  amputation — is,  I  think,  chiefly  this,  that  if  the  operation  fail, 
excision  is  rendered  much  more  difficult.  I  cannot  here  at  all  agree 
with  the  statement  of  my  old  friend,  the  chief  authority  on  this  subject, 
that  erasion,  if  it  fail,  leaves  the  limb  little,  if  at  all,  in  worse  condition 
for  excision  afterwards.  This  is  true  of  the  limb,  but  not  of  the  joint. 
In  one  of  my  erasions  which  required  excision,  I  found  that  the  pre- 
vious operation  had  entirely  obliterated  the  usual  landmarks,  and  that 
great  difficulty  was  experienced  and  much  care  needed  in  dealing  with 
such  parts  as  the  remains  of  the  posterior  ligament.  The  ultimate 
result  here  (vide  infra)  was  good.  Another  minor  disadvantage,  and  one 
shared  by  excision,  is  the  after-flexion.  In  my  opinion  the  liability 
to  this  is  greater  after  erasion.  After  both  operations,  prolonged 
fixation,  for  at  least  two  years  after  erasion,  is  to  be  insisted  upon. 

To  recapitulate,  the  cases  most  suitable  for  erasion  are  those  where 
the  disease  is  limited,  or  almost  limited,  to  the  synovial  membrane, 
with  little,  if  any,  caseation  ;  where  the  cartilage  and  bones  are  almost 
intact,  where  there  are  no  abscesses  or  sinuses,  where  there  is  no 
evidence  of  other  tuberculous  disease,*  and  where  the  power  of  repair 
is  satisfactory. 

*  That  bone  disease  elsewhere  is  not  absolutely  prohibitive  is  shown  by  the  following  : 
Three  of  my  seventy-seven  cases  of  excision  (footnote,  p.  951)  had  had  spinal  disease, 
well-marked   bosses  remaining  in  all.     Each  made  an  excellent  recovery.     One  I  saw 


950  OPERATIONS   ON    THE   LOWER    EXTREMITY. 

Operation. — The  preliminaries  are  the  same  as  for  excision  (p.  953). 
A  trans-patellar  incision  (Fig.  398,  p.  954)  should  be  employed.  Many 
other  incisions,  e.(\.,  a  Hap  usually  going  through  the  ligament,  a 
median  vertical  one  splitting  the  quadriceps,  patella  and  ligament,  and 
two  lateral  incisions,  have  all  been  employed.  I  have  used  the  first, 
but  prefer  that  through  the  patella  as  best  combining  adequate 
exposure  of  the  parts  and  retention  of  the  patella  in  order  to  meet 
the  inevitable  tendency  to  flexion.  But  to  ensure  thorough  exposure 
of  the  supra-patellar  region,  a  very  dangerous  area  on  account  of  its 
numerous  nooks  and  crannies,  which  give  lurking-places  to  tuberculous 
mischief,  I  always  slit  this  pouch  right  up  to  its  very  top  with  a  sharp- 
pointed  bistoury,  thus  dividing  the  upper  flap  into  two.  (I.  A.  Wright  in 
his  last  paper  writes:  "I  now  do  the  transverse  trans-patellar  operation 
with  a  vertical  upward  incision  occasionally  added  to  facilitate  removal 
of  disease  tracking  up  the  sub-crural  sac.  I  usually  divide  the 
aponeurosis  on  each  side  of  each  half  of  the  patella  for  an  inch  or  more 
to  facilitate;  exposure."  The  flaps  being  then,  one  by  one,  thoroughly 
everted  with  a  sharp  hook,  taking  the  upper  half  of  the  joint  first,  I 
seize  the  tip  of  one  of  the  flaps  with  mouse-tooth  forceps,  and  then, 
with  blunt-pointed  scissors  curved  on  the  flat,  dissect  the  diseased 
synovial  membrane  off  the  under-surface  of  the  split  quadriceps  expan- 
sion in  a  continuous  strip  till  the  uppermost  limit  of  the  supra-patellar 
pouch  is  reached.  The  reflection  of  the  synovial  membrane  over  the 
front  of  the  femur  is  then  dealt  with  in  the  same  way,  leaving  the 
periosteum  on  this  quite  clean.  The  joint  being  then  well  bent,  and 
the  tibia  being  brought  forward  as  directed  (p.  956,  Fig.  399),  the 
crucial  ligaments,  the  semilunar  cartilages,  the  inter-condyloid  notch, 
and  the  synovial  reflections  behind  the  crucial  ligaments  are  carefully 
inspected.  To  do  this  thoroughly,  it  is  absolutely  needful  to  divide 
the  lateral  ligaments  sufficiently.  With  regard  to  the  other  structures, 
some  retain  the  semilunar  cartilages,  if  healthy  ;  others  remove  them 
in  any  case.  For  my  part,  as  it  is  so  essential  to  remove  all  the 
synovial  membrane,  and  this  is  impossible  unless  the  semilunar 
cartilages  go,  I  always  remove  them.  With  regard  to  the  crucial 
ligaments,  the  anterior  nearly  always  requires  removal ;  as  regards 
the  posterior,  the  whole  ligament,  or  as  much  of  it  as  possible,  should 
be  left,  since  its  removal  is  extremely  liable  to  be  followed  by  back- 
ward displacement  of  the  tibia.  The  inter-condyloid  notch,  and  the 
reflection  behind  the  crucial  ligaments,  is  then  taken  in  hand,  very 
wide  flexion  of  the  joint,  and  a  finger  of  an  assistant  in  the  popliteal 
space,  here  facilitating  this,  the  most  difficult  and  important  part  of  the 
operation.  When  much  disease  is  present  here  in  the  synovial  mem- 
brane, both  crucial  ligaments  must  be  unhesitatingly  removed,  and,  if 

fourteen  years  later.  In  spite  <>f  the  old  spinal  disease  and  marked  shortening  of  the  Limb 
owing  to  excision  being  required  after  evasion,  this  patient  was  able  to  make  his  way  daily 
Erom  Brixton  to  Westminster  and  back,  and  earn  Ins  living  as  a.  solicitor's  clerk.  Limited 
tuberculous  disease  of  the  tarsus  existed  in  two  others  and  was  cured  by  operation  by  the 
time  the  knee  was  sound.  In  two.  disease  of  the  hip-joint  coexisted  :  in  one.  the  limb  had 
to  be  removed  by  a  Furncaux  Jordan  amputation,  the  child  recovering  :  in  the  other  (the 
disease  being  on  the  opposite,  side),  the  knee,  after  a  t  rans-patellar  excision,  healed  soundly. 
the  hip  disease  being  cured  by  rest.  A  case  in  which  both  knees  were  excised  is  shown 
at  p.  962. 


EXCISION    OF    THE    KNEE-JOINT.  951 

needful,  the  overhanging  posterior  part  of  the  condyles  must  be  cut 
away,  [n  dealing  with  the  synovial  membrane  in  the  inter-condyloid 
nut  eh,  the  surgeon  must  remember  that  he  will  never  have  a  similar  chance 
of  dealing  with  the  disease  here,  and  that,  if  any  is  left  behind,  excision, 
and  perhaps  amputation,  will  be  called  for.  The  synovial  membrane 
around  the  lower  half  of  the  patella  is  then  removed,  and  finally  the 
ends  of  the  bones  are  examined.  Any  pits  and  foci  are  gouged  out, 
and  more  extensive  ulceration  shaved  off  with  a  strong  sharp  knife. 
Drainage  is  rarely  required,  save  of  course  in  infected  cases,  or  where 
the  condition  of  the  parts  will  certainly  give  rise  to  much  oozing  later. 
The  two  ends  of  the  wound  should  never  be  closely  sutured.  The 
dressings  are  applied  with  the  precautions  given  at  p.  959,  and  not 
until  all  is  completed  is  the  Esmarch's  bandage  removed.  Throughout 
the  operation  in  infected  cases,  irrigation  with  lot.  hydr.  perch.,  I  in 
3000,  should  be  diligently  employed. 

The  after-treatment  is  the  same  as  after  excision  (p.  961).  As  there 
is  the  same  long-continued  tendency  for  the  limb  to  become  flexed, 
there  is  the  same  urgent  need  for  a  rigid  apparatus  for  at  least  two 
years. 

Causes  of  Failure  after  Erasion. — These  are  much  the  same  as  those 
given  at  p.  961.  The  chief  of  them,  persistence  of  the  disease  from 
failure  to  eradicate  it  at  the  first  operation,  is  there  dealt  with. 

EXCISION*    OF    THE    KNEE-JOINT. 

(Figs.  397—404.) 

Indications. — A.  For  Disease.     B.  Injury. 

A.  For  Disease. 

(i.)   Tuberculous  disease. 

On  this  subject  the  remarks  already  made  (p.  948)  on  erasion  should 
be  referred  to.  The  following  points  require  mention  as  well :  One 
is  age.  The  chief  growth  of  the  femur  takes  place  at  its  lower  end 
(P-  958)-  By  fifteen,  and  still  more  by  seventeen,  the  growth  of  the 
bone  is  largely  completed.  Thus,  in  young  subjects,  especially  before 
ten,  as  little  of  the  bones  as  possible  should  be  removed,  and  gouging 
should  largely  replace  the  saw.  While  the  old-fashioned  excision,  in 
which  attention  was  chiefly  directed  to  the  ends  of  the  bones,  is,  as 
alread}T  stated,  very  largel}'   an  operation  of  the  past  in  tuberculous 

*  This  operation  is  contrasted  with  erasion  of  the  knee  at  p.  948.  I  may  perhaps 
here  say  that  I  have  excised  the  knee  seventy -seven  times,  and  performed  erasion  on 
twenty-six  occasions.  Of  the  cases  of  excision  four  died  of  effects  of  the  operation,  one 
(mentioned  below)  from  shock,  another  (also  mentioned  beluw),  with  bony  ankylosis  and 
angular  displacement,  from  threatening  gangrene,  a  third  from  surgical  scarlet  fever,  and 
a  fourth  from  septicaemia.  The  child  with  surgical  scarlet  fever  was  moved,  during  my 
absence  from  town,  into  an  empty,  chilly  ward ;  the  eruption  became  dusky  and  then 
suppressed ;  coma,  followed  by  death,  ensued.  Six  have  been  submitted  to  amputation, 
making  good  recoveries.  This  number  would  probably  haye  been  seven,  as  a  patient,  aged 
53,  whose  knee  had  been  excised  for  disorganisation  after  osteo-arthritis  and  whom  I  had 
advised  to  submit  to  amputation,  went  out  able  to  walk  a  little  with  a  stick,  but  with  two 
sinuses.  Of  the  cases  of  erasion  I  had  to  perform  excision  in  two,  and  amputation  in  two 
others.     All  the  patients  recovered. 


952  OPERATIONS   ON   THE    LOWER    EXTREMITY. 

cases,  it  may  still  be  called  for  in  the  following:  where  the  disease  is 
of  long  standing;  where  there  is  backward  displacement  of  the  tibia; 
where  the  disease  has  stalled  as  an  epiphysial  osteitis. 

While  the  subject  of  tuberculous  disease  of  the  knee-joint  is  being 
considered,  the  question  of  amputation  will  arise  in  certain  cases. 
Sir  H.  Howse  (Guy's  Hosp.  Rep.,  1894)  gives  the  following  conditions 
which  call  for  this  step.  They  are:  A.  Constitutional,  (a)  Lar- 
daceous  disease,  (ft)  Tuberculous  disease  of  the  lungs  or  other 
viseus.  (y)  Great  emaciation  without  any  very  evident  visceral  disease. 
(8)  Multiple  joint  disease  (vide  p.  949).  13.  Local,  (a)  I  >stritis  or 
periostitis  extending  along  the  shafts  of  either  femur  or  tibia,  as  shown 
by  great  thickness  or  tenderness  of  the  bone.*  (ft)  Very  great  infiltra- 
tion of  tuberculous  material  into  the  soft  parts,  extending  far  beyond 
the  limits  of  the  joint. 

(ii.)  Some  cases  of  failed  erasion  in  which  the  mischief  is  too 
extensive  for  curetting,  but  does  not  call  for  amputation. 

(iii.)  Threatening  disorganisation  of  the  knee,  with  caries,  after 
pyaemia,  and  other  forms  of  infective  arthritis. 

(iv.)  Osteo-arthritis. — Where  one  joint  only  is  affected,  and  the 
patient  is  not  past  middle  life,  excision  gives  good  results.  The 
surgeon  must  be  prepared  for  sawing  very  dense  bones. 

(v.)  Ankylosis. — Excision  can  usually  be  abandoned  here  for  better 
operations  (p.  963),  e.g.,  dividing,  with  aseptic  precautions,  the  union, 
with  an  osteotome  introduced  first  on  one  side  and  then  on  the  other, 
and  worked  forwards  under  the  patella  and  skin,  and  backwards  as  far 
as  the  popliteal  artery  allows.  If  this  fail,  a  double  osteotomy  of  the 
femur  and  tibia  should  be  performed  rather  than  excision,  an  operation 
which,  in  the  case  of  true  bony  ankylosis,  is  liable  to  be  severe,  pro- 
longed, and  to  leave  a  large  wound,  and,  in  the  case  of  young  subjects, 
to  lead  to  further  shortening  of  a  limb  already  atrophied  and  weakened 
from  disease.  I  would  strongly  urge  caution  in  rapidly  and  completely 
straightening  a  knee-joint  which  has  long  been  the  seat  of  a  bony 
ankylosis  in  a  bad  position  and  call  attention  to  the  case  related 
at  p.  963. 

(vi.)  Old,  Neglected  Infantile  Paralysis. — The  question  of  excision 
here  is  referred  to  (p.  963),  under  the  heading  of  Arthrodesis. 

B.  Injury. — Here  such  injuries  as  those  from  gunshot  and  those 
from  a  lacerated  wound  or  a  compound  fracture  must  be  considered 
separately. 

1.  Gunshot. — "The  results  of  the  excisions  of  the  knee-joint  performed  during  the 
late  civil  war.  whether  the  operations  were  primary,  intermediary,  or  secondary,  were  nol 
very  encouraging,  forty-four  of  the  fifty-four  cases  in  which  the  issues  were  ascertained 
having  terminated  fatally,  a  mortality  of  81-4  per  cent.,  exceeding  the  mortality  of  the 
amputations  of  the  thigh  (53S)  by  276  per  cent."  (Otis,  loc.  tupra  fit.,  p.  419).  Sir 
T.  LoDgmore  (Sytt.  of  Surg.,  vol.  i.  p.  565)  lays  down  these  definite  rules:  •'  From  all 
the  experience  which  has  been  gained  regarding  gunshot  wounds  in  whicb  the  knee-joinl 
has  been  opened,  especially  if  the  surfaces  of  the  bone  have  escaped  damage,  as  may 
uonally  happen  with  modern  narrow  rifle  bullets,  and  even  in  other  casus  where  one 

*  Sir  H.  Howse  points  out  that,  occasionally,  tenderness  and  thickening  may  be  due  to 

a  Bequestrum,  which  may  be  successfully  removed,  and  later  on  a  useful  limb  obtained  by 
excision. 


EXCISION    OF   THE    KNEE-JOINT. 


95 ; 


of  tlic  bones  has  been  Assured,  or  partial  Eracture  has  occurred,  provided  early  immob 
t it m  ol'  the  injui c<l  parts  can  be  seemed,  antiseptic  treatmenl  carried  out,  and  the  general 
Borroandings  are  sufficient ly  hygienic,  it  may  now  be  Laid  down  as  a  rule  that  conservative 
treatment  ought  to  be  adopted.  When,  however,  the  circumstances  under  which  the 
wounds  have  been  inflicted  are  such  that  the  precautionary  methods  and  modes  of  treat- 
menl mentioned  cannot  be  put  into  practice,  when  the  patients  are  Liable  tn  be  moved 
frequently  or  to  long  distances  hurriedly,  and  without  adequate  protection,  or  when  the 
joint  is  oot  only  penetrated,  but  the  surrounding  coverings  are  much  Lacerated,  orthe 
bones  are  comminuted  and  the  fragments  completely  detached,  ;  I  be  limb  by 

am  |  mi  a  i  lmi  above  the  joint  is  the  only  measure  calculated  to  afford  a  fair  promise  of  Bafel  v 

..I'  lite  to  the  pat  lent." 

Mr.  Makins,  O.B.,  in  his  standard  work  (•'  Surgical  Experiences  in  South  Africa,  1899 
— 1900"),  from  which  1  have  already  quoted,  writes(p.  238),  that  while  the  knee-joinl 

the  one  most  commonly  injured,  ''  injuries  to  the  joint  gave  less  anxiety  than  is  the  case  in 
civil  practice.  The  old  difficulty  of  deciding  on  partial  as  against  full  excision  or  amputa- 
tion was  never  met  with  by  us.  We  had  merely  to  do  our  first  dressings  with  care,  lix 
the  joint  for  a  short  period,  and  be  careful  to  commence  passive  movements  as  soon  as  the 
wounds  were  properly  healed  to  obtain  in  the  great  majority  of  eases  perfect  results.  If 
suppuration  occurred,  the  choice  between  incision  and  amputation  had  to  be  considered. 
Amputation  was  sometimes  indicated  in  cases  of  severe  bone-splintering,  but  was  as  a  rule 
only  performed  after  an  ineffectual  trial  to  cut  short  general  infection  of  the  septicaemic 
type  by  incision."  Association  of  popliteal  aneurysm  with  wounds  of  the  knee-joint  was 
comparatively  common. 

2.  Injuries  other  than  gunshot. — Excision  is  rarely  practicable  here.  A  very  careful 
consideration  of  the  local  and  general  conditions  present  is  needful.  Amongst  the  former, 
damage  limited  to  the  articular  surfaces,  but  little  splintering  of  the  shafts  of  the  bones, 
and  an  intact  condition  of  the  soft  parts  behind  the  joint  are  absolutely  essential.  Not 
important  is  it  to  weigh  the  more  general  points  connected  with  the  patient — viz.,  his  a_re 
not  reckoned  by  years  only,  the  condition  of  his  viscera,  and  his  habits  ;  all  these  points 
are  considered  in  the  account  of  "The  Treatment  of  Compound  Fractures,"  given  later  on. 

Operation. — Before  and  throughout  an  excision  of  the  knee,  or  rather 
a  combination  of  partial  excision  with  erasion,  the  operator  should 
bear  in  mind  the  following  points  :  (1)  to  remove  every  atom  of  the 
disease  ;  (2)  to  secure  good  drainage;  (3)  to  leave  the  bones  in  good 
position;  (4)  to  ensure  absolute  immobility  afterwards ;  (5)  to  watch 
for  and  at  once  attack  any  relapse.  The  more  I  performed  this 
operation,  the  more  did  1  feel  the  truth  of  the  words  of  Prof.  Bruns, 
of  Tubingen,  that,  while  formerly  its  chief  object  was  to  remove  all 
affected  bone,  it  should  now  be  considered  of  chief  importance  to 
remove  all  the  tuberculous  material  that  can  possibly  be  got  away,  and 
that  the  surgeon  should  not  content  himself  with  snipping  away  all  he 
can,  leaving  the  rest  to  caseate  or  become  scar-tissue  if  it  will,  but 
pursue  it  with  the  same  earnest  aim  of  extermination  as  he  would  in 
the  case  of  malignant  disease.  I  would  not  by  the  above  seem  to  speak 
slightingly  of  the  value  of  securing  healthy  and  correctly  sawn  surfaces 
of  bone,  as  on  these  largely  depends  firm  ankylosis  and  a  sound  and 
useful  limb,  but  I  would  insist  on  the  fact  that  such  surfaces  are 
secured  in  vain  if  tuberculous  material  is  allowed  to  remain,  and  that 
other  instruments — e.g.,  sharp  spoons  and  scissors  curved  on  the  flat — 
are  to  the  full  as  useful  as  the  saw. 

Before  the  time  of  the  excision,  any  flexion  of  the  knee  should  be 
corrected  as  far  as  possible  by  careful  weight-extension.  A  knee  should 
never  be  excised  while  flexed.  Such  a  step  will  only  be  liable  to  lead 
to  removing  bone  needlessly  in  order  to  straighten  the  limb.  The  risk 
of  gangrene  is  alluded  to  at  p.  963. 


954 


OPERATIONS    ON    THE    LOWES    EXTREMITY. 


The  parts  having  been  duly  sterilised,  and  an  Esmarch'a  bandage* 
applied  a1  the  top  of  the  thigh,  the  Limb  is  brought  over  the  edge  of  the 
table,  flexed,  and  held  by  an  assistant  as  in  Fig.  399. 

From  the  moment  of  commencing  the  operation  to  its  very  close  the 
surgeon  must  bear  in  mind  the  inveteracy  of  tuberculous  material 
(malignancy  would  probably  not  be  too  strong  a  word),  and  in  his 
endeavours  to  extirpate  the  disease  completely  his  operation  will 
combine  the  operations  of  erasion  and  excision  rather  than  follow  the 
typical  lines  of  either.! 

The  following  modes  of  exposing  the  joint  will  be  given  here: 

A.  Transverse,  removing  the  Patella.  B.  Transverse,  through 
the  Patella.  C.  The  Semilunar  Flap  (lately  recommended  by  .Mr. 
Darker,  and  attributed  by  him  to  Moreau). 


Fig.  397. 


Fig.  398. 


Transverse  incision,  the  patella  being  removed. 


Trans-patellar  incision. 


A.  Transverse,  removing  the  Patella  (Fig.  397). — This,  the  older 
method,  is  still  resorted  to  by  those  surgeons  who,  like  Sir  II.  Howse, 
believe   that,    if  the   patella  is   retained,  a   most   serious  risk  is  run  of 


*  Some  object  to  the  bandage  as  needless  and  as  likely  to  lead  to  troublesome  oozing 
after  the  operation.  This  may  be  met  by  firm  pressure  and  even  bandaging  on  of  the 
dressings,  so  as  to  distribute  any  oozing  uniformly  throughout  them.  If  an  Esmarch's 
bandage  is  not  applied,  the  bleeding  daring  the  operation  interferes  with  the  removal  of 
diseased  tissues,  requires  constanl  pressure  to  arrest  it.  and  taxes  the  patient's  resources 
considerably.  Its  use  meets  another  risk,  which  is  possibly  hypothetical,  and  thai  is.it 
renders  impossible  the  general  diffusion  "f  tuberculous  material  by  the  cut  veins  and 
lymphatics.  The  application  of  one  bandage,  preceded  by  due  elevation  of  the  limb, 
suffices.  The  bandage  must  lie  applied  as  high  as  ip"s~il>]e.  so  as  t.>  be  above  the  splint. 
As  in  all  prolonged  operations,  to  avoid  harmful  pressure  "n  the  nerves,  it  is  well  to  apply 
the  bandage  over  a  collar  of  boracic  acid  lint. 

t  If  operations  for  tuberculous  knee  are  resorted  to  at  an  earlier  stage  the  bones  will 
less  and  less  need  interfering  with. 


EXCISION    OF    THE    KNEE-JOINT.  955 

leaving  behind  tuberculous  material  which  will  require  removal  later  on 
under  less  Favourable  circumstances,  and  this  failing,  may  lend  in 
amputation. 

The  surgeon,  standing  on  the  left*  side  of  the  diseased  knee  (the 
opposite  limb  being  tied  to  the  table),  makes  an  incision  right  across  the 
joint  from  the  back  of  one  condyle  to  that  of  the  other. t  This  incision 
passes  over  the  lower  part  of  the  patella  and  exposes  the  lateral  ligaments 
at  once.  The  soil  parts  being  then  dissected  up  lor  two  inches  above 
the  patella,  so  as  to  expose  the  supra-patellar  pouch,  deep  incisions  are 
made  above  and  below  the  patella,  which  is  then  removed  and  the  joint 
opened. 

If  the  patella  is  ankylosed  to  the  condyles,  it  must  be  removed  by  a 
blunt  elevator,  aided  by  a  narrow  saw,  or,  better,  by  an  osteotome  and 
mallet.  No  violence  should  be  used  in  opening  a  joint  partially 
ankylosed,  or  tin;  epiphyses  may  easily  be  separated  from  the  shaft, 
especially  in  a  child. 

I  invariably,  when  raising  the  flap  of  soft  parts  in  an  excision  of  the 
knee,  however  performed,  slit  them  up  by  a  vertical  incision,  going  to 
the  upper  limit  of  the  supra-patellar  pouch,  so  as  to  expose  fully  all  its 
folds  and  recesses.  Unless  this  is  done,  tuherculous  material  is  very 
easily  left  behind,  and,  later  on  breaking  down,  leads  to  oedema, 
persistent  sinuses,  perforation  of  the  pouch  and  spread  of  disease 
amongst  the  adductors  and  into  the  vicinity  of  the  femoral,  and 
perforating  vessels,  where  it  is  impossible  to  eradicate  it,  amputation 
being  eventually  called  for. 

B.  Transverse,  through  the  Patella  (Fig.  398). — This  method,  by 
preserving  the  patella  and  the  insertion  of  the  quadriceps,  partly 
counterbalances  the  flexing  action  of  the  ham-strings  (p.  961)  at  the 
same  time.  Used  by  Volkmann  many  years  ago,  it  was  again  brought 
under  the  notice  of  English  surgeons  by  Mr.  Golding  Bird  in  a  case 
which  he  brought  before  the  Clinical  Society  {Trans.,  vol.  xvi.  p.  82). 

For  arguments  against  preserving  the  patella  I  must  refer  my  readers 
to  Sir  H.  Howse's  article  (loc.  siijnacit.).  I  am  of  opinion,  myself,  that 
in  young  subjects  where  the  union  is  certain  to  yield  for  some  time,  it 
is  well  worth  while,  in  cases  where  the  disease  is  not  too  advanced,  to 
preserve  the  patella,  though,  to  ensure  the  full  benefit  of  this  step, 
fresh  osseous  surfaces  should  be  prepared  on  this  bone  and  on  the 
femur  and  tibia,  so  as  to  promote  bony  union.  Another  and  minor 
argument  in  favour  of  preserving  this  bone  is  that  the  anastomoses 
about  the  joint  are  less  interfered  with.  This  method  is  not  adapted 
to  cases  where  caseation  is  advanced,  and  its  adoption  only  lessens,  but 
does  not  remove,  the  liability  to  subsequent  flexion. 

The  transverse  incision  is  made  here  much  as  in  the  first  method, 
only  across  the  middle  of  the  patella ;  this  is  sawn  through  or  divided 
with  a  stout  knife,  the  fragments  turned  up  and  down,  and  the  joint 
freely  opened  (Fig.  398). 

C.  Semilunar  Flap  (Moreau,  Barker). — Here  a  large  U-shaped  flap 

*  This  position  renders  it  much  easier  for  him  to  saw  the  femur  and  tibia. 

}  Beyond  this  spot  the  incision  should  not  go,  for  fear  of  wounding  the  internal 
saphena  vein.  This  would  lead  to  troublesome  oedema  of  the  foot  and  leg,  and,  if  the 
wound  should  become  infected,  might  bring  about  phlebitis  and  pyaemia. 


956 


OPERATIONS    ON    THE    LOWEB    EXTREMITY. 


Fig 


is  raised  by  B  semilunar  incision,  starting  above  one  condyle,  descend- 
ing to  the  level  of  the  tibial  tubercle,  crossing  the  leg  here  and  running 
up  to  a  corresponding  point  on  the  other  side.  In  raising  this  flap, 
which  includes  all  the  soft  parts  down  to  the  bone,  either  the  liga- 
mentum  patella?  should  be  severed  (suturing  of  tins  being  resorted  to 
biter),  or  the  tuberosity,  attached  to  the  ligament,  is  removed  with  a 

chisel,  and  subsequently  wired 
down  (Barker). 

The  joint  having  been  opened 
by  one  of  the  above  incisions, 
it  is  well  to  slit  with  a  sharp 
bistoury  the  supra  -  patellar 
pouch*  up  to  its  upper  limits 
(readily  reached  by  a  finger), 
so  as  to  lay  bare  every  crevice 
and  to  remove  every  atom  of 
diseased  tissue.  The  cut  mar- 
gins being  held  on  the  stretch 
by  two  Spencer  Wells's  forceps, 
the  surgeon  with  mouse-toothed 
forceps  seizes  the  cut  edge  of 
the  synovial  lining  of  the  cap- 
sule, and  with  curved  scissors 
removes  it  in  one  piece,  first 
from  under  the  vasti  muscles 
and  then  along  its  reflexion  on 
to  the  femur  down  to  where  it 
ceases  at  the  margins  of  the 
articular  cartilage. 

Next  the  lateral  and  crucial 
ligaments  are  examined,  and 
every  particle  of  diseased  tissue 
removed,  only  bright,  glisten- 
ing, clearly  healthy  ligamentous 
tissue  being  left.  +  But  as 
naked-eye  examination  in  parts 
perhaps  not  absolutely  blood- 
less ma}-  easily  be  fallacious, 
it  is  much  better  in  doubtful 
cases  to  remove  these  com- 
pletely than  to  run  any  risk 
whatever.  The  assistant  who 
is  in  charge  of  the  limb  now 
brings  the  head  of  the  tibia  well  into  view  by  pulling  the  calf  of  the  leg 
well  forward  with  one  hand  while  he  further  dislocates  the  bone  by 
pushing  up  the  leg  (Fig.  399). 

*  I  look  on  this  as  one  of  the  most  cardinal  points  of  the  operation. 

t  Prof.  Oilier  (loc.  'infra  tit.  and  Rev.  <lr  Chir..  1882)  drew  attention  to  preserving 

the  lateral  ligaments,  if  possible,  together  with  all  healthy  periosteum  and  eapsule — 
i.e..  those  tissues  which  will  keep  the  bones  in  place  and  which  will  tend  to  produce  ossify- 
ing material.     This  will  not  interfere,  if  carefully  carried  out,  with  extirpating  diseased 

parts,  while  it  will  go  far  to  prevent  progressive  flexion  of  the  joint. 


i:\('IS|()N    OF    TIIK    KNKK  JOINT. 


957 


The  conditio!)  of  the  semilunar  cartilages  is  next  examined,  and  if 
they  are  invaded  by  tuberculous  tissue,  if  it  is  intended  to  perform 
a  complete  excision,  they  must  be  cut  away  entirely. 

The  back  of  the  joint  is  next  taken  in  hand.     This  region  can  be  far 

more  effectively  dealt  with  after  removal  of  the  bones.  If,  owing  to 
the  case  being  an  early  one,  with  little  or  no  caries,  the  surgeon  desires 
l.)  remain  content  with  an  erasion,  he  must  still  deal  thoroughly  with 
the  posterior  ligament*  and  deeper  parts  of  the  sides  of  the  joint  with 
all  recesses  and  folds  of  the  synovial  membrane.  To  expose  these 
parts  thoroughly  is  a  matter  of  some  difficulty.  The  assistant  should 
manipulate  the  limb  as  above  directed  at  one  time,  at  another  flex  the 
leg  back  towards  the  table,  while  occasionally  a  sterilised  linger  in  the 
popliteal  space  will  keep  within  reach  any  altered  tissue  that  it  is 
desired  to  deal  with.  Every  pains  must  be  taken  to  use  the  scissors 
systematically  and  thoroughly  here  as  elsewhere  until  healthy  tissues 
are  reached,  and  not  to  dread  the  popliteal  artery  too  mucin  This 
should  be  enforced  for  two  reasons. 

If  any  diseased  tissue  is  left  here,  it  *'ia-  4°°- 

will  be  shut  in  after  the  limb  is 
extended  and  be  impossible  to  deal 
with,  save  by  a  fresh  and  probably 
unsuccessful  operation.  Again,  there 
is  always  a  risk,  especially  in  a 
surgeon's  earlier  operations,  of  his 
not  dealing  with  disease  here  with 
sufficient  thoroughness  from  dread 
of  injuring  the  popliteal  artery. 
This  vessel  may  be  avoided  by 
(i)  not  dipping  the  points  of  the 
scissors  deeply,  but  using  the  blades 
as  far  as  possible  parallel  with  the 
course  of  the  vessel ;  (2)  remember- 
ing that  even  after  the  posterior  crucial  ligament  has  been  removed 
(a  detail  often  imperfectly  carried  out)  there  is  still  a  considerable 
thickness  of  tissue  in  front  of  the  artery. 

After  all  diseased  tissues  at  the  back  have  been  thoroughly  eradicated, 
the  deeper  aspects  of  the  sides  of  the  joint  must  be  examined.  Where 
caseating  foci  have  spread  down  on  the  inner  side  of  the  joint,  the 
tendons  of  the  sartorius,  semi-membranosus,  and  semi-tendinosus  may 
need  exposing. 

It  remains  to  describe  the  removal  of  the  bones  in  case  erasion  is 
not  sufficient.  Where  excision  is  evidently  needed,  the  bones  should 
be  sawn  after  the  supra-patellar  pouch  is  cleared  out,  and  before  the 
posterior  aspect  of  the  joint  is  taken  in  hand,  as  this  step  will  be  much 
facilitated  thereby. 

The  femur,  held  as  steady  as  possible,  is  taken  first.  A  groove  for 
the  saw  is  first  so  marked  out  with  the  scalpel  as  to  remove  about 
one-third  of  the  condyles.  In  severer  cases,  or  where  the  above  section 
will  clearly  be  insufficient,  half,  or  even  two-thirds,  of  the  articular 


*  This  and  the  posterior   parts   of    the   semilunar   fibro-cartilages  are  liable   to   be 
inefficiently  treated. 


958 


OPERATIONS   ON   THK    LOWEB    EXTREMITY 


surface  may  be  removed,  but  no  section  should  be  made  farther  back 
than  this,  or  the  epiphysis  will  he  trenched  upon  with  serious  after- 
results.*  Care  should  be  taken,  in  making  the  section  of  the  femur, 
to  ensure  that  the  plain-  of  the  sawn  surface  shall  be  at  right  angles  to 
the  axis  of  the-  shaft.  Sir  II.  Howse  prefers  to  saw  the  femur  while 
this  is  held  vertically. 

The  tibia  is  taken  next,  and  a  groove  marked  out  with  the  knife 
about  half  an  inch  below  the  articular  cartilage.  A  Butcher's  saw,  set 
horizontally,  is  used  from  behind  forwards,  ami  on  a  perfectly  level 
plane.  Neither  here  nor  in  sawing  the  femur  must  the  slightest 
wobbling  of  the  saw  be  permitted. 

About  half  an  inch  only  of  the  tibia  should  be  removed,  just  enough 
in  fact  to  expose  healthy  cancellous  tissue,  and  no  more.  Of  the 
femur  no  more  than  an  inch  and  a  half  should  be  removed  if  possible.! 
Any  soft,  yellow,  cheesy,  fatty  patches,  any  cancellous  tissue  into 
which  pulpy  tissue  has  dipped  after  perforating  the  cartilage,  should  be 

carefully  removed  with  a  gouge. 
Fig.  401.  Where,  however,  there  is  much 

caries,  or  the  above  patches 
are  numerous,  breaking  down 
readily  under  the  finger-nail, 
more  than  one  slice  of  bone  had 
better  be  removed. 

The  whole  wound  is  now 
finally  m<  >st  carefully  scrutinised, 
every  outlying  angle  and  recess 
being  examined  for  tuberculous 
tissue  left  behind. 

The    Esm arch's   bandage    is 

now    by    some    removed,    and 

while  sterile  pads  wrung  out  of 

hot  1  in  2,000  bydr.  perch,  are 

held  firmly  over  the  sawn  tibia, 

any  bleeding  points  in  the  upper 

half  of  the  wound  are  attended  to.     The  safest  way  of  arresting  the 

bleeding  is  by  under-running  with  chromic  gut  and  fine  needles  all  the 

vessels  which  spirt, J  as  practised  by  Sir  H.  Howse,  or,  as  I  greatly 


*  Dr.  Hoffa,  of  Wuraburg  (Arch.  f.  Jdin.  Chir.,  Band  xxii.  Heft  4.  1SS5  ;  Annul*  of 
Surgery,  March,  1886),  brings  forward  cases  to  Bhow  that  removal  of  Loth  epiphyses  led, 
at  the  end  of  ten  years,  to  shortening,  amounting  to  25J  cm.  (1  cm.  =  fa  inch),  while  in 
another  case  it  amounted  in  two  years  to  10  cm.  Loss  of  the  femoral  epiphysis  alone 
showed  17  cm.  of  shortening  in  six  years,  and  7  cm.  in  a  year  and  a  half.  Two  cases  of 
the  like  duration  affecting  the  tibial  line  showed  respectively  15J  and  6  cm.  I 
however,  well  known  that  considerable  shortening  may  occur  in  cases  treated  expectantly. 

t  If  the  surgeon  is  obliged  to  trench  upon  the  epiphyses  it  should  be  with  the  gouge, 
and  not  with  the  saw,  if  possible.  In  one  case  of  a  boy,  aged  7,  the  bones  being  carious, 
soft,  and  fatty,  a  large  patch  of  cheesy,  fatty  bom  itself  in  the  head  of  the 

tibia  after  the  first  slice  had  been  removed.     On  removing  this,  the  gouge  entered  the 
medullary  canal,  which  was  ex]  ng  on  the  sawn  surface.       I  was  doubtful  how 

far  union  would  take  place  here,  but  three  years  later  the  boy  had  a  most  useful  limb, 
probably  from  a  ring  of  epiphysial  tissue  being  left. 

X  The  following  .ill   be  found   to  give  the   chief  trouble  after  a  combined 


EXCISION    OF   THE    KNEE-JOINT. 


959 


Fio.  402. 


prefer, by  Mr.  Barker's  plan  (vide  infra).  Bleeding  from  the  cancellous 
tissue  will  be  arrested  by  placing  the  bones  in  contact,  [f  there  is  any 
tendency  of  the  edges  of  the  skin  to  fold  in,  these  must  be  shortened. 

The  best  means  of  meeting  the  hemorrhage,  and  one  which  I  have 
followed  in  all  my  later  cases  of  excision 
and  erasion,  is  that  advised  by  Mr.  Barker 
(Hunt.  Lect.,  supra  <it.).  The  Esmarch's 
bandage  is  here  not  removed  until  the 
dressings  in  sufficiently  thick  successive 
layers — e.g.,  Iodoform  gauze  and  salicylic 
wool — are  firmly  bandaged  in  position.  To 
admit  of  sufficient  pressure  being  applied 
to  check  the  oozing  and  to  distribute  it 
uniformly  throughout  the  dressings,  a 
sterile  wdiite  bandage  should  first  be  ap- 
plied from  the  foot  to  the  upper  third  of 
the  leg.  If  one  of  Sir  H.  Howse's  splints 
is  employed,  the  Esmarch's  bandage  must 
be  applied  sufficiently  high  up  the  thigh 
not  to  interfere  with  the  limb  being  placed 
in  the  splint,  as  this  has  to  be  done  before 
the  dressings  are  applied.  I  have  found 
this  plan  most  satisfactory. 

The  patella,  if  sawn,  is  now  drilled  and  from  the  front.  That  of  the 
wired,  or  united  with  stout  silk  or  chromic  fibula  is  ako  seen.  They  are 
gut.  I  prefer  the  first,  the  wire  being  cut 
short  and  embedded  in  the  front  of  the 
patella  in  the  way  described  at  p.  971. 
As  an  additional  precaution  against  the 
inevitable  tendency  to  flexion,  Mr.  A.  H. 
Tubby  advises  (Brit.  Med.  Journ.,  vol.  ii., 
1903,  p.  893)  that  the  anterior  aspects  of 
the  ends  of  the  femur  and  tibia  and  the 
posterior  aspects  of  the  patella  be  removed. 
The  four  portions  of  bone  are  then  united 
with  a  silver  wire,  which  is  embedded. 

The  question  now  arises  whether  the 
tibia  and  femur  should  be  united  by 
wiring  or  pegging.*  I  am  of  opinion  that 
if  the  bones  have  been  so  sawn  as  to 
bring  their  faces  squarely  together,  with 
sufficiently  exact  closeness  to  prevent  more 
than  a  finger-nail  being  inserted  between 
them,  and  if  they  are  put  up  with  the 
security  which  is  given  by  Sir  H.  Howse's 
method,  the  above  aids  are  not  needed.! 

erasion  and  excision  :  one  or  two  running  down  in  the  periosteum  over  the  femur,  one  or 
two  in  the  cut  periosteum  surrounding  the  sawn  margin  of  the  tibia,  and  one  from  the 
azygos  articular  in  the  posterior  ligament. 

*  The  bones  have  been  united  with  different  forms  of  pegs  or  nails,  or  by  wire,  stout 
carbolised  silk,  or  chromic  gut. 

t  I  may  be  speaking  with  insufficient  knowledge,  but  I  am  under  a  strong  impression 


This  and  the  next  figure  show 
the  line  of  the  epiphyses  which 
enter   into   the   knee-joint,   seen 


taken  from  a  well-grown  subject 
of  about  18.     (Farabeuf.) 


Fig.  403. 


Failure  of  excision  is  due 


96o  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

not  to  deficiency  of  repair  in  the  bones,  but,  as  a  rule,  to  persistence 
of  tuberculous  material. 

The  need  of  drainage  must  vary  with  the  experience  of  the  operator. 
h  the  bone  surfaces  are  well  together,  if  the  angles  of  the  wound  are 
left  open,  and  if  aseptic,  precautions  have  been  taken  throughout, 
drainage  is  rarely  required.  Two  or  three  sutures  may  be  made  use 
of  in  the  middle  of  the  incision,  the  sides  being  always  left  open. 
Before  (losing  the  wound,  I  rub  a  little  sterilised  aristol  over  the 
different  surfaces,  and  dry  these  scrupulously,  before  the  sutures  are  in 
place.  Sir  H.  House's  splint  is  now  applied.  To  those  who  are  not 
familiar  with  it  the  following  brief  account*  may  be  useful.  The 
arrangement  will  be  found  most  simple,  and  equally  efficient  in 
admitting  of  antiseptic  dressing  and  maintaining  the  parts  in  absolute 
rest.  The  splint  consists  of  two  interrupted  tinned-iron  troughs  for 
the  thigh  and  leg  joined  by  a  posterior  bar.  This  is  from  four  to  six 
inches  long,  according  to  the  age  of  the  patient;  it  is  convex  from  side 
to  side  to  avoid  cutting  into  the  popliteal  space,  and  can  be  lengthened 
or  shortened  if  any  alterations  in  the  interruption  are  required.  At 
the  end  of  the  splint  is  an  adjustable  foot-piece. 

The  limb  being  laid  in  the  splint,  attention  must  be  paid  to  the 
posterior  bar  being  in  the  centre  of  the  popliteal  space;  the  foot  must 
be  well  down  on  the  foot-piece  ;  if  the  splint  grips  the  thigh  or  leg  too 
tightly  or  rides  too  loosely,  it  must  be  bent  out  or  in  with  iron 
"crows."  The  dressings  are  now  applied  as  at  p.  959.  Great  care 
must  be  taken  to  bandage  from  below  upwards  and  from  within  outwards, 
the  bandage  being  laid  on  evenly  and  firmly  so  as  to  distribute  the 
discharges  evenly  right  through  the  dressings,  and  to  prevent  their 
coming  through  at  one  or  two  spots.  The  splint  is  next  secured  to 
the  limb  with  "  waxed  bandages,"  prepared  by  passing  them  through  a 
mixture  of  ordinary  yellow  wax  and  olive  oil,  in  proportions  sufficient 
to  make  the  wax  soft  and  workable.  After  they  are  applied  to  the  leg 
and  thigh  they  are  painted  over  with  a  little  hot  wax-mixture,  so  as  to 
make  them  weld  into  one  mass.  I  The  limb,  thus  secured,  is  slung 
with  cord  and  pulley  to  Sir  H.  Howse's  modification  of  Salter's  cradle. 
This  occupies  the  lower  part  of  the  bed  ;  the  patient  lies  on  a  half 
water-bed.  Thomas's  knee-splint  may  also  be  used.  G.  A.  Wright 
employs  a  back  and  two  side  splints  for  about  three  weeks,  and  then  a 
Thomas's  splint,  which  is  kept  on  for  at  least  two  years. 

The  chief  points  now  are  (1)  to  ensure  as  absolute  immobility  as 
possible ;   (2)  to  employ  as  infrequent}  dressings  as  practicable  ;  (3)  to 

thai  the  advocates  of  these  aids  have  not  made  trial  of  the  absolute  fixity  ensured  by  a 
well-applied  Howse's  splint  (vide  infra).  Mr.  Bforrant  l'.aker's  and  Mr.  Howard  Marsh's 
methods  of  fixing  the  bones  by  steel  or  bone  pins  will  be  found  in  the  Brit.  . Mai .  .Joum., 
1887,  vol.  xi.  pp.  321,  389. 

*  Guy's  Hosp.  Reports,  1877,  vol.  xxii.  p.  503,  and  the  accompanying  plate. 

(  The  splint  is  usually  lined  with  lint  wrung  out  of  the  above  mixture,  or  boracie  acid 
lint.  I'.ui  the  popliteal  bar  and  any  of  the  splint  close  to  the  wound  must  be  metal  only, 
uncovered,  to  prevent  infection.  If  any  spaces  exisl  between  the  limb  and  the  splint 
they  may  be  filled  in  with  cotton-wool,  soaked  in  some  of  the  hot  wax-mixture. 

X  Lnfrequency  of  dressings  has  been  strongly  insisted  on  by  Prof.  Oilier  (Ret.  <fc  Chir., 
August,  1887  ;  A  iimih  of  Surgery,  November,  1887,  p.  424).  This  most  important  economy 
—of  pain  to  the  patient,  and  time  to  the  surgeon — is  only  d>  lie  secured  by — (1)  Removing 


EXCISION    OF   THE    KNEE  JOINT.  961 

watch  for  every  sign  of  reappearance  of  the  disease,  and  to  attack  it  at 

once.* 

After-treatment. — Morphia  or  laudanum  should  be  used  freely  at 
first,  if  needful.  It'  there  be  no  reason  to  the  contrary  the  dressings 
should  he  left  undisturbed  for  about  a  week,  when  an  ana&thetic  may 
be  given,  if  needful,  to  remove  the  wire  if  the  excision  has  been  a 
trans-patellar  one.  If  tuberculous  foci  persist,  these  must  be  slit  up 
with  a  sharp-pointed  curved  bistoury,  and  scraped  out  with  sharp 
spoons.  While  this  may  be  repeated  every  two  weeks  on  five  or  six 
occasions  successfully,  the  more  deliberately  the  surgeon  endeavours 
to  extirpate  the  disease  both  in  the  soft  parts  and  in  the  bones,  the 
more  he  treats  it  as  if  malignant,  at  first,  the  less  often  will  he  have  to 
interfere  later  on. 

In  about  three  months,  Sir  H.  Howse's  splint  may  be  left  off  and 
a  Thomas's  splint  or  one  of  leather  carrying  a  metal  bar  to  resist  the 
tendency  to  flexion  fitted  on.  Some  such  fixed  apparatus  should  be 
worn,  in  children,  for  two  to  three  years.  If  the  case  be  lost  sight  of, 
the  splint  will  be  removed,  with  the  inevitable  result  of  flexion. 

In  early  life  callus-like  material  is  thrown  out  quickly,  and  often 
somewhat  irregularly,  between  the  bones,  but  it  is  extremely  slow  in 
really  ossifying.  As  the  quadriceps  extensor  wastes  much  more 
quickly  than  the  hamstrings,  even  when  the  patella  is  retained,  the 
latter  muscles  keep  up  their  action  on  the  tibia  for  months,  and  even 
for  years,  until  the  union  is  firm.  Tenotomy  has  been  advised,  and 
even  resection  of  all  the  hamstring  tendons  (Dr.  Phelps,  New  York 
Med.  Record,  July  21,  1886;  Annals  oj  Surgery,  October,  1886, 
p.  364).  I  think,  however,  that  retaining  the  bones  immobile  and  in 
good  position,  securing  early  healing  of  the  wound,  wearing  a  stiff 
apparatus,  and,  whenever  practicable,  using  the  trans-patellar  method, 
will  best  ensure  a  limb  soundly  ankylosed  in  good  position.  A  knee 
bent  later  on  can  be  easily  straightened. 

Causes  of  Cases  not  doing  well,  Failure  and  Death  after 
Erasion  and  Excision  of  the  Knee. — 1.  Inveterate  persistence  of 
the  disease  leading  to  (a)  giving  way  of  the  supra-patellar  pouch, 
and  the  results  mentioned  at  p.  950;  (/?)  to  formation  of  caseating 
foci,  especially  at  the  back  of  the  joint  (p.  957),  and  only  to  be 
removed  by  re-excision  or  amputation.  2.  An  unhealthy  condition  of 
the  bone  ends,  with  caries  and  chronic  osteo-myelitis.  3.  Slowly 
progressive  thickening  creeping  up  along  the  lower  end  of  the  femur 
and  down  the  upper  end  of  the  tibia,  indicating  a  persistent  tuberculous 
periostitis.  While  the  latter  mischief  can  be  often  dealt  with  b}r 
vigorous  curetting,  all  these  conditions  are  grave,  and  where  the 
vitality  of  the  patient  is  poor,  or  when  other  unfavourable  conditions 
are  present,  indicate  the  need  of  considering  the  advisability  of  ampu- 
tation.    While  an  unpromising  limb  can  often  be  saved  by  vigorous 

every  atom  of  the  disease  that  can  be  got  at.  (2)  Providing  drainage.  The  more 
thoroughly  the  disease  is  extirpated,  the  less  need  is  there  to  drain  ;  but  however  com- 
pletely the  disease  is  removed,  many  sutures  should  not  be  employed,  especially  at  the 
ends  of  the  wound.     (3)  Securing  as  dry  a  wound  as  possible. 

*  It  is  especially,  I  think,  from  neglect  of  this  last  detail,  that  the  fact  arises  that 
there  are  almost  as  many  failures  from  mistakes  in  the  after-treatment  as  from  want  of 
skill  in  the  operation. 

S. VOL.  II.  6l 


962 


nl'KKATIONS    ON    THE    LOWER    EXTREMITY. 


I'M 


404 


curettings  repeated  two  or  three  times  at  intervals  of  a  week,  the 
treatment  to  be  aimed  at  is  preventive  by  thoroughly  going  over  the 

ground  at  the  first  operation.  When 
the  surgeon  is  in  doubt  as  to  ampu- 
tation he  should  not  hesitate  to  open 
up  the  old  operation  wound,  flex  the 
limb,  and  investigate  the  condition 
of  the  end  of  the  bone,  back  of  the 
joint,  &c.  Where  after  repeated 
curetting  a  cavity  persists,  perhaps 
with  the  tibia  for  its  base,  time  may 
be  saved  by  "  papering  "  this  with 
Thiersch's  grafts,  or  better,  in  my 
experience,  by  turning  in  a  flap  of 
soft  parts.  Even  where  the  surgeon 
cannot  be  certain  that  he  has  extir- 
pated all  the  bacilli  and  spores  of 
tubercle,  the  bringing  in  thus  of 
healthy  tissues  will  often  be  found 
to  have  a  beneficial  effect.  4.  De- 
ficient reparative  power,  leading  to 
bed-sores,  emaciation,  and  hectic. 
5.  Co-existence  or  subsequent  de- 
velopment of  such  visceral  diseases 
as  phthisis,  &c.  6.  Surgical  scarlet 
fever.  7.  Infective  conditions. — 
For  these  the  surgeon  will,  nowa- 
days, be,  as  a  rule,  entirely  to  blame. 
8.  Tetanus.  9.  Secondary  haemor- 
rhage.— Another  very  rare  condi- 
tion. 10.  Fat  embolism. — This  is 
a  still  rarer  condition,  but  one 
which,  on  account  of  the  interest  it 
excited  some  years  ago,  and  because 
it  has  once,  at  least,  proved  fatal, 
deserves  mention  here. 

The  case  was  that  of  a  child,  aged  12,  sub- 
mitted to  excision  for  pulpy  disease  by  Vogt, 
of  Griefswald  {Cent.  f.  Chir.,  1883,  S.  24). 
The  bones  were  so  fatty  as  to  cut  with  a  knife. 
Though  but  little  chloroform  had  been  given, 
and  the  loss  of  blood  had  been  slight,  the 
patient  died  twenty-four  hours  later  with 
shallow  respirations,  feeble  pulse,  and  low 
temperature.  Fat  embolism  of  the  lungs, 
extensively  diffused,  was  found  post  mortem. 
Vogt  considered  that  this  case  predisposed  to 
fat  embolism.  Thus  cut  vessels  were  exposed 
on  the  sawn  surl'aees  with  plenty  of  free  oily 
matter  close  by,  and  unable  to  escape,  owing 
to  the  bone-ends  being  in  close  contact  (two  wire  sutures  were  used).  A  similar  ease, 
after  hip  resection,  by  Prof.  Liicke,  is  mentioned.  Prof.  Vogt  thought  that  he  would 
amputate  in  another  case  if,  after  excision  of  the  knee,  the  limb  could  not  lie  straightened 
Without  elose  apposition  of   the  sawn  fatty  bone-ends. 


A  case  of  excision  of  both  knees,  two 
years  after  the  operation,  from  a  patient 
under  my  care  at  the  Hospital  for  Children 
and  Women,  sent  to  me  by  Dr.  A.  T.  F. 
Brown,  of  Rochester.  Both  knees  were 
the  subject  of  tuberculous  disease  on  ad- 
mission. One  was  excised  three  months 
after  the  other. 


ARTHRODESIS.  •  963 

11.  Shock. — This,  though  rare,   must  be  remembered.     Twenty-one 
years  ago  I  lost  a  case  from  this  cause. 

The  patient  was  a  delicate  boy,  aged  7,  with  a  large  tuberculous  knee.  As  there  was 
no  suppuration,  uo  sinuses,  uor  evidence  of  much  mischief  in  the  bones,  I.  unwisely  as  it 
was  proved,  tried  to  save  the  Limb.  The  child  saidc  a  few  hours  afterwards.  Volkmann 
(Cent.  f.  Chi,:,  Bd.  xii.,  Heft  9,  Feb.  28,  1885  ;  Ann.  of  Surg.,  May,  1885,  p.  486)  draws 
attention  to  the  need  of  taking  care  in  children  that  too  much  blood  is  not  lost,  and 
that  deep  narcosis  is  not  too  prolonged. 

12.  Flexion  and  ankylosis. — The  frequency  of  these  and  their  pre- 
vention have  already  been  referred  to.  In  cases  occurring  after  erasion 
the  union  is  always  fibrous,  and  the  limb  can  usually  be  straightened 
with  the  aid  of  an  anaesthetic  and  division  of  the  hamstrings  (q.v.). 
Great  care  must  be  taken  not  to  strain  the  epiphysial  lines.  In  those 
cases  where  backward  displacement  of  the  tibia  is  present  as  well,  the 
old  incision  should  be  opened  up,  and  the  uniting  material  divided 
with  an  osteotome.  If  this  fail  a  partial  excision  must  be  performed, 
no  formal  wedge  being  taken  away,  but  the  ends  of  the  bone  succes- 
sively chiselled  away  until  the  limb  can  be  straightened.  But  where  a 
much-flexed  limb  is  completely  straightened  at  once,  the  warning  given 
below  must  be  remembered.  After  excision  the  union  is  usually  bony. 
In  the  slighter  degrees  of  deformity  division  of  the  bony  material  with 
a  chisel  or  osteotome  usually  suffices,  the  limb  being  gradually 
straightened.  Where  the  deformity  is  more  marked,  osteotomy  of  the 
femur  above  the  joint,  and,  if  needful,  the  tibia  also,  is  preferable  to 
performing  a  second  excision,  or  removing  a  wedge  of  bone. 

As  I  shall  not  have  space  again  to  refer  to  this  matter  of  ankylosis 
of  the  knee,  I  would  strongly  urge  caution  in  rapidly  and  completely 
straightening  a  knee-joint  which  has  long  been  the  seat  of  bony  ank}'- 
losis  in  a  bad  position.  My  attention  was  drawn  to  this  matter  in  a 
painful  wa}r  many  years  ago. 

A  girl  of  19  had  been  admitted  under  my  care  with  bony  ankylosis  of  the  knee  at  a 
right  angle,  dating  to  disease  seventeen  years  before.  Finding  that  I  was  unable  to 
materially  improve  the  position  by  subcutaneously  sawing  through  the  bony  union,  I 
excised  the  joint  and  straightened  it  completely.  The  foot  and  leg  remaining  cold,  an 
anaesthetic  was  given  next  day,  and  the  limb  put  up  flexed.  The  mischief  was,  however, 
done.  The  coldness  remained,  all  pulsation  in  the  tibials  stopped,  and  gangrene  evidently 
threatening,  the  thigh  was  amputated,  the  patient  sinking  afterwards.* 

At  the  necropsy,  osteophytes  were  found  on  the  posterior  border  of  the  tibia  projecting 
backwards,  and  it  was  evident  that  over  these,  when  the  limb  was  straightened,  the 
popliteal  vein,  a  very  small  one,  had  been  stretched  and  closed. 

ARTHRODESIS. 

By  the  above  term  is  meant  the  denuding  of  a  joint  of  its  cartilage 
so  as  to  produce  either  partial  or  complete  ankylosis,  the  object  being 
to  save  a  hospital  patient  with  a  flail-joint  the  need  of  expensive 
apparatus.     The  operation  was  first  practised  by  Albert,   of  Vienna, 

*  Just  after  this  another  London  surgeon  published  a  very  similar  case.  Sufficient 
attention  has  not  been  drawn  to  this  matter.  It  would  have  been  much  wiser  on  my 
part,  with  such  dense  and  old-standing  ankylosis,  to  have  put  the  limb  up  flexed  at  first, 
or  to  have  rectified  the  position  in  two  stages  with  an  osteotome.  I  have  adopted  the 
step  successfully  since,  in  much  older  patients,  with  almost  as  much  contraction. 

6l — 2 


964  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

in  1878,  and  was  introduced  into  this  country  by  Mr.  II.  J.  Jones, 
of  Liverpool,  who  reported  twenty-six  cases  operated  on  without 
mishap  in  the  Provincial  Medical  Journal  of  December,  1894. 

As  the  knee  and  the  ankle-joints  frequently  require  combined 
attention,  arthrodesis  of  these  two  joints  is  considered  together. 

The  operator  aims  at  partial  or  complete  ankylosis.  It  is  not  easy 
to  predict  accurately  which  will  occur.  Partial  ankylosis — ten  or 
fifteen  degrees  of  movement  being  advantageous  for  walking  purposes 
— is  desired  usually  at  the  ankle.  Without  the  removal  of  much  bone 
it  is  not  easy  to  bring  about  a  complete  ankylosis  here.  If  a  partial 
ankylosis  is  desired  merely,  a  thin  layer  of  cartilage  is  gouged  away, 
care  being  taken  that  the  whole  area  of  cartilage  is  removed.  If  the 
ankle  be  wholly  paralysed,  ankylosis  should  be  as  complete  as  possible. 
If  arthrodesis  is  employed  as  an  aid  to  tendon-transplantation,  the 
ankylosis  is  best  if  partial. 

Complete  ankylosis  is  generally  desirable  at  the  knee,  as  partial 
fixation,  with  no  controlling  muscles,  inevitably  means  stretching  of 
the  fibrous  union.  It  is  necessary,  except  in  very  young  children,  to 
completely  peel  the  joint  of  its  cartilage,  even  attacking  the  patella. 

The  indications  for  arthrodesis  are  given  by  Messrs.  Tubby  and  R.  J. 
Jones  ("Surgery  of  Paralysis,"  p.  173)  as  follows:  (a)  complete 
paralysis  of  all  the  muscles,  resulting  in  a  flail  limb  ;  (b)  complete 
paralysis  of  muscles  about  a  joint,  resulting  in  a  flail  joint;  (c)  par- 
tially paralysed  joints,  where  the  deformity  is  fixed,  or  where  the  joint 
becomes  deformed  the  moment  pressure  is  put  upon  it ;  (d)  as  an  aid 
to  muscle-transplantation,  where  it  is  necessary  to  guard  against  over- 
stretching of  newly  transplanted  tendons,  or  where  these  tendons  are 
not  strong  enough  to  control  the  joint. 

The  disadvantages  of  the  operation  are — (a)  some  probable  shorten- 
ing of  the  limb  ;  (/>)  the  limitation  of  extension  or  flexion  ;  (c)  the 
need  of  a  support  in  certain  cases. 

The  authors  do  not  consider  the  amount  of  shortening  to  be  a  factor 
sufficiently  serious  to  lay  stress  upon.  "  In  reference  to  the  loss  of 
extension  and  flexion,  we  must  admit  that  there  are  circumstances  where 
such  a  loss  may  be  keenly  felt.  This  is  scarcely  applicable  to  the  ankle, 
but  markedly  so  in  the  knee-joint.  Many  people  with  complete  para- 
plegia or  monoplegia,  who  have  ample  means  to  renew  their  supports, 
will  feel  acutely  the  disadvantage  of  not  being  able  to  bend  the  knee 
when  sitting.  In  public  places  the  stiff,  straight  limb  has  obvious 
drawbacks.  To  a  working  lad,  however,  it  is  a  great  boon  to  be  inde- 
pendent of  supports,  with  their  expense  and  worries,  and  this  independ- 
ence is  not  at  all  compensated  by  the  power  of  flexion.  Such  cases 
must  be  treated  in  accordance  with  their  desires,  bearing  in  mind  that 
a  patient  may  quite  well  know  what  will  suit  him  best.  The  argument, 
however,  never  obtrudes  in  the  case  of  the  ankle,  where,  in  the  rare 
cases  of  complete  fixation,  a  tolerable  degree  of  movement  is  carried  on 
at  the  mid-tarsal  joint." 

A  painful  condition  after  arthrodesis,  when  weight  is  borne  on  the 
joint,  is  comparatively  common  in  adults,  but  it  usually  disappears  in  a 
few  weeks  or  months. 

The  writers  mentioned  above  do  not  recommend  arthrodesis  in  the 
case  of  the  hip-joint.     "  It  would  be  difficult  to  carry  it  to  a  successful 


ARTHRODESIS.  965 

issue,  and,  generally  speaking,  preternatural  mobility  at  the  hip  is  not 
so  serious  a  disadvantage.  The  results  at  the  ankle-joint  are  better 
than  those  at  the  knee." 

As  an  aid  to  tendon-transplantation  at  the  ankle  (Vol.  I.  p.  55), 
arthrodesis  has  been  found  by  Messrs.  Tubby  and  R.  J.  Jones  very 
successful.  In  equino-valgus  this  is  especially  the  case.  Given  an 
ankle  with  very  slackened  structures,  paralysis  of  the  tibiales,  and 
preternatural  mobility,  arthrodesis  will  limit  movement  of  the  ankle  to 
a  few  degrees,  combined  with  the  introduction  of  appropriate  tendons 
into  the  tibiales  or  into  the  periosteum  in  order  to  restore  the  move- 
ment of  inversion.  An  operation  on  similar  lines  may  be  needed  in 
equino-varus.  In  talipes  calcaneus  arthrodesis  of  the  ankle,  combined 
with  shortening  of  the  tendo  Achillis,  is  far  superior  to  shortening  of 
the  tendon  alone,  which  is  liable  to  be  disappointing  from  yielding  of 
the  shortened  tendon. 

It  is  necessary  in  all  cases  to  prolong  the  use  of  apparatus,  as  it 
takes  a  considerable  time  for  the  joints  to  become  fixed. 

Arthrodesis  of  the  Knee-joint. — The  skin  having  been  sterilised 
and  a  tourniquet  applied,  an  incision  is  made  across  the  front  of  the 
joint,  traversing  half  its  circumference,  and  curved  so  as  to  pass  below 
the  lower  end  of  the  patella.  The  flap  is  turned  up,  the  joint  flexed 
strongly,  the  semilunar  cartilages  removed,  and  with  a  sharp,  short- 
bladed  knife  or  gouge  the  cartilage  should  be  peeled  off  the  bones,  so  as 
to  leave  a  raw  surface  over  their  whole  extent.  The  crucial  ligaments 
may  or  may  not  be  left.  All  haemorrhage  having  been  arrested,  the 
joint  is  closed  without  drainage. 

Arthrodesis  of  the  Ankle-joint. — This  may  be  performed  in  one  of 
four  ways,  according  to  the  circumstances  of  the  case  :  (1)  by  a 
transverse  incision  across  the  front  of  the  joint ;  (2)  by  a  perpendicular 
incision  along  the  mid-line  in  front  of  the  joint ;  (3)  by  an  antero- 
external  incision  just  external  to  the  tendons  of  the  extensor  communis 
digitorum  ;   (4)  by  a  posterior  incision  over  the  tendo  Achillis. 

In  old-standing  cases,  where  the  foot  assumes  the  equino-varus 
position,  and  where  all  the  muscles  are  paralysed,  the  transverse 
incision  across  the  front  of  the  joint  is  preferable.  The  division  of 
the  tendons  is  then  of  no  consequence,  and  an  excellent  view  is 
obtained  of  the  joint.  If  there  be  any  compunction  in  dividing  the 
tendons  they  can  quite  easily  be  drawn  aside,  with  the  exception, 
perhaps,  of  the  peroneus  tertius.  If  firm  union  be  desired  not  only 
all  the  cartilage,  but  even  some  of  the  bone  as  well,  must  be  removed. 
"Where  some  power  still  remains  in  the  extensors  of  the  toes,  a  linear 
vertical  incision  may  be  preferred,  and  so,  too,  where  talipes  equinus 
is  present  and  the  astragalus  is  displaced  forwards.  The  posterior 
incision  is  useful  in  talipes  calcaneus,  where  the  joint  can  easily  be 
reached  from  behind.  The  incision  is  made  close  to  the  centre  of  the 
tendo  Achillis,  which  is  drawn  to  one  side  or  divided,  while  the  incision 
is  carried  down  to  the  bone.  The  capsule  is  opened,  and  the  gouging 
completed.  If  there  be  any  power  in  the  gastrocnemius,  the  tendo 
Achillis  must  be  shortened  through  the  same  incision. 

Before  having  recourse  to  arthrodesis  and  tendon-transplantation, 
care  should  be  taken  to  completely  overcome  by  mechanical  means  any 
deformity  of  the  foot  or  leg.     If  this  be  not  done,  considerable  traction 


966  OPERATIONS    ON    THE    LOWEB    EXTREMITY. 

may  be  needed  immediately  after  operation  :i  process  to  be  avoided 
when  possible.  In  spite  of  the  trophic  nature  of  the  lesions,  wounds 
heal  rapidly  and  soundly. 

In  the  after-treatment  a  Thomas's  knee-splint  is  recommended  while 
the  patient  is  in  bed,  and  this  should  he  changed  to  a  "caliper"  when 
walking  commences.  For  the  ankle  nothing  is  better  than  a  posterior 
splint. 

My  own  experience  of  arthrodesis  is  somewhat  limited,  being  derived 
from  six  cases  of  the  operation  in  the  knee-joint  and  three  in  the  ankle, 
in  two  of  which  the  ankle  and  knee-joints  were  operated  upon  simul- 
taneously.* I  have  never  succeeded  in  obtaining  more  than  close 
fibrous  union  even  when  the  ends  of  the  hone  had  been  actually 
trenched  upon.  The  knee  was  exposed  by  the  trans-patellar  incision 
(p.  955),  and  care  was  taken  not  to  damage  the  lateral  ligaments  more 
than  could  be  helped  ;  the  menisci  and  the  anterior  crucial  ligament 
were  removed.  In  the  removal  of  the  articular  cartilage  by  gouge, 
chisel,  or  a  curved,  blunt-pointed  knife,  a  good  deal  has  to  be  done  by 
touch,  if  the  ligaments  of  the  already  unstable  joint  are  not  to  be 
needlessly  weakened.  In  the  case  of  the  ankle-joint  I  made  use  of  a 
transverse  incision,  suturing  most  of  the  severed  tendons  afterwards, 
and  in  this  joint  I  consider  the  insertion  of  a  wire  between  the  tibia 
and  astragalus  most  advisable,  as  a  means  of  increasing  the  stability. 
In  two  of  the  cases  thus  treated,  when  seen  respectively  three  and  five 
years  later,  the  wire  had  caused  no  trouble. 

As  in  the  case  of  tendon-transplantation  (Vol.  I.  p.  64),  too  much 
must  not  be  expected  from  arthrodesis.  In  only  two  of  my  cases  am 
I  able  to  say  with  certainty  that  the  result  admitted  of  the  patient 
entirely  dispensing  with  supporting  apparatus.  The  simplicity  and 
uncomplicated  nature  of  arthrodesis  justify  resort  to  it  in  the  hope  that 
it  will  improve  the  ability  of  the  patient  to  make  use  of  any  remaining 
power  which  he  may  possess.  Even  when  the  ends  of  the  bone  have 
been  thoroughly  exposed — and  this  is  essential — it  is  difficult  to  ensure 
stable  bony  ankylosis.  The  conditions  necessary  for  such  ankylosis 
are  wanting.  In  early  life,  even  if  small  sections  of  bone  are  removed 
with  the  saw — and  no  more  is  permissible  for  fear  of  further  serious 
interference  with  the  growth  of  the  already  dwarfed  and  dwindled 
limb — the  surfaces  of  bone  are  scant  and  puny.  The  rims  of  cartilage 
exposed  are,  relatively,  very  large.  Further,  the  loss  of  power  over 
the  muscles  of  the  thigh  and  leg  is,  usually,  advanced  and  confirmed. 


WIRING  FRACTURES  OF  PATELLA. 

In  the  words  of  Lord  Lister,  who  introduced  the  operation  in  1883, 
"  no  man  is  justified  in  performing  such  an  operation  unless  he  can  say 

with  a  clear  conscience  that  he  considers  himself  morally  certain  of 
avoiding  the  entrance  of  any  septic  mischief  into  the  wound." 

The  chief  points  to  consider  here  are  (1)  the  age  of  the  patient,  i.e., 


*  It  is  right  that  I  should  add  that  my  cases  of  arthrodesis  were  performed  at  a  time 
before  tendon-transplantation  was  in  vogue.  I  thus  failed  to  obtain  any  of  those 
advantages  which  may  accrue  from  the  combination  of  the  two  operations. 


WIRING    FRACTURES   OF    PATELLA.  967 

up  to  about  forty-five,  the  state  of  his  tissues  and  viseera,  and  his 
amenability  to  directions ;  (2)  the  amount  of  separation,  j.r.,  a  distance 
of  over  half  an  inch  ;  (3)  marked  tilting  of  the  fragments  backwards  or 
forwards;  (4)  great  distension,  as  this  is  an  indication,  as  far  as  it 
goes,  of  laceration  of  the  lateral  parts  of  the  capsule  ;  (5)  the  occupa- 
tion of  the  patient:  the  more  active  this  is,  the  more  it  involves  work 
on  different  levels,  the  more  is  operative  treatment  indicated. 

In  iiuy  ease  the  two  sides  of  the  question  and  the  risks  should  be 
put  before  the  patient.  He  should  understand  that  while  good  results 
are  certainly  obtainable  by  ordinary  means,  lifelong  care  will  be 
needed  to  avoid  such  strains  as  are  involved  in  stumbling,  especially 
on  going  up  and  down  stairs,  and  he  should  realise  that  much  of  the 
success  of  the  after-treatment  rests  with  him.  As  I  have  stated  in  the 
account  of  fracture  of  the  olecranon,  it  is  well  that  the  patient  should 
have  an  opportunity  of  discussing  the  matter  with  another  who  has 
been  operated  upon. 

The  above  remarks  apply  to  cases  of  simple  fracture  ;  in  compound 
cases,  the  need  of  cleansing  the  joint  by  irrigation,  &c,  is  an  additional 
reason  for  operating. 

Operation. — 1.  I  shall  first  take  cases  of  recent  fracture.  The  rarer 
ones  of  older  standing  are  considered  at  p.  969.  The  question  as  to 
the  best  time  for  interference  now  arises.  While  several  who  are 
authorities  recommend  operation  during  the  first  few  hours,  I  should 
advise  waiting  until  the  third  day.  My  chief  reason  is  that  this  gives 
more  time  for  thoroughly  sterilising  the  parts.  Owing  to  its  density 
and  ruga?,  the  skin  here  is  one  of  the  most  difficult  to  deal  with  satis- 
factorily. If  operation  is  resorted  to  at  once  the  vigorous  measures 
required — e.g.,  in  a  patient  habitually  working  in  dust — may  lead  to  a 
condition  of  dermatitis.  Boracic  acid  fomentations,  applied  at  once 
and  continually  to  remove  the  horny  epithelium  here,  pave  the  way 
for  thorough  sterilisation.  Further,  in  my  opinion,  waiting  till  the 
third  day  gives  opportunities  for  a  more  thorough  examination  of  the 
patient  externally — e.g.,  for  other  injuries,  the  presence  of  any  focus 
of  suppuration,  &c. — while  it  finds  him  in  a  better  state  for  the 
anaesthetic.  I  admit  that  this  delay  may  lead  to  more  coagulation  in 
the  joint,  but  this  disadvantage  I  consider  a  minor  one. 

Every  detail  for  the  securing  of  complete  asepsis  having  been 
secured,  the  parts  are  best  exposed  by  a  flap-incision.*  I  have 
generally  employed  one  with  its  convexity  downwards,  believing  that 
this  best  secures  the  vitality  of  the  flap.  The  incision  commences  on 
a  level  with  the  upper  margin  of  the  patella,  about  one  inch  to  one 
side,  passes  downwards  to  a  point  a  little  below  the  level  of  the  line  of 
fracture,  where  it  is  carried  across  the  limb  and  then  upwards  to  a 
point  corresponding  to  that  from  which  it  started.  I  have  not  found 
that  this  incision  in  any  way  interferes  with  kneeling  afterwards,  an 
objection  which  has  led  others  to  prefer  a  flap  with  its  extremity 
upwards.  A  flap-incision  has  the  undoubted  advantages  of  better 
exposure  of  the  parts,  facilitating  the  dealing  with  the  fragments,  the 

*  An  Esmarch's  bandage  is  not  needed,  and  would  have  the  objections  of  causing 
oozing  afterwards  into  the  joint-cavity,  and  also  of  preventing  that  bringing  down  of  the 
extensors  of  the  thigh  which  may  be  required  in  cases  of  wide  separation. 


968  OPERATIONS   ON   THE    LOWER   EXTREMITY. 

removal  of  clots,  and  uniting  the  lateral  parts  of  the  capsule,  if 
injured;  lastly,  where  drainage  is  necessaiy,  it  is  easily  secured. 

But,  while  the  flap-incision  has  the  ahove  advantages,  it  must  be 
remembered  that  it  involves  more  disturbance  of  the  parts,  especially 
where  these  have  been  much  contused  and  where  their  circulation  is 
not  yet  re-established.  Lord  Lister  used  the  vertical  incision  ;  Prof. 
Kocher  employs  a  slightly  curved  one.  In  any  case  the  transverse 
part  of  the  incision  should  never  be  opposite  the  line  of  frac- 
ture, and  in  marking  out  and  raising  a  flap  care  should  be  taken  to 
secure  uniform  nutrition  and  vitality  and  to  interfere  with  the  parts  as 
little  as  possible.  For  the  exposure  of  the  fragments,  removal  of  any 
intervening  tissue,  clearing  away  of  clots,  drilling  the  bones,  and 
passage*  of  and  dealing  with  the  wire,  the  details  given  for  like 
treatment  of  the  olecranon  (Vol.  I.  p.  127)  should  be  carefully  followed. 

By  some  American  surgeons  wire  has  been  replaced  by  absorbable 
material — e.g.,  catgut,  silk,  kangaroo-tendon — thus  doing  away  with 
any  risk  of  after-trouble  with  the  wire,  a  risk  which  is  nowadays 
extremely  small.  Some  have  gone  farther  and  advised  suture  only 
of  the  torn  periosteum  and  fibrous  tissues  (Gibbon,  Rodman,  Ann.  of 
Surg.,  June,  1904,  pp.  1023,  1026).  In  a  number  of  cases  this  has 
been  found  sufficient,  as  there  is  no  risk  of  the  fragments  here  shifting 
longitudinally  or  laterally  if  the  quadriceps  extensor  be  kept  relaxed 
for  two  or  three  weeks.  The  arguments  for  and  against  this  step 
appear  to  me  to  be  as  follows :  Drilling  the  fragment  is  the  most 
difficult  part  of  the  operation,  and  necessarily  adds  to  the  amount  of 
disturbance  of  the  parts,  and  the  risk  of  infection.  On  the  other  hand, 
if  the  fragments  themselves  are  not  wired,  the  after-rest  must  be  pro- 
longed in  order  to  secure  bony  union.  Instead  of  the  splint  being 
removed  in  ten  days  and  the  patient  being  up  in  a  fortnight,  a  period 
of  at  least  six  weeks  will  be  required.  During  this  time  massage  will, 
of  course,  be  assiduously  employed. 

I  have  no  experience  of  Mr.  Barker's  method  of  passing  wire  around 
the  fragments  (Brit.  Med.  Journ.,  April  18,  1896).  Dr.  J.  B.  Roberts 
(Ann.  of  Surg.,  June,  1904,  p.  1027)  has  employed  a  simpler  method 
by  passing  a  silk  or  catgut  purse-string  suture  round  the  fragments. 
These  are  encircled  with  a  suture  passed,  by  means  of  four  punctures, 
through  tendon  and  aponeurosis.  This  method  does  not  open  the 
joint,  and  while  not  securing  such  perfect  adaptation  of  the  fragments 
as  is  secured  by  wiring,  has  been  followed  by   satisfactory  function. 

*  While  it  is  well  to  take  precautions  here,  it  probably  does  not  matter  much 
(supposing,  of  course,  that  strict  aseptic  precautions  are  taken)  if  the  wire  is  passed 
within  the  joint.  Lord  Lister  gives  the  following  aid  to  making  the  two  drill-holes  exactly 
correspond  :  '•  Supposing  that  on  one  side  the  instrument  should  have  come  too  far  down, 
it  may  be  into  the  cartilage,  we  do  not  regard  that  at  first,  but  pass  the  wire  through  the 
two  drill-holes,  and  then  on  that  side  on  which  the  hole  has  come  too  far  down,  by  means 
of  the  bradawl  we  simply  chip  away  a  little  of  the  material  that  is  above  the  wire,  until 
the  wire  comes  to  be  in  a  position  exactly  opposite  to  the  hole  on  the  other  side."  If,  in 
another  case,  there  is  a  dilliculty  in  making  the  drill  emerge  upon  the  fractured  surface, 
Lord  Lister  would  advise  the  withdrawal  of  the  drill  and  substitution  of  the  blunt  end  of 
a  needle,  and  then  with  a  gouge  or  bradawl  an  opening  is  excavated  upon  the  fractured 
surface,  opposite  to  the  other  drill-hole,  until  the  needle  is  exposed ;  the  wire  can  then  be 
easily  passed. 


WIRING    FRACTURES   OF    PATELLA.  g6g 

One  of  Dr.  Roberts's  patients  was  able  to  carry  kegs  of  beer  up  and 
down  stairs  as  well  as  was  the  case  before  the  fracture.  In  answer  to 
the  objection  to  such  methods  that  they  do  not  admit  of  removal  of 
blood  clots  or  fibrous  tissue  between  the  fragments,  Dr.  Roberts  argues 
that  Nature  will  remove  the  former  "  by  absorption,  as  she  has  been 
doing  for  years  before  the  open  operation  was  advocated."  As  to  any 
periosteum  between  the  fragments,  this  can  be  removed  without  open- 
ing the  joint  by  elevating  the  limb  so  as  to  relax  the  quadriceps,  and 
rubbing  firmly  together  the  approximated  fragments.  The  "  dull 
crepitus  at  the  beginning  of  the  manipulation  will  be  followed  by  a 
sharp  bony  crepitus  as  the  fragments  of  periosteum  are  crowded  away." 

2.  Certain  Cases  of  Old  Fracture  of  the  Patella. — This  important 
matter  must  be  taken  somewhat  in  detail.*  The  chief  points  here 
justifying  resort  to  wiring  are :  (a)  Failure  of  previous  treatment, 
especially  in  hospital  patients,  (b)  A  useless  limb,  especially  in  a  man 
whose  occupation  entails  much  walking  or  standing,  where  the  gait  is 
helpless  and  requires  much  attention,  or  where  many  falls  have  followed 
involving  serious  risk  of  fracture  on  the  opposite  side,  (c)  Where 
both  patellae  are  fractured,  (d)  Where  the  patient  is  }roung  and  has 
many  yeavs  of  active  life  before  him.  (e)  Where,  if  not  young,  the 
patient  is  sufficiently  healthy.  (/)  Where  enough  is  known  of  the 
patient's  habits  to  ensure  his  being  amenable. 

Operation. — The  fragments  when  exposed  f  are  generally  found 
embedded  in  fibrous  tissue,  thickened  synovial  membrane,  and  old 
decolorised  coagulum.  This  must  be  snipped  or  cut  away,  and  any 
spirting  vessels  in  the  thickened  synovial  membrane  must  be  secured. 
A  very  thin  section  from  each  fragment  is  then  removed  with  a  narrow- 
bladed  saw,  this  needing  much  caution  in  the  case  of  the  lower  one, 
which  is  the  smaller  of  the  two.  If  the  fragments  can  now  be  pressed 
into  close  apposition,  nothing  usually  remains  save  to  wire  them,  but 
the  case  is  b}r  no  means  so  simple  where  the  bones  are  widely  apart. 

Thus,  in  one  of  my  cases,  many  years  ago,  after  paring  the  fragments — these  were  quite 
two  and  a  half  inches  from  each  other — and  after  most  forcible  traction  the  upper  could 
only  be  made  to  descend  three-quarters  of  an  inch.  Malgaigne's  hooks  were  applied  and 
tightly  screwed  up,  but  with  no  result  on  the  desired  approximation.  The  lateral  expan- 
sions of  the  quadriceps  were  next  still  more  fully  divided  (cut  muscular  fibres  being  seen 
on  the  inner  side),  but  the  fragments  were  almost  as  far  apart  as  ever.  As  the  only 
alternative  to  excising  the  joint  (in  order  to  substitute  a  firm  support  for  the  flail-like 
limb),  I  now  divided  partially  the  rectus  tendon,  but  it  was  not  till  the  upper  fragment 
was  only  held  by  a  narrow  stout  band  at  its  upper  and  inner  parts  that  it  could  be  brought 
in  apposition  with  the  lower  one.  The  result  was  excellent.  At  the  present  day,  elonga- 
tion of  the  rectus  tendon,  performed  as  in  the  case  of  the  triceps  (Vol.  I.  p.  129),  with 
division  of  the  lateral  parts  of  the  quadriceps,  if  needful,  would  be  employed. 

Owing  to  the  tension,  wire  must  be  used  in  these  cases,  according 
to  the  directions  given,  Vol.  I.  p.  127.     Owing  to  the  bones  being 

*  Lord  Lister  goes  so  far  as  to  consider  (Lancet,  Nov.  3,  1883)  that  "  the  ununited  case 
is  in  every  respect  worse  as  a  subject  of  operation  than  the  recent."  This  is  chiefly 
owing  to  the  wasting  of  the  fragments  and  their  greater  separation.  Again,  in  recent 
cases,  there  is  no  need  to  pare  the  fragments,  for  after  sponging  away  of  clots  the  surfaces 
are  ready  for  coaptation. 

f  In  one  case,  the  skin  being  dimpled,  puckered  down,  and  adherent  between  the 
fragments,  I  had  to  cut  away  a  piece  about  three-quarters  of  an  inch  wide. 


970 


ol'KIIATloXS    ON    THK    LnWKI!    KXTREMITY. 


probably  degenerated  from  disuse,  the  bradawl  should  be  Inserted  a 

full  half- inch  from  the  fractured  surfaces. 

In  these  difficult  eases  it  must  be  remembered  that  it  is  not  abso- 
lutely necessary  to  get  the  fragments  into  exact  apposition.  If,  after 
wiring,  they  come  within  a  quarter  of  an  inch  of  each  other,  the  limb 
will  be  a  most  useful  one,  though  of  course  exact  apposition  is  to 
be  desired.* 

Where  the  lower  fragment  is  too  small  to  hold  a  wire,  this  may  be 
passed  through  the  ligamentum  patellae,  as  has  been  done  by  Lord 
Lister  (loc.  supra  cit.)  and  Mr.  Teale  {Brit.  Med.  Jowrn.,  June  9,  1883). 
One  wire  would  appear  to  be  sufficient.  Though  this  unites  the  centre 
of  the  fragments  exactly,  a  very  slight  interval  remains  at  the  edges, 
but  does  not  interfere  with  an  excellent  result. 

Before  the  wire  is  hammered  down,  if  this  course  is  decided  upon, 
the  surgeon  must  decide  as  to  drainage  of  the  joint.  When  the  opera- 
tion has  been  difficult,  if  it  has  involved  much  separation  of  adhesions 
and  interference  with  the  parts,  if  there  be  troublesome  oozing,  drainage 
should  be  employed,  either  by  gauze  from  the  ends  of  the  wound,  or 
through  the  wound  to  the  most  dependent  part  of  the  joint  at  the 
outer  side  (Lister),  dressing  forceps  being  thrust  here  through  the 
joint  and  soft  parts,  cut  upon  it,  and  a  drain  drawn  through.  The 
wound  is  then  united  and  dressed.  As  soon  as  the  wound  is  healed, 
every  pains  must  be  taken,  by  massage,  &c,  to  improve  the  atrophy 
of  the  quadriceps.     Healing  should  be  complete  in  two  weeks. 

The  question  of  passive  movement  now  arises.  Usually,  in  two  to 
three  weeks  after  the  operation  the  patient  may  get  up  and  begin  to 
use  the  limb  (with  the  aid  of  two  sticks  at  first),  flexion  and  extension 
being  diligently  practised.  Unless  the  joint  is  very  stiff,  massage, 
friction,  and  gentle  persevering  movement,  aided  by  time  and  patience, 
will  be  sufficient.  If  an  anaesthetic  is  given,  movements  must  be  made 
cautiously,  as  the  patella  has  been  refractured  on  this  occasion  more 
than  once.f 

Difficulties  in  Wiring  the  Patella. 

I.  Atrophied  surfaces  of  the  fragments,  making  it  difficult  to  refresh 
them  satisfactorily.  2.  A  very  small  lower  fragment.  3.  Fragments 
embedded  in  very  firm  fibrous  tissue,  fascial,  periosteal,  and  synovial, 
or  old  coagulum. — This  condition  will  prevent  satisfactory  apposition 
unless  the  intervening  tissue  be  all  removed.  In  a  very  interesting 
case  recorded  by  Mr.  ().  Ward  {Lancet,  Nov.  1,  1884)  it  was  found,  on 
exploring  the  fragments,  that  the  capsular  tissues  torn  off  the  lower 
fragment  remained  attached  above,  and  hung  like  a  flap  between  the 
fractured  surfaces,  effectually  preventing  their  apposition.  It  is 
suggested  that  some  such  complication  may,  in  many  cases  which  have 


*  In  a  case  of  Mr.  Wheelhouse's  (Jirlt.  Med.  Journ.,  .June  9,  1883)  the  fragments, 
originally  an  inch  and  a  half  apart,  could  only  be  brought  within  half  an  inch  of  each 
other  ;  an  excellent  limb  resulted. 

•j-  In  one  of  Lord  Lister's  cases  (loo.  supra  <-if.).  passive  movement  being  employed 
with  ''considerable  force"  four  weeks  after  the  wiring,  the  rigid  quadriceps  not 
yielding,  the  wire  gave  way,  and  the  cicatrix  (a  long  longitudinal  one),  which  had 
healed  save  where  the  wire  projected,  opened.  The  joint  was  at  once  washed  out 
antiseptically,  and,  six  days  later,  some  coagula  were  removed,  and,. the  old  wire 
retwisted.     An  excellent  limb  was  the  result. 


WIRING    FRACTURES   OF    PATELLA  971 

been  treated  in  the  usual  way,  cause  the  fragments  to  fall  apart  as  time 
goes  on.  This  is  the  view  held  by  Sir  \V.  Macewen  (Lancet,  Nov.  17, 
1883;  Ann.  of  Kitr;/. ,  March,  1887,  p.  178),  who  collected  thirteen  cases 
of  transverse  fracture  of  the  patella,  in  which  portions  of  soft  tissue 
intervened  between  the  fragments  in  such  a  manner  as  to  render 
osseous  union  an  impossibility.  4.  A  contracted,  rigid  quadriceps 
(p.  969).  5.  [ndipping  skin  (p.  969).  6.  Multiple  fragments. — This 
may  cause  much  difficulty,  especially  if  it  is  the  lower  and  usually 
smaller  fragment  which  is  comminuted.  If  the  lower  fragment  is  not 
large  enough  to  bear  wiring,  the  wire  may  be  passed  through  the 
ligamentum  patella).  Where  the  fracture  is  multiple,  the  smaller 
fragments  may  first  be  united  by  fine  wire,  and  then  by  stouter,  to  the 
larger  one.  But  where  they  are  found  to  be  much  loosened  in  their 
periosteal  covering,  it  will  be  wiser  to  be  content  with  carefully  uniting 
the  torn  periosteum,  and  enforcing  longer  rest  afterwards. 

Causes  of  Failure,  or  Trouble  afterwards. — These  are  mainly  : 
1.  Infective  conditions  (p.  972).  2.  Trouble  with  the  wire. — This  rarely 
occurs  where  the  wire  has  been  well  hammered  down,  some  adjacent 
fibrous  tissue  drawn  over  it,  and  the  flap-incision  made  use  of,  or  a 
transverse  one  lying  below  the  site  of  the  wire.  In  one  of  my  cases  of 
old  fracture  the  patient  returned,  nearly  a  year  later,  with  great  tender- 
ness over  the  wire.  She  was  extremely  thin,  and  had  knelt  early  and 
much.  On  removing  the  wire  I  found  that  I  had  made  three  or  four 
half-twists  instead  of  two.  In  another  case,  operated  on  by  the  late 
Mr.  Davies  Colley,  a  small  bursa,  the  size  of  a  thrush's  egg,  containing 
fluid,  formed  around  the  twist.  This,  made  with  the  greatest  symmetry, 
consisted  of  four  half-twists.  Where  it  is  necessary  to  remove  the 
wire,  this  may  be  done,  with  the  aid  of  eucaine,  by  a  small  incision 
over  it.  The  wire  is  first  untwisted  and  straightened ;  one  end  is 
next  cut  off  short,  and  the  other  grasped  in  dressing  forceps  and  wound 
round  these.  It  is  then  extracted  without  jerking.  If  this  step  be 
required  before  a  period  of  six  or  eight  weeks  after  the  operation,  care 
not  to  break  down  the  union  will  be  needful.*  3.  Inability  to  bring  the 
fragments  together  in  long-standing  cases. — Mr.  Turner  {Clin.  Soc. 
Trans.,  vol.  xviii.  p.  41)  mentions  a  case  in  which  the  operation  was 
abandoned,  as  it  was  found  impossible  to  get  the  fragments  together 
after  wiring  them.  The  patient  was  "  no  better  and  no  worse " 
eventually.  4.  Necrosis  of  a  fragment. — This  is  a  complication  rather 
than  a  cause  of  failure.  It  is  especially  likely  to  occur  after  severe 
compound  fractures  in  which  the  periosteum  was  much  injured  at  the 

*  The  following  show  that  the  wire  may  occasionally  excite  irritation  and  lead  to 
serious  results.  Sir  W.  Macewen  (loe.  infra  cit.')  mentions  a  case  which  came  under 
observation  three  months  after  suture  of  the  patella,  with  acute  suppurative  arthritis  of 
the  joint  and  ulceration  of  the  cartilage.  A  probe  passed  through  a  sinus  detected  the 
wire  surrounded  by  carious  bone.  The  twist  was  still  intact,  but  the  loop  was  loose,  the 
bone  having  become  inflamed,  softened,  and  ulcerated.  Excision  of  the  joint  was 
required.  This  shows  that  occasionally  the  wire  may  excite  irritation,  and  thus  lead  to 
serious  results.  Mr.  Turner  (Lancet,  1887,  vol.  i.  p.  572)  records  a  case  in  which  Mr.  M. 
Robson,  of  Leeds,  had  wired  an  ununited  fracture  of  the  patella,  three  gold  wires  being 
employed.  The  patient,  an  epileptic,  probably  injured  the  knee  repeatedly,  the  wires 
worked  out,  and  the  knee-joint  became  acutely  inflamed,  requiring  free  incisions  and 
drainage. 


OPERATIONS    ON    THE    LOWEB    EXTREMITY 


time  of  the  accident.  This  happened  with  an  upper  fragment  in  a 
case  oi  I>r.  Gk  It.  Fowler's  (.1//'/.  of  Surg.,  1885,  p.  248).  About  three 
months  after  tin-  wiring,  this  fragment,  about  the  Bize  of  a  walnut,  was 

removed.  It  was  now  found  that  "  the  joint  was  perfectly  closed  by 
a  thick  fibrous  capsule  underlying  the  necrosed  portion,  connected  to 

the  upper  margins  of  the  now  firmly  united  two  lower  fragments,  and 
forming  a  strong  bond  of  union  between  the  quadriceps  above  and 
what  remained  of  the  patella  below."  The  resulting  limb  was  useful, 
with  considerable  movement  at  the  knee-joint.  5.  With  the  increasing 
frequency  with  which  this  operation  is  resorted  to,  there  is  another 
cause  of  failure,  partial  at  least,  for  which  surgeons  must  be  prepared 
in  patients  no  longer  young,  and  that  is  a  condition  allied  to  osteo- 
arthritis, set  up  by  the  injury,  and,  in  part,  by  the  wiring.  A  patient 
of  mine,  aged  42,  in  whom  the  healing  and  movements  regained  had 
been  most  satisfactory,  returned  six  weeks  later  on  account  of  pain  and 
increasing  stiffness  in  the  joint.  The  wire  was  giving  no  trouble 
whatever,  but  both  to  the  feel  and  the  ear  the  joint  gave  marked  evidence 
of  osteo-arthritis  ;  there  had  not  been  time  for  the  occurrence  of  lipping. 

REMOVAL    OF    LOOSE    BODIES^     FROM     THE    KNEE-JOINT. 

This  is  another  instance  of  an  operation  rendered  safe  and  simple  by 
the  teaching  of  Lord  Lister.  Removal  by  direct  incision  will  therefore 
be  alone  described  here. 

Operation. — The  parts  should  be  kept  at  rest  and  most  scrupulously 
sterilised  for  some  days.  I  will  draw  attention  to  the  danger  in  opening  a 
large  and  complicated  joint  like  the  knee,  even  greater  care  being  needed 
here  than  in  the  case  of  the  peritoneal  sac  owing  to  the  smaller  power 
of  resistance  possessed  by  the  synovial  membrane.  Gloves  should  be 
worn  here,  and  as  in  the  previous  and  next  operations,  the  fingers  should 
be  repeatedly  dipped  in  some  antiseptic  solution,  and  any  ligatures 
which  may  need  tying  within  the  joint  should  be  fastened  by  forceps. 
Owing  to  the  great  mobility  of  some  of  these  bodies,  it  is  well  to 
harpoon  them  with  a  sterilised  needle,  if  possible,  at  the  beginning  of 
the  operation.  The  joint  is  then  deliberately  and  sufficiently  opened. 
Where  the  body  cannot  be  found  a  free  incision  must  be  made  at  its 
most  usual  site,  or  the  angular  incision  mentioned  below  or  a  flap 
with  its  base  at  one  side  of  the  joint  may  he  employed.  Some  advise 
that  the  incision  through  the  skin  and  that  into  the  capsule  should  be 
in  different  planes  to  guard  against  possible  subsequent  infection  from 

*  The  following  classification  may  be  useful  to  a  surgeon  about  to  operate  for  one  of 
these  bodies :  (i)  A  thickened  or  indurated  synovial  fringe  which  has  become  peduncu- 
lated and  perhaps  detached  ;  (2)  a  fibro-enchondroma  originating  in  those  cartilage  cells 
which  are  naturally  found  in  the  synovial  fringes;  (3)  a  portion  of  articular  cartilage 
detached  by  injury.  Seven  yea:-  ago]  moved  one  of  these  loose  bodies  from  the  knee- 
joint  of  a  railway  porter  who  came  to  me  for  synovitis,  with  the  history  that  the  att 
dated  from  the  time  when  a  cask  which  he  was  moving  had  slipped  and  struck  obliquely 
the  inner  side  of  his  right  knee-joint  [Lancet,  18S9,  vol.  ii.  p.  363)  :  (4)  a  bit  of  cartilage 
may,  after  injury,  gradually  become  detached  by  a  process  of  quiet  necrosis  (Paget)  ; 
(5)  blood  effused  into  a  synovial  fringe  ;  (6)  a  mass  of  tibrine  :  (7)  a  steophyte  ; 

(8)  Mr.  EL  Marsh  (Z*/.<.  ofjirinti,  p.  1S2)  mentions  a  case  of  Mr.  Shaw's,  in  which  a  loose 
body  on  removal  was  found  to  contain  the  point  of  a  needle. 


DETACHMENT   OF   A    FIBRO-CARTILAGE.  973 

without.  In  any  case  the  incision  through  the  synovial  membrane 
must  lie  at  a  sufficient  distance  from  the  margins  of  the  patella  and 
tibia  to  allow  of  this  membrane  being  independently  sutured.  In  a 
very  few  cases  whore  a  loose  body  is  known  to  exist,  hut  cannot  be 
found,  or  where  it  is  multiple,  extensive  incisions,  e.g.,  trans-patellar 
(P«  955)>  <>r  turning  down  a  flap  of  the  quadriceps  and  capsule,  have 
been  employed.  In  difficult  cases  a  loose  body  may  he  brought  into 
view  by  putting  the  joint  through  its  different  movements,  or  by 
Hushing  it  out  with  sterile  saline  solution.  These  steps  should  always 
be  taken  before  making  free  incisions  which  are  likely  to  interfere  with 
the  joint's  functions,  or  hefore  even  putting  a  finger  into  the  joint.  In 
some  cases  a  second  smaller  incision  may  be  the  wisest  step. 

In  the  case  due  to  injury  (footnote,  p.  972),  on  cutting  freely  into  the  joint,  I  came 
down  upon  a  tiny  pedunculated  body  attached  close  to  a  healed  depressed  gap  in  the  rim 
of  the  internal  condyle.  As  it  was  certain  that  this  body  could  not  be  the  offending  one, 
tin-  portion  of  detached  articular  rim  was  only  found  after  a  prolonged  search  in  the 
extreme  upper  end  of  the  supra-patellar  pouch.  The  patient  made  an  excellent  recovery, 
and  resumed  his  work  as  a  South  Eastern  Railway  porter.  This  case  proves  conclusively 
that  the  late  Sir  G.  M.  Humphry  was  wrong  in  his  statement  that  the  articular  cartilages 
are  too  strong  and  too  well  protected  for  any  fragment  to  be  dislodged  save  by  disorganising 
violence. 

Where  one  body  has  been  removed  the  surgeon  must  make  certain  that 
no  others  are  present.  Mr.  R.  Jones  (loc.  infra  cit.)  thus  emphasises  this 
point :  "  I  have  on  three  occasions  had  to  open  up  a  joint  a  second 
time  to  remove  bodies  evidently  present  from  the  first." 

All  haemorrhage  having  been  arrested,  the  joint  rendered  absolutely 
dry,  the  wound  is  closed  in  two  layers  as  advised  below.  A  sterilised 
white  bandage  having  been  applied  from  the  toes  to  mid-leg,  the 
dressings  are  firmly  bandaged  on  with  uniform  pressure.  Where  the 
search  has  been  prolonged,  the  parts  interfered  with,  many  bodies 
removed,  or  when  there  is  likely  to  be  oozing,  drainage  must  be  provided 
by  sterilised  gauze,  horsehair,  or  a  small  tube.  The  after-treatment  is 
the  same  as  that  indicated  at  p.  970. 


DETACHMENT      OF      A      FIBRO-CARTILAGE     AND       OTHER 
FORMS    OF    INTERNAL    DERANGEMENTS    OF     THE     KNEE. 

Before  the  question  of  operative  interference  is  considered  the 
following  remarks,  the  outcome  of  exploration  of  nineteen  cases,  may 
be  useful.  I  shall  divide  the  cases  into  two  groups :  (A)  Where 
a  fibro-cartilage,  far  more  frequently  the  internal,*  has  been 
injured,  and  perhaps  displaced  ;  (B)  where  other  conditions  are 
present.     A.  These  fall  into  two  classes,  the  typical  and  atypical  ones. 

*  The  greater  frequency  of  displacement  of  the  internal  fibro-cartilage  is  due  to  its 
being  more  fixed  and,  therefore,  to  its  feeling  strains  more,  especially  strains  of  the 
internal  lateral  ligament,  as  when  the  flexed  knee-joint  is  suddenly  rotated  outwards.  The 
internal  fibro-cartilage,  in  addition  to  its  attachments  by  the  coronary  and  transverse 
ligaments,  is  fastened  all  along  its  convex  border  to  the  inside  of  the  capaule,  and  to  the 
internal  lateral  ligament,  strongly.  The  external  fibro-cartilage,  on  the  other  hand,  is 
more  weakly  attached  to  the  capsule,  especially  opposite  to  the  popliteus  tendon,  and  has 
no  attachment  to  the  external  lateral  ligament. 


974  OPERATIONS    ON    THE    LOW T.K    EXTREMITY. 

(i)  In  the  latter,  not  infrequently,  though  the  fibro-cartilage  may 
have  been  much  injured,  there  is  little  local  external  evidence,  and  it 
is  impossible  to  tell  accurately  what  the  exact  condition  is  ;  at  the 
operation,  marked  mischief  is  found.  (2)  Where  a  fibro-cartilage  has 
been  undoubtedly  injured,  it  is  not  always  easy  at  the  time  of  operation 
to  be  certain  as  to  the  nature  of  the  injury.  In  many  cases  where 
the  fibro-cartilage  is  detached  at  either  end,  or  still  attached  but  torn 
through  its  centre,  with  one  or  more  slips  torn  off,  the  mischief  is 
obvious.  But  this  is  not  so  in  other  cases,  e.g.,  where  a  fibro-cartilage, 
which  there  is  every  reason  to  believe  to  be  the  cause  of  the  trouble, 
is  found  to  be  in  situ.  Here  its  mobility  must  be  determined  ;  if  an 
aneurysm-needle  can  be  easily  slipped  under  the  fibro-cartilage  from 
end  to  end,  and,  still  more,  if  it  can  be  readily  hooked  forwards  or 
folded  backwards  into  the  joint,  the  indications  for  its  removal  are 
obvious — for  I  am  not  an  advocate  of  suture  (see  below) — but  there  are 
other  cases  not  so  easily  cleared  up  and  in  which  a  thoughtful  surgeon 
finds  it  difficult  to  be  certain  as  to  the  exact  degree  of  mischief  present, 
and  this  uncertainty  is  increased  by  the  limited  wound  which  it  is 
usually  advisable  to  make.  13.  Often  much  less  typical  cases,  where 
other  conditions  than  injury  to  a  fibro-cartilage  are  present.  Diagnosis 
here  is  often  at  fault;  even  with  the  great  increase  of  these  operations, 
we  are  not  yet  familiar  with  all  the  different  conditions  which  may 
more  or  less  closely  resemble  a  displaced  fibro-cartilage.  First  of 
course  are  the  "loose  bodies"  of  which  I  have  written  at  p.  972.  These 
may  simulate  the  results  of  injury  to  a  fibro-cartilage  very  closely.  Of 
the  other  much  less  obvious  conditions  which  may  cause  pain, 
recurrent  effusion,  perhaps  locking  and  a  more  or  less  defined  swelling, 
and  cripple  the  joint  to  a  varying  degree,  I  shall  mention  a  few  with 
which  I  am  familiar.  Time  will  bring  to  light  others  which  I  have 
overlooked.  When  a  knee-joint  is  opened  and  the  fibro-cartilages  are 
found  to  be  normal  in  position  and  fixity,  where  no  loose  body  is 
present,  the  first  condition  to  think  of  is  (a)  an  altered  condition  of 
the  synovial  fringes,  especially  the  pads,  alaria,  and  mucosum. 

I  have  had  three  cases  in  which  I  believed  this  condition  to  be  the  cause  of  the  trouble. 
All  were  young  adults.  In  none  had  locking  been  a  prominent  feature.  On  exploration 
of  the  synovial  recess  between  the  tibia  and  patella,  a  large  reddish  yellow  fringe  with  its 
margin  much  thickened  in  places  was  found.  In  two  of  the  cases  it,  was  easily  shown 
that  the  fringe  passed  during  certain  movements  of  the  joint  between  the  articular 
surfaces  of  the  femur  and  tibia.  In  two  of  the  cases  the  synovial  membrane  appeared 
generally  injected  ;  in  none  of  them  was  any  effusion  present.  The  fringes  were  cut  away, 
a  ligature  being  applied  in  one  case,  and  drainage  employed.  All  made  good  recoveries,  but 
I  have  not  had  the  opportunities  needful  to  enable  nie  to  state  whether  the  results  were 
permanently  good.  Microscopical  examination  showed  an  ordinary  synovial  fringe, 
chronically  inflamed,  and  with  ecchymoses  of  different  dates.  Prof.  Annandale,  who 
did  most  useful  pioneer  work  in  the  removal  of  displaced  flbro-cartilages,  was,  I  believe, 
the  first  to  call  attention  to  these  bodies  (Brit.  Med.  Journ.,  1SS7,  vol.  i.  p.  320).  Dr.  C.  P. 
Flint,  of  New  York,  has  recorded  three  cases  in  which  he  operated  (Ann.  of  Surg., 
September,  1905,  p.  445).     Excellent  illustrations  ac< ipany  the  paper. 

Mr.  R.  Jones,  of  Liverpool  (infra,  p.  976),  writes  :  "Hypertrophy  of 
the  synovial  villi  is  frequently  confused  with  a  damaged  semilunar. 
The  condition  is  much  more  common  than  is  usually  suspected,  and  I 
have  frequently  met  with  it  when  exploring  joints."     On  one  occasion, 


DKTACHMKNT    OF    A    FIBRO-CARTILAGE  975 

failing  to  find  any  injury  to  the  semilunar  in  a  case  with  typical 
symptoms,  Mr.  -Jones,  on  enlarging  his  incision,  found  a  ligamentum 
alarium  actually  detached  ami  lying  in  the  intercondyloid  notch.     Its 

removal  resulted  in  a  perfect  recovery. 

(b)  AVhile  the  semilunar  cartilage  is  normal  in  position  and  its 
attachments,  it  lias  been  bruised,  and  the  adjacent  head  of  the  tibia  is 
the  seat  of  osteitis  and  periostitis,  (c)  The  parts  are  normal  save 
perhaps  for  some  injection  of  the  synovial  membrane.  While  making 
due  allowance  for  my  faulty  diagnosis  and  the  limited  access  for 
exploration,  I  am  convinced  that  such  cases  do  occur  in  neurotic 
patients,  as  in  some  other  conditions  submitted  to  frequent  operation 
at  the  present  day.  On  this  subject  and  the  varied  causes  of  recurrent 
effusion  into  the  knee-joint,  my  readers  should  consult  a  most  instruc- 
tive article  by  Sir  W.  Bennett,  K.C.V.O.  (Lancet,  Jan.  7,  1905). 
Before  leaving  this  part  of  my  subject  I  will  add  two  cautions,  one, 
that  in  cases  where  only  injection  and  other  slight  changes  in  the 
synovial  membrane  are  all  that  can  be  found  it  will  always  be  well  to 
bear  in  mind  the  possibilit}'  of  early  tuberculosis.*  The  other  is  one 
to  which  I  have  drawn  attention  at  p.  972.  This  operation,  especially  if 
followed  by  stiffness  and  the  treatment  necessary  to  meet  this  condition, 
may  light  up,  especially  in  patients  no  longer  young,  a  tendency  to 
osteo-arthritis. 

Indications  for  Operation. — The  chief  of  these  are  :  (1)  Confidence 
on  the  part  of  the  surgeon  that,  as  regards  both  himself  and  the  patient, 
he  can  secure  an  aseptic  result  throughout;  (2)  failure  of  palliative 
treatment,  especially  in  recurrent  cases;  (3)  cases  of  especial  expediency, 
e.g.,  where  the  employment  entails  especial  risks,  where  the  patient  is 
likely  to  be  remote  from  surgical  aid,  or  where  a  future  career  or 
some  particular  pursuit  will  be  interfered  with.  Thus  in  a  case  of 
Mr.  F.  J.  Steward's— 

The  patient — a  student — -had  suffered  for  over  seven  years  from  repeated  displacement, 
latterly  brought  about  by  quite  trivial  movements,  such  as  stepping  off  a  kerb.  The 
operation  was  performed  in  August,  1900  ;  the  cartilage,  which  had  been  completely 
torn  from  its  anterior  attachments,  being  removed.  In  January,  1902,  the  patient  was 
playing  football  regularly,  and  did  not  notice  the  slightest  difference  between  his  two 
knees. 

Mr.  It.  Jones,  of  Liverpool,  gives  the  indications  for  operation  better 
thus  : — "  In  the  first  place,  I  refuse  to  operate  in  any  case  I  see  early, 
the  subject  of  a  first  derangement.  I  discourage  operation  in  those 
recurrent  cases  where  the  symptoms  are  transient  and  not  followed 
by  irritation  of  the  joint.  I  strongly  urge  operation  in  those  cases  where 
a  recurrent  displacement  is  at  times  followed  by  acute  symptoms.  I 
advise  it  in  all  recurrent  cases  where  a  strenuous  athletic  life  is  a 
means  of  livelihood  or  a  physical  necessity.  I  think  operation  absolutely 
imperative  in  the  case  of  men  who  work  in  dangerous  places."  As  "of 
two  cases,  carefully  watched,  each  refusing  operation,  one  resulted  in 
rheumatoid   and  the  other  in  tubercular  change,"  Mr.  Jones  advises 

*  I  refer  especially  to  those  cases  where  the  synovial  membrane  is  found  generally 
injected,  and  some  effusion  is  present.  It  is  noteworthy  that  in  one  of  Dr.  Flint's  cases 
the  fringe  removed  showed  the  existence  of  tuberculosis.  A  generally  villous  or  papillary 
synovitis  would  be.  obviously,  most  suspicious. 


«,;h      OPERATIONS  ON  THE  LOWEB  EXTREMITY. 

"  that  this  danger  should  be  kept  well  in  view,  and  that  patients  with 
either  a  tubercular  or  rheumatoid  diathesis  subject  to  recurrent  derange- 
ment should  early  be  persuaded  to  have  the  exciting  cause  removed." 
Mr.  Jones's  paper  (Clin.  Journ.,  May  9,   1906)  only  came  into  my 

hands  when  these  sheets  were  passing  through  the  press.  It  is  well 
worthy  of  a  most  careful  study  from  the  writer's  well-known  experience, 
proved  ;it  many  points  by  the  lucid  practical  details,  especially  where 
he  is  dealing  with  the  difficulties  which  are  present  in  the  diagnosis 
and  treatment  of  "  certain  derangements  of  the  knee." 

Operation. — The    area    having  been    carefully    sterilised    and    the 
strictest  precautions  taken  in  every  way  (p.  972),  an  angular  incision  is 
made — I  shall  take  the  case  of  exploration  of  the  internal  fibro-cartilage 
— the  first  part  nearly  three  inches  long,  three-quarters  of  an  inch  from 
the  inner  border  of  the  patella,  vertically  downwards  to  the  interval 
between  the  femur  and  tibia,  and  then  inwards  as  far  as  the  internal 
lateral  ligament.     The  reason  for  placing  the  incision  at  the  above-men- 
tioned distance  from  the  patella  is  explained  later  ;  the  most  important 
internal  lateral  ligament  is  to  be  interfered   with  as  little  as  possible. 
The  capsule,  together  with  the  synovial  membrane,  is  now  incised  in 
the  same  line,  and  all  haemorrhage  carefully  arrested.     The  condition 
of  the   fibro-cartilage  is  now   investigated,  with  the  joint  flexed  and 
extended.     Many  of  the  various  degrees  of  damage  which  it  may  have 
received   and   several  of  the  other  conditions  which  may   be   present 
have    already    been    alluded    to.      Where   the  fibro-cartilage   is   much 
damaged  its  removal  is  of  course  indicated  by  dragging  it  forward  and 
snipping  it  away  with  curved  blunt-pointed   scissors.     Where  its  con- 
dition is  more  doubtful* — i.e.,  where  it  is  only  partially  frayed — I  am 
of  opinion  that  its  removal  is  the  wisest  step.     In  cases  of  doubt  the 
longitudinal  incision  must  be  converted  into  a  flap,  or  a  second  incision 
made  on  the  opposite  side.     Attempts  to  suture  the  fibro-cartilage  are 
never  advisable.     This  procedure  is  difficult :  the  sutures  are  veiy  likely 
to  give  way,t  and  the  more  prolonged  rest  now  needed — three  or  four 
weeks  instead  of  ten  days — will  very  likely  lead  to  after-stiffness.     The 
wound  is  dealt  with,  and  the  after-treatment  conducted,  as  indicated  at 
p.  970.     Suture  of  the  synovial  membrane  with  separate  buried  sutures 
of  sterilised  silk  is  most  important  here  :  it  promotes  early  union  of  the 
deep  parts  of  the  wound,  thus  at  once  facilitating  the  regaining  of  move- 
ments, and  shutting  out  the  risk  of  after-infection.     For  the  insertion 
of  these  sutures  the  synovial  membrane  must  not  be  divided  close  to 
the  patella,  or  there  will  be  no  edge  to  take  up. 

The  case  that  follows  illustrates  the  liability  of  clamps  to  fail 
suddenly  after  a  prolonged  period  of  usefulness,  and  the  presence  of 
osteo-arthritis,  in  a  very  marked  degree,  in  a  young  subject. 

It.  ('.,  aged  35,  had  had  repeated  displacement  of  his  left  fibro-cartilage  since  a  wrench 
of  his  kuee  when  17  years  old.     A  clamp  gave  great   relief  for  some  time,  bul  latterly  this 

*  In  all  doubtful  eases,  Mr.  Jones's  advice  (p.  977)  must  he  remembered  as  to  the 
possibility  of  mure  than  one  mechanical  factor  existing  in  a  joint. 

t  Mr.  M.  Moullin  {Lancet.  1895,  vol.  i.  p.  1233)  mentions  two  cases  in  which  the 
displacement  recurred  after  suture.  In  his  words,  ••sutures  ami  adhesions  cannot  make 
it  stronger  than  it  was  before  it  was  hurt,  unless  they  fix  it  so  that  it  is  completely  rigid  ; 
and  if  it  gave  way  before,  it  will  give  way  all  the  more  easily  a  second  time  if  exposed  to 
a  Bimilar  strain." 


DETACHMENT    OF    A    FIBRO-CARTILACK.  qyy 

ceased  to  be  any  safeguard,  In  April,  1894,  T  opened  the  knee-joint  by  a  vertical  incision 
three  inches  long,  placed  about  an  inch  from  the  inner  margin  of  the  patella, and  beginning 

opposite  its  centre.  'The  first  thing  to  come  into  view  when  the  joint  was  opened  was  the 
inner  condyle,  with  its  margin  converted  into  a  huge  lip,  everted  and  raised  and  covered 
with  a  network  of  many  minute  vessels.  The  head  of  the  tibia,  as  far  as  seen,  presented 
the  same  appearance  along  its  articular  rim.  The  internal  fibro-cartilage  was  found 
detached  from  its  connections  to  the  tibia  and  carried  up  with  the  femur.  It.  was  thin, 
flaccid,  and  limp,  Battened  out,  its  circumferential  border  having  lost  its  thickness  and 
convexity.  No  bleeding  followed  on  snipping  through  its  posterior  attachments.  The 
"  lipping"  of  the  cartilage  on  the  femur  and  tibia  was  rounded  off  with  a  metacarpal  saw, 
some  sessile  growths  of  the  synovial  membrane  were  snipped  away,  and  two  small  osteo- 
phytes removed  from  the  articular  surface  of  the  patella.  The  inner  aspect  of  the 
joint  was  carefully  dried  out  with  aseptic  sponges,  and,  as  much  oozing  was  expected 
from  the  sawn  surfaces,  a  drainage-tube  was  passed  into  the  upper  cul-de-sac  and  brought 
out  through  the  wound.  The  wound  healed  quickly;  a  month  later  the  patient  could 
walk  across  Hyde  Park,  but  it  was  not  till  nearly  six  months  after  the  operation  that 
flexion  and  extension  were  completely  restored,  and  the  patient  could  say  that  there 
was  "not  much  to  choose  between  the  two  knees."  I  saw  him  five  years  after  the 
operation  ;  he  could  then  use  the  lower  limbs  with  equal  freedom,  and  the  movements  of 
the  left  knee  were  quite  smooth.  He  was  able  to  walk,  ride,  and  shoot  with  entire 
comfort. 

A  case  brought  by  Mr.  Lockwood  before  the  Clinical  Society  (Trans., 
vol.  xxvii.  p.  133  ;  Lancet,  1894,  vol.  i.  p.  673),  where  twenty-one 
months  had  elapsed  since  the  operation,  emphasises  the  importance  of 
the  patient  not  taking  liberties  with  the  joint  for  some  time.  This 
is  a  point  liable  to  be  neglected  by  young  adults  after  rapid  healing  of 
the  wound. 

The  left  knee  had,  after  an  injury,  been  liable  to  become  locked  under  circumstances 
which  rendered  the  patient's  occupation,  that  of  an  engineer,  dangerous.  Though  nothing 
could  be  felt  externally,  when  the  joint  was  opened  the  internal  fibro-cartilage  was  found 
to  have  its  anterior  third  torn  up  from  the  tibia.  This  poition  was  cut  away,  and  the 
remainder  sewn  down  to  the  tibia  with  silk  sutures.  The  patient  made  a  rapid  recovery, 
but  neglecting  the  advice  given  not  to  play  tennis  or  football  for  a  year,  had  synovitis 
with  considerable  effusion  after  taking  violent  exercise.  Later  on  he  reported  that  for 
walking,  riding,  and  swimming  the  knee  was  as  good  as  the  other.  Exercises  involving 
any  risk  of  twisting  the  joint  he  had  avoided. 

In  closing  this  subject  I  cannot  do  better  than  quote  Mr.  Jones's 
article  (loc.  supra  cit,  p.  976)  on  the  possibility  of  failure  of  opera- 
tion :  "  Is  operative  treatment  invariably  successful  ?  The  answer 
is  emphatically,  No.  In  the  great  majority  of  cases  a  perfect  recovery 
may  be  predicted  ;  in  a  certain  small  percentage  the  symptoms  recur. 
The  recurrences  were  far  more  numerous  some  few  years  back,  when 
the  cartilages  were  sewn  to  their  tibial  attachments."  In  other  cases 
"it  will  be  discovered  that  the  so-called  recurrence  is  due  to  an 
overlooked  accessory  factor  in  the  production  of  the  symptoms  of 
derangement."     Mr.  R.  Jones  illustrates  this  by  two  cases : — 

In  one  the  anterior  half  of  a  torn  external  semilunar  had  been  removed.  Slipping  again 
occurred  within  a  month,  and,  on  opening  the  joint  on  its  inner  side,  Mr.  Jones  found  a 
small  fibrous  nodule  floating  by  a  thin  pedicle. 

In  the  other  case  the  anterior  part  of  the  internal  semilunar  had  been  found  abnormally 
free  and  removed.  For  some  months  normal  function  remained  restored.  The  troubles 
then  reappeared,  with  pain,  referred  again  to  the  inner  side  of  the  joint.  il  I  followed 
the  line  of  the  old  scar  and  searched  for  a  cause.  I  was  almost  closing  the  wound,  when 
internal  rotation  of  the  tibia  dislodged  a  loose  body." 

S. — VOL.  II.  62 


CHAPTER  V. 
OPERATIONS  ON  THE  POPLITEAL  SPACE. 

LIGATURE     OF      THE      POPLITEAL     ARTERY.    —    MATAS'S 
OPERATION     FOR     ANEURYSM. 

Indications. — Extremely  few.  i.  Stab  or  punctured  wound. — Here 
the  surgeon  would  only  resort  to  ligature  (i)  if  pressure  (p.  926)  was  un- 
suitable ;  (2)  if  suture  (p.  917)  was  found  impossible  ;  (3)  if  the  patient 
insisted  on  running  the  risk  of  gangrene  ;  (4)  it  would  be  well,  if  possible, 
to  get  leave  for  immediate  amputation  if  the  vein  was  found  injured  also, 
and  beyond  remedy  by  suture,  ii.  In  some  cases  of  ruptured  popliteal 
artery  it  will  be  right  to  explore  and  see  if  any  other  complication 
exist  beyond  the  rupture  of  the  artery.*  If  there  is  no  injury  to  the 
vein,  nerves,  or  the  joint  (a  very  unlikely  contingency),  the  rupture 
should  be  treated  by  Murphy's  method  of  resection  (p.  917),  if  possible, 
and,  this  failing,  by  double  ligatures.  The  surgeon  must  afterwards  be 
prepared  to  amputate  through  the  lower  third  of  the  thigh  on  the  first 
sign  of  gangrene  appearing.  The  operation  of  ligature  of  the  popliteal 
artery  is  extremely  difficult  here,  owing  to  the  depth  of  the  vessel,  the 
strong  fascia,  the  amount  of  coagulated  blood,  and  the  infiltrated, 
obscured  condition  of  the  parts.  Primary  amputation  will,  as  a  rule, 
be  required  in  cases  of  ruptured  popliteal  artery,  especially  where  skilled 
assistance  and  facilities  for  aseptic  treatment  are  not  at  hand.  A  free 
incision  will  enable  the  surgeon  to  investigate  the  amount  of  injury, 
and  at  the  same  time  will  relieve  tension  if  an  attempt  be  made  to  save 
the  limb.  This  incision  may  form  part  of  the  amputation  (p.  946). 
iii.  The  artery  has  been  wounded  in  the  course  of  an  osteotomy  of  the 
lower  end  of  the  femur.  In  such  a  case  the  vessel  should  be  reached 
by  the  incision  shown  in  Fig.  406. 

Extent. — From  the  opening  in  the  adductor  magnus  to  the  lower 
border  of  the  popliteus. 

Guides. — Behind  :  A  line  drawn  from  just  inside  the  inner  hamstrings 
above  to  the  centre  of  the  lower  part  of  the  popliteal  space.  In  front : 
The  tendon  of  the  adductor  magnus. 

Relations  (in  the  popliteal  space)  : 

Behind. 

Skin ;  fasciae  ;  small  sciatic  nerve  above ;  short 
saphena  vein  and  external  saphena  nerve  below ; 
fat;  glands. 

*  Poland,  Guy's  Hbtp.  Reports,  third  series,  vol.  vi.  p.  294. 


LIGATUBE   OF   THE    POPLITEAL   ARTERY.  979 

Semi-membranosus   above  ;     gastrocnemius,    plan- 

taris,  soleus,  below. 
Internal    popliteal   nerve;     popliteal    vein,    outside 

above,  inside  below,  exactly  over  the    artery    in 

the  centre  of  the  space. 
Branch  of  obturator  above. 

Outside.  Inside. 

Biceps   above;    gastrocnemius  Semi-membranosus   above;- 

and  plantaris  below.  gastrocnemius  below. 

Popliteal   artery. 

In  Front. 

Femur. 

Posterior  ligament. 

Popliteus. 

Collateral  Circulation. 

Above.  Below. 

Anastomotica  magna,  supe-  Inferior  articular,  and  re- 

rior  articular,  descending  .,,                   current    from    anterior 

branch    of  external   cir-  tibial, 
cumflex. 

Operations  (Figs.  405,  406). — The  artery  may  be  tied  in  three 
places.  A.  At  the  upper  part  of  the  popliteal  space.  B.  At  the  lower 
part  of  the  popliteal  space.  C.  From  the  front,  at  the  inner  side  of  the 
limb.  For  the  sake  of  experience,  all  should  be  practised  on  the  dead 
body. 

A.  At  the  Upper  Part  of  the  Popliteal  Space. — The  patient 
being  rolled  two-thirds  on  to  his  face,  and  the  limb  at  first  extended, 
a  free  incision  three  inches  and  a  half  long  is  made,  in  the  line  of  the 
vessel,  along  the  outer  margin  of  the  semi-membranosus,  and  then 
downwards  and  outwards  to  the  centre  of  the  space.  The  small  sciatic 
nerve,  if  seen,  should  be  drawn  to  one  side ;  the  deep  fascia  is  then 
freely  opened  up,  and  the  pulsation  of  the  artery  felt  for  at  the  outer 
margin  of  the  semi-membranosus.  The  nerve  is  generally  seen  first, 
and  this  and  the  vein  are  to  be  drawn  to  the  outer  side  with  blunt 
hooks.  The  needle  should  be  passed  from  the  vein.  A  good  deal  of 
loose  fat  is  usually  in  close  contact  with  the  vessels,  and  is  liable  to  be 
a  source  of  trouble  wherever  the  artery  is  ligatured,  especially  in  the 
dead  subject. 

B.  At  the  Lower  Part  of  the  Popliteal  Space  (Fig.  405). — The 
limb  being  in  the  same  position,  an  incision  four  inches  long  is  made, 
in  the  line  of  the  artery,  from  the  centre  of  the  popliteal  space  to  the 
junction  of  the  upper  and  middle  thirds  of  the  back  of  the  leg.  The 
external  saphena  vein  and  its  nerve  being  avoided,  the  deep  fascia  is 
freely  opened  and  the  limb  flexed.  The  exact  interval  between  the 
heads  of  the  gastrocnemius  is  next  sought  for.  The  following  structures 
may  now  be  met  with  overlying  the  artery,  and  must  be  drawn  aside 
— viz.,  the  plantaris,  the  sural  arteries  which  run  down  on  the  vessel, 
and  the  communicans  tibialis  nerve.     The  popliteal  vein  now  lies  to 

62 — 2 


980 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


the  inner  side,  together  with  the  popliteal  nerve,  which  is  superficial 
to  it,  if  this  has  not  given  off  its  branches.  These  structures  should 
be  drawn  to  either  side,  and  the  needle  passed  as  is  convenient. 

C.  From  the  Front,  at  the  Inner  Side  (Fig.  406). — This  operation 

FlO.  405. 


ire  of  the  popliteal  artery.  1,  Deep  fascia.  2,  Internal  popliteal  nerve. 
3.  Popliteal  vein.  4.  Popliteal  artery.  5.  Outer  head  of  gastrocnemius. 
6,  Inner  head  of  gastrocnemius.  7,  Communicans  tibialis.  8,  External 
saphenous  vein.    9,  Head  of  fibula.     (Kocher.) 


might  he  useful  in  cases  where  haemorrhage  recurs  after  osteotomy  at 
the  lower  end  of  the  femur  (p.  1071). 

The    following     account     is    taken    from    Sir  Wm.    MacCormae 

(Ligature  of  Arteries,  p.  no)  :  "  Flex  the  knee  and  place  the  limb  on 

the  outer  Bide.      Make  an   incision   three   inches  long    immediately 
behind  and  parallel  to  the  tendon  of  the  adductor  magnus  downwards 

from  the  junction  of  the  middle  and  lower  thirds  of  the  thigh.     Divide 


MATAss   OPERATION. 


the  skin,  superficial  and  deep  fasciae;  avoid  the  long  saphenous  nerve ; 
seek  the  tendon  <>i  i In-  adductor  magnus  ;  draw  it  forwards  and  the 
hamstring    tendons    backwards.     The  artery  will  then  be  found  sur- 

l'n;.  406. 


Relation  of  parts  in  ligature  of  the  popliteal  from  the  front  at  the  inner  side. 
(Esinarch  and  Kowalwitz.) 

rounded  by  fatty  areolar  tissue.     The  nerve  and  vein  do  not  necessarily 
come  into  view,  being  on  the  external  aspect  of  the  vessel." 


MATAS'S    OPERATION   (Figs.  407  to  420). 

This  original  method  of  treating  aneurysms,  thought  out  and  con- 
firmed in  value  by  four  successful  cases,  will  be  found  in  the  Trans. 
Amer.  Surg.  Assoc,  1902,  p.  396,  and  Ann.  of  Surg.,  February,  1903 
(Figs.  407  to  420).  The  sac  is  not  extirpated  or  interfered  with,  except 
so  far  as  is  needed  to  empty  it  and  freely  expose  its  interior;  no 
ligatures  are  applied  to  the  main  artery,  and  the  circulation  in  the  sac 
is  arrested  and  haemorrhage  prevented  by  suturing  the  arterial  orifices 
found  in  the  sac.  The  sac  is  obliterated  by  sutures  which  infold  it, 
aided  by  plastic  effusion  from  the  intima.*  There  is  but  little  dis- 
turbance of  the  sac  or  of  its  vascular  relations  ;  the  collateral  circu- 
lation is  not  interfered  with.  Dr.  Matas  considers  his  operation 
applicable  to  all  aneurysms,  whether  sacculated  or  fusiform,  whether 
idiopathic  or  traumatic,  in  which  provisional  lnemostasis  can  be 
secured.  In  true  sacciform  aneurysms  with  a  single  orifice  this  opera- 
tion will  allow  of  obliteration  of  the  aneurysm  without  the  lumen  of 
the  vessel  being  obstructed,  the  risk  of  gangrene  being  thus  obviated. 
Dr.  Alatas  considers  arterio-venous  aneurysms  and  diffuse  hamiatomata 
of  recent  origin  better  suited  to  arteriorraphy  (p.  919). 

*  Dr.  Matas  points  out  that,  while  in  large  and  old  aneurysms  the  endothelial  intima 
will  be  largely  lost,  the  orifices  and  adjacent  areas — the  parts  chiefly  concerned  in  the 
suturing — will  retain  the  characters  of  this  layer. 


982 


OPERATIONS    ON    THE    LOWJEK    EXTREMITY. 


The  following  are  the  steps  of  the  operation  as  applied  to  peripheral 
aneurysms  of  the  larger  arteries. 

1.  Prophylactic  hamostasis. — This  is  effected  by  an  Esmarch's  ban- 
dage ;  by  exposing  the  artery  near  the  cardiac  end  of  the  aneurysm 
and  compressing  it  by  a  loop  held  by  an  assistant,  or  by  pressure  at 
this  spot  by  the  finger  of  an  assistant,  the  vessel  being  protected  by  a 
pad  of  sterile  gauze  ;  or  by  a  clamp  such  as  Crile's  (vol.  i.  p.  763). 
Dr.  Matas  prefers  a  silk  traction-loop,  as  it  is  always  at  hand.  In 
cervical  aneurysms  the  artery  should  be  controlled,  if  possible,  on  both 
sides  of  the  aneurysm. 


Fig.  407. 


Fig.  408. 


This  shows  the  interior  of  a  large  aneu- 
rysmal sac  of  the  fusiform  type  exposed  by 
retraction.  The  two  openings  lead  respec- 
tively into  the  parent  trunk  on  the  cardiac 
and  peripheral  sides,  and  the  groove  be- 
tween them  represents  the  continuity  of 
the  arterial  walls  blending  with  the  aneu- 
rysmal walls.  The  orifice  of  one  collateral 
branch  originating  in  the  sac  is  slmwu.  and 
another  opening,  near  the  orifice  of  com- 
munication on  the  cardiac  side,  into  the 
main  trunk.     (Matas.) 


The  orifices  in  the  aneurysmal  sac  are 
shown  in  process  of  obliteration.  The  first 
plane  of  sutures  may  be  made  with  fine 
silk,  but  chromicised  catgut  is  preferred. 
The  sutures  are  inserted  very  much  like 
Lemberfs  sutures  in  intestinal  work  ;  the 
first  plane  should  be  sufficient  to  secure 
complete  haemostasia  The  orifice  of  the 
collateral  vessel  on  the  left  upper  side  of 
the  sac  is  shown  closed  by  three  continued 
sutures.     (Matas.) 


2.  Exposure  of  the  sac. — When  all  pulsation  has  been  absolutely 
arrested,  an  incision  is  made  down  to  the  sac,  so  as  to  expose  it 
from  one  end  to  the  other.  When  the  aneurysm  is  deeply  situated, 
the  more  superficial  portion  of  the  sac — but  no  more — should  be 
exposed  by  careful  dissection  in  case  any  important  structures  are 
adherent  to  this  surface. 

3.  Opening  and  evacuation  of  t)i>  sac  ;  recognition  of  its  type,  the  number 
oj  openings  into  it,  <tc. — A  free  longitudinal  incision  is  next  made 
through  the  whole  length  of  the  sac,  and  the  contents  evacuated  so 
that  the  interior  is  freely  exposed  to  view,  the  edges  being  well 
retracted.  If  it  be  a  fusiform  aneurysm  two  large  openings  are  usually 
seen   at  the  bottom    of  the   sac,  separated   by  an  intervening  space  of 


\l.\TAs\s   OPERATION. 


983 


variable  length,  frequently  marked  by  a  shallow  groove  representing 
the  floor  of  the  artery  (Fig.  407).  If  the  aneurysm  be  sacci- 
mnii  (Figs.  409  to  411),  the  opening  will  be  single,  of  variable  size  and 
shape.  In  fusiform  aneurysm,  as  the  continuity  of  the  artery  can- 
not be  restored,  the  object  of  the  sutures  is  to  seal  the  openings 
into  the  vessel  for  the  purposes  of  lnemostasis  and  obliteration  of 
the  sac.  In  the  sacciform  variety  it  is  often  possible  to  close  the 
opening  without  obliterating  the  lumen  of  the  vessel  (Figs.  411,  412, 
and  418). 

A.  Treatment  of  fusiform  aneurysms.  —  The  sac  having  been 
emptied  and  the  two  main  openings  identified,  the  next  step  is  to 
discover  the    openings    of  any    collaterals,*   which,    if  not   carefully 


Fig.  409. 


Fig.  410. 


Sacciform  aneurysm  with  one  orifice  of 
communication  with  the  sac.  It  is  possible 
in  this  class  of  cases  to  close  the  orifice  by 
suture  without  obliterating  the  lumen  of 
the  artery,  and  without  interfering  with  the 
circulation  in  the  main  artery.     (Matas.) 


Sacciform  aneurysm  opened.  Thedotted 
lines  indicate  the  relations  of  the  main 
artery  to  the  sac  and  orifice  of  communi- 
cation. The  closure  of  the  orifice  with  a 
continued  suture  is  shown.     (Matas.) 


sutured,  would  give  rise  to  troublesome  haemorrhage.  Such  bleeding, 
according  to  Dr.  Matas,  only  occurs  when  the  circulation  in  the  sac 
is  controlled  by  a  traction-loop  or  other  contrivance,  and  not  by  general 
circular  constriction  at  the  root  of  the  limb.  When  it  occurs,  such 
haemorrhage  is  readily  controlled  by  pressure  applied  by  the  finger  or 
sterile  sponges  over  the  openings  until  these  are  closed  by  rapid  con- 
tinuous sutures  (Fig.  408).  The  "  toilet  "  of  the  sac  is  then  completed 
by  scrubbing  the  intima  gently  and  thoroughly  with  gauze  soaked  in 
sterile  solution,  so  as  to  clear  away  all  clots  and  prepare  the  lining 
membrane  for  prompt  plastic  reaction  when  the  surfaces  of  the  sac  are 
brought  into  apposition. 


*  Such  openings  of  collaterals  are  more  likely  to  exist  in  fusiform  aneurysms,  in  which 
a  larger  area  of  arterial  wall  is  involved.     (Matas.) 


984 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


4.  Closure  of  the  anewrysmal   orifices    in   the  fusiform  type   of  sac 

(Figs.  407,  408,  and  417). — The  tissues  adjacent  to  these  orifices  un- 
usually strong  and  resisting  and  hold  sutures  well.  The  material  used 
may  he  silk,  chromicised  catgut,  or  the  finest  kangaroo-tendon; 
Dr.  Matas  prefers  catgut.      The  needle  should    he  round  and  fully 

curved.  The  continuous  suture  will  usually  he  found  the  most  rapid 
and  effective.  The  number  of  sutures  will  depend  upon  the  size  of 
the  opening  to  be  closed.  Eight  to  ten  to  the  inch  are  more  than 
sufficient.  In  closing  the  larger  openings  in  a  fusiform  aneurysm, 
the  needle  should  penetrate  at  least  one  quarter  or  one-sixth  of  an 


Fig.  411. 


To  show  the  closure  of  the  orifice  of  communication  in  a  sacciform  aneurysm 
with  an  interrupted,  instead  of  a  continuous,  suture.  Whether  the  continued  or 
interrupted  suture  be  used  (the  former  being  preferred  by  Dr.  Matas),  it  is 
important  that  the  suture-line  be  some  distance  from  the  orifice,  so  as  to  enfold  a 
considerable  surface  of  the  sac  ;  then  care  must  be  exercised  to  insert  the  sutu 
so  as  to  grasp  a  considerable  surface  of  the  margin,  in  a  manner  that  the  point  of 
the  needle  shall  penetrate  the  entire  thickness  of  the  margin,  and  yet  not  so  far 
within  the  lumen  of  the  artery  as  to  encroach  upon  its  calibre,  or  to  leave  the 
suture  material  in  contact  with  the  blood  current.  When  the  sutures  a 
tightened  they  should  bring  the  marginal  surfaces  into  broad  apposition  without 
projecting  into  the  anterior  portion  of  the  artery,  or  encroaching  excessively  upon 
the  lumen  of  the  vessel.     (Matas.) 

inch  beyond  the  margin  of  the  orifice,  and  then,  after  reappearing  at 
the  margin,  dip  again  into  the  floor  of  the  artery,  and  continue  to  the 
opposite  margin,  as  in  the  start  (Fig.  408).  This  method  sec  tin 
complete  apposition  of  a  large  marginal  area,  including  the  floor  of 
the  artery  visible  under  the  orifice.  When  the  openings  must  be 
closed  quickly,  as  in  cases  of  considerable  collateral  bleeding,  the  dip 
of  the  needle  into  the  floor  of  the  vessel  may  be  omitted,  and  the 
margins  of  the  orifices  brought  together  quickly  with  a  continuous 
suture.  When  the  intervening  space  is  not  too  great,  Dr.  Matas 
prefers  to  extend  the  line  of  suture  from  one  orifice  to  the  other  (Fig. 
408).  If  the  floor  is  rigid  or  bound  down  by  adhesions,  the  sutures 
should  be  limited  to  the  orifices. 


MATAS'S    OPKRATKW. 


985 


Fig.  412. 


B.  Sacciform  aneurysm  with  a  single  orifice,  sutures  here  hemostatic 
(Did  reconstructive  with  the  view  of  preserving  the  lumen  of  the  artery 
(Figs.  410,  411,  412,  418). — The  same  material  and  needles  are  used. 
The  chief  point  to  bear  in  mind  is  that  the  sutures  should  be  inserted 
at  a  sufficient  distance  from  the  margins  of  the  opening  to  secure  a 
firm  and  deep  hold  (Figs.  410,  411,  and  418).  The  needle  should  be 
made  to  appear  just  within  the  lower  edge  of  the  margin,  care  being 
taken  that  when  the  sutures  are  tightened,  the  calibre  of  the  artery 
will  not  be  encroached  upon  too  much,  and  that  the  threads  will  not  be 
in  contact  with  the  blood  in  the  lumen  of  the  artery.  Greater  care 
must  be  exercised  in  securing  accurate 
coaptation  in  this  class  than  in  the 
fusiform  type.  As  shown  in  Figs.  410 
and  411,  it  will  be  advantageous  to 
begin  the  line  of  suture  at  some  dis- 
tance from  the  orifice,  as  this  will 
secure  a  broader  and  stronger  line  of 
approximation. 

5.  Removal  of  constrictor  and  test  of 
sutures. — The  interior  of  the  cavity 
should  now,  if  all  visible  orifices  in  the 
sac  have  been  closed  by  suture,  be 
perfectly  dry.  If  any  oozing  persists, 
this  will  be  stopped  by  pressure  or 
by  the  means  subsequently  adopted  to 
obliterate  the  sac* 

6.  Obliteration  of  the  sac. — This  step 
is  the  same  in  all  cases  (Figs.  413,  414, 
and  415).  In  large  sacs,  where  there 
is  an  abundance  of  material,  it  will  be 
well  to  reinforce  the  first  line  of  occlu- 
sive sutures  by  a  second  row,  applied 
also  on  the  Lembert  plan  at  a  higher 
level.  This  second  row  will  raise  up 
and  bring  together  a  considerable  sur- 
face of  the  floor  and  lateral  walls  of 
the  sac,  and  will  not  only  bury  the  first 
row  of  sutures,  but  will  reduce  the 
dimensions  of  the  sac  considerably 
(Fig.  413).  The  closure  of  the  sac  is 
now   readily  accomplished  by  turning 

the  relaxed  flaps  of  skin  into  the  cavity.  If  the  sac  has  not  been 
previously  dissected  from  its  surroundings,  the  skin  flaps  will  be  lined 
by  smooth  sac  walls,  and  can,  as  a  rule,  be  made  to  touch  the  bottom 
of  the  cavity  with  comparative  ease.     One  or  two  relaxation-sutures, 

*  In  a  case  of  Dr.  Gessner's,  of  New  Orleans  (Ann.  of  Surg.,  January,  1905,  p.  115), 
of  popliteal  aneurysm,  in  which  the  two  openings  had  been  sutured,  removal  of  the  con- 
strictor was  followed  by  the  escape  of  arterial  blood  above,  showing  either  that  the  closure 
was  defective  or  that  some  collateral  had  escaped  detection.  Complete  hajmostasis  was 
effected  by  a  Lembert's  suture,  taking  up  at  least  an  inch  of  the  sac  wall  on  either  side. 
Thus  the  walls  of  the  sac  were  brought  together  directly,  instead  of  being  turned  in  on 
themselves  (vide  mfra). 


This  shows  the  completed  oblitera- 
tion of  the  orifice  of  the  sac  in  a  sacci- 
form aneurysm.  If  the  suture  has  been 
properly  applied,  the  hasmostasis  will 
be  complete,  and  the  circulation  in  the 
main  artery  restored.  The  insertion  of 
the  second  row  of  protective  sutures 
(Fig.  413),  and  the  other  details  of  the 
technique  of  the  obliteration  of  the 
sac  (Figs.  414  to  416)  should  be  carried 
out  precisely  as  in  dealing  with  aneu- 
rysms of  the  fusiform  type.     (Matas.) 


g86 


OPKKATIOXS    ()N    TIIK    LOWEB    EXTREMITY. 


best  applied  with  a  large  fully  curved  needle,  will  usually  suffice  to  hold 
down  the  skin  Haps  in  contact  with  the  bottom  and  sides  of  the  sac. 
Through  the  entire  thickness  of  this  the  needle  should  usually  pene- 
trate. '  By  carrying  it  through  in  this  way  a  loop  is  funned,  the  two 
ends  o\'  which  are  carried  through  the  skin  flaps  by  transfixion  with  a 
straight  Reverdin's  needle,  and  tied  firmly  over  a  loose  pad  of  gauze 
(Figs.  415  and  416).  After  the  relaxation-sutures  have  been  tied  a  few- 
sutures  should  complete  the  approximation  of  the  edges  of  the  skin. 

Fig.  413. 


This  shows  the  second  row  of  sutures,  a  technical  detail  which  is  advan- 
tageous, but  not  necessary  in  every  case.  The  first  row  has  been  completed,  and 
the  arterial  orifices  have  been  obliterated.  As  the  walls  of  the  sac  are  usually 
relaxed,  it  is  easy  to  insert  a  second  row  of  sutures,  which  add  security  to  the  first, 
ami,  in  addition,  reduce  the  size  of  the  cavity  to  be  obliterated  by  inversion  of 
the  skin  and  surplus  sac  walls  at  a  later  stage.  This  second  row  is  applied,  as  in 
the  case  of  the  first,  by  either  the  continued  or  interrupted  method,  with  a 
curved  needle  and  Nos.  i,  2,  or  3  chromic  catgut.  A  large  surface  is  thus  brought 
into  apposition,  and  the  best  opportunity  given  for  plastic  endarteritis.  If  the 
floor  of  the  sac  is  too  rigid,  or  too  adherent  to  the  underlying  parts,  this  second 
row  may  be  omitted,  and  the  obliteration  of  the  sae  undertaken.     (  Matas.) 


Instead  of  a  bulging  swelling,  there  will  he  a  depression  varying  in 
depth.     There  is  no  need  for  drainage. 

In  operations  upon  abdominal  aneurysms  the  peritoneum  should  be 
left  adherent  to  the  sac,  and  is  utilised  in  place  of  the  skin.  In  cases  of 
deep-seated  aneurysms  of  the  extremities  or  neck,  in  stout  or  muscular 
patients,  where  the  vitality  of  the  skin  might  be  imperilled  by  over- 
stretching in  the  efforts  to  make  it  meet  the  bottom  of  the  sac,  1  >r.  MataS 
advises  that  the  sac  should  be  obliterated  by  its  own  walls.  After  the 
tying  of  the  second  or  protective  row  of  sutures  (Fig.  413)  the  excess 
of  the  wall  remaining  above  this  row  is  excised,  and   the    edges  of  the 


\l  ATAS's   OPERATION. 
Fig.  414. 


987 


To  show  the  method  of  obliteration  after  the  floor  of  the  sac  has  been  raised 
by  the  second  row  of  sutures.  Two  deep  supporting  and  obliterating  sutures  of 
chromic  catgut  are  inserted  through  the  floor  of  the  sac  on  each  side.  The 
number  of  these  will  vary  with  the  size  and  length  of  the  sac.  In  the  smaller 
aneurysms  one  of  the  deep  sutures  on  each  side  will  suffice  ;  in  others  two  or 
more  may  be  required  to  keep  the  surfaces  in  close  contact.  After  the  sutures 
are  passed  through  the  floor  of  the  sac  the  free  ends  of  the  threads  are  carried 
through  the  entire  thickness  of  the  flap  by  transfixion.  The  figure  shows  the 
mode  of  placing  these  sutures  on  the  left  side  preparatory  to  transfixion  of  the 
flap.  The  two  sutures  on  the  right  side  have  been  carried  through  a  flap,  and  are 
in  position.     (Matas.) 


Fig. 


4i5- 


To  show  the  deep  supporting  sutures  in  position  and  the  details  of  transfixion 
of  the  flaps.  The  Reverdin  needle  is  used  to  carry  the  free  ends  of  the  sutures 
through  the  flaps  formed  by  the  skin  and  walls  of  the  aneurysm.     (Matas.) 

sac  itself  approximated   with    catgut  sutures.      The   wound   is    then 
closed   by  rows  of  buried  sutures. 

With  regard  to  atheroma,  Dr.  Matas  is  of  opinion  that,  with  the 
advantages  of  aseptic  surgery,  the  fear  that  degenerative  changes  will 


,,SS 


OPERATIONS   ON    TH  K    LOWEB    EXTREMITY. 


interfere  with  repair  of  the  arterial  tunics  lias  been  proved  to  be 
greatly  exaggerated. 

Dr.  Matas's  third  and  fourth  cases,  in  which  the  aneurysms  were 
the  result  of  disease,  prove  that  the  orifices  into  such  aneurysms  can 
be  successfully  sutured.  How  far  the  rigidity  of  such  diseased  walls 
may  sometimes  interfere  with  the  later  steps  of  his  operation,  and 
necessitate  partial  plugging  with  gauze,  time  will  show. 

Dr.  Matas  contrasts  the  dangers  of  the  method  of  Antyllus  and  that 

Fig.  41G. 


To  show  the  operation  completed.  In  this  figure  only  two  supporting  sutures 
are  shown  on  each  side  instead  of  the  four  shown  in  some  of  the  others.  The 
skin  and  walls  of  the  sac  form  two  lateral  flaps  on  each  side  of  the  incision,  and 
readily  fall  to  the  bottom  of  the  Bac,  thus  lining  and  obliterating  the  entire 
cavity.  A  series  of  absorbable  interrupted  sutures  bring  the  edges  of  the  skin  into 
contact,  several  of  these  including  the  floor  of  the  sac  in  their  bite  (as  shown  in 
cross-section,  Fig.  417),  so  as  to  close  the  space  entirely  in  the  middle  line.  The 
two  lateral  supporting  sutures  are  tied  firmly  over  email  mils  of  sterile  gauze. 
thus  bringing  all  the  interior  of  the  sac  into  apposition.     (Matas.) 


of  extirpation  of  the  sac  with  the  safety  of  his  own  technique.  In  the 
method  of  Antyllus,  preliminary  ligature  of  the  main  artery  above  and 
below  the  sac  will  not  always  control  the  bleeding  from  the  collaterals, 
which  often  open  into  the  aneurysm  or  into  the  main  trunks  between 
the  orifices  in  the  sac  and  the  seats  of  ligature.  In  order  to  Becure 
all  the  collaterals,  a  more  or  less  extensive  dissection  of  the  sac  would 
be  usually  rendered  necessary  unless  the  uncertain  process  of  plugging 
the  openings  and  the  sac  is  resorted  to.  By  the  above  dissection  the 
difficulties  of  the  operation  are  much  increased,  and  the  vitality  of  the 
limb  endangered,  by  the  interference  with  the  collateral  circulation, 
which,  in  many  cases,  is  most  freely  developed  in  the  neighbourhood 


MATAS'S    OPKIIATIo.Y 
Fig.  417. 


989 


A  sectional  diagram  showing  the  method  of  obliterating  the  aneurysmal  sac 
in  the  fusiform  type  with  two  openings.  In  this  class  of  cases  (Fig.  407)  the 
tunics  of  the  artery  blend  with  the  sac,  and  the  arterial  channel  cannot  be 
restored.  The  diagram  shows  the  first  row  of  sutures  (1)  which  obliterate  the 
orifice  of  the  artery  at  the  bottom  of  the  sac.  The  second  row  (2)  is  shown 
higher  up,  and  also  the  effect  of  this  row  in  reducing  the  capacity  of  the  sac. 
The  obliteration  of  the  remaining  part  of  the  cavity  by  the  folding  in  of  the  sac 
walls,  with  the  attached  overlying  skin,  is  shown  in  (3).  The  function  of  the 
deep  sutures  (4)  tied  over  gauze  rolls  and  of  the  more  superficial  skin  sutures  (5) 
in  obtaining  firm  contact  of  the  opposed  surfaces  is  also  shown.     (Matas.) 

Fig.  418. 


A  diagram  showing  a  sectional  view  of  the  obliterated  sac  in  the  sacciform 
type  of  aneurysm  when  the  lumen  of  the  artery  is  preserved,  and  the  vessel 
originally  communicates  with  the  aneurysm  by  a  single  orifice.  1,  First  row  of 
sutures,  which  close  the  orifice  of  communication,  and  restore  the  lumen  of  the 
parent  vessel.  2,  Second  row  of  protecting  sutures,  which  also  reduce  the  size  of 
the  sac.  3,  Supporting  through-and-through  sutures,  which  bring  the  roof  and 
floor  of  the  aneurysm  into  contact.  4,  Sutures  which  hold  the  skin  flap  in  contact 
with  the  bottom  of  the  cavity.  This  diagram  will  also  show  the  result  of  the 
procedure  illustrated  in  Figs.  411  and  412. 

of  the  sac.  Another  serious  objection  is  that  the  sac,  packed  or 
drained,  has  to  heal  by  granulation,  thus  inviting  infection  and  secondary 
haemorrhage. 


990 


OPERATIONS   ON    TIIK    LOWEB    EXTREMITY. 

in..  419. 


This  shows  a  method,  suggested  by  Dr.  Matas  as  possible,  but  not  yet  tried,  of 
restoring  the  large  lumen  of  the  artery  in  cases  of  fusiform  aneurysm,  with  two 
openings,  where  the  healthy  and  flexible  character  of  the  sac  will  permit  of  the 
restoration  of  the  arterial  channel  by  lifting  up  two  lateral  folds  of  the  sac  and 
bringing  them  together  by  suture  over  a  soft  rubber  catheter.  The  principle 
of  this  operation  is  precisely  like  that  of  a  Witzel's  gastrostomy.  The  Bofl 
catheter  is  seen  lying  on  the  floor  of  the  sac,  and  inserted  in  the  two  orifices  of 
communication.  The  sutures  are  placed  while  the  catheter  is  in  position,  acting 
as  a  guide. 

Fig.  420. 


This  Bhows  a  more  advanced  stage  of  the  procedure  in  Fig.  420.  The  Butnrea 
arc  nearly  all  tied,  and  the  new  channel  is  completed  except  in  the  centre.  The 
two  middle  sutures  are  hooked  out  of  the  way  while  still  in  position,  and  the 
catheter  is  withdrawn.  The  obliteration  of  the  sac  and  the  final  steps  of  the 
operation  are  carried  out  as  in  Figs.  413,  416. 


MATAS'S    OPERATION.  ggi 

Extirpation  of  the  sac  is  accompanied  by  uncertainties  and  dangers 
even  greater  than  those  met  with  in  the  method  of  Antyllus,  owing  to 
the  greater  risk  of  injury  to  the  veins  and  nerves,  and  the  interference 
with  the  collateral  circulation,  and  the  risk  of  gangrene  is  here 
greater  still. 

Four  cases  illustrate  Dr.  Matas's  paper,  two  of  traumatic  aneurysm 
of  the  brachial;  one  of  the  popliteal,  sacciform;  and  one,  fusiform, 
of  the  femoral  artery.  All  were  successfully  treated  by  his  method. 
The  oldest  patient  was  forty-five. 


CHAPTER  VI. 
OPERATIONS    ON    THE   LEG. 

LIGATURE  OF  POSTERIOR  TIBIAL  ARTERY.— LIGATURE 
OP  ANTERIOR  TIBIAL  ARTERY.— LIGATURE  OP  PERO- 
NEAL ARTERY.— AMPUTATION  OP  LEG.— OPERATION 
FOR  NECROSIS.— TREATMENT  OP  COMPOUND  FRAC- 
TURE.—OPERATIONS  FOR  SIMPLE  FRACTURE.— OPERA- 
TIONS   ON  VARICOSE    VEINS. 

LIGATURE    OP    THE    POSTERIOR    TIBIAL    ARTERY. 

Indications. — Very  few.     i.  Chiefly  wounds.    Mr.  Cripps,*  in  a  very  valuable  paper, 

divides  the  sources  of  hemorrhage  from  the  upper  two-thirds  of  the  posterior  tibial  into 
(i)  haemorrhage  after  amputation  ;  (2)  haemorrhage  from  injury  to  the  vessels  in  con- 
tinuity. (1)  Haemorrhage  after  amputation. — This  is  usually  due  to  a  diseased  condition 
of  the  vessels,  and  to  the  fact  that  the  vessels  lying  between  the  bones  are  now  especially 
difficult  to  take  up.  If  from  their  constantly  breaking  away  it  is  found  impossible  to 
deal  with  them,  the  limb  should  at  once  be  amputated  above  the  knee.  If  the  haemor- 
rhage occurs  later  on,  well-adjusted  pressure  (p.  926)  should  be  carefully  tried,  aided  or 
followed  by  ligature  of  the  femoral  or  by  amputation  higher  up.  (2)  Haemorrhage  from 
wounds  of  the  tibials  in  continuity. — Three  chief  causes  may  lead  to  this  :  («.)  An  incised 
wound,  (b)  A  punctured  wound,  (c)  Wounds  other  than  punctured  or  incised.  Four 
methods  of  treatment  are  open  to  the  surgeon — viz.,  («)  Pressure  and  bandaging. 
(h)  Ligature  of  both  ends  of  the  vessel,  (r)  Ligature  of  the  femoral.  (d)  Amputation. 
(#)  Incised  Wound. — If  this  is  seen  soon  after  its  infliction,  the  bleeding  point,  should 
be  sought  for  and  tied,  the  wound  being  enlarged  if  needful.  If  sloughing  and  extra- 
vasation of  blood  have  taken  place,  amputation  will  probably  be  the  wiser  course,  though, 
if  the  patient  decide  to  run  the  risk,  an  attempt  may  be  made  to  save  his  Limb  by  making 
free  incisions,  providing  drainage,  plugging  the  wound  (rendered,  as  Ear  as  may  be,  aseptic 
with  irrigation  and  iodoform)  with  aseptic  gauze,  bandaging  evenly  and  firmly,  and  tying 
the  femoral  in  Hunter's  canal.  (&)  Punctured  Wound.  If  this  is  deep,  and  the  vessel 
injured  uncertain,  the  question  of  treatment  is  a  very  serious  one.+  Mr.  Cripps  shows 
that,  in  the  majority  of  instances,  pressure  deserves  a  fair  and  thorough  trial.  If  it  is 
useless,  or  prejudicial  to  other  treatment, either  the  femoral  must  lie  tied,  or  the  wound 
enlarged  to  secure  the  wounded  vessel.  Between  these  operations  the  features  of  the 
particular  case  must  decide.  If  pressure  is  made  use  of.  it  should  be  applied  methodi- 
cally and  with  intelligent  purpose  (p.  926),  and  bo  thai  it  needs  no  alteration  or  repetition. 

*  St.  Barthol.  Ifo.sp.  Reports,  vol.  xi.  p.  94  :  Diet,  of  Surg.,  vol.  ii.  p.  626. 

■j"  Where  the  wound  has  passed  obliquely,  Dupuytren's  words  Bhould  be  remembered. 
They  refer  to  haemorrhage  from  the  calf  caused  by  a  pistol-bullet.  "Should  a  ligature 
be  placed  on  the  ends  of  the  divided  vessel.'     But  what  wi  vessels.'     Was  it  the 

anterior  or  posterior  tibial,  or  the  peroneal  or  the  popliteal  ?  Was  it  several  of  them  at 
the  same  time?     Should  they  be  attacked  before  or  behind  .' " 


LIGATURE   OF   THE    POSTERIOB    TIBIAL    ARTERY. 

(r)  Wounds  other  than  Punctured  or  Incised  viz.,  Injury  to  the  Vessel  from  Fracture  or 
Gunshot  Won  ml.  In  main  cases  conditions  willbepresenl  which  will  call  for  amputation— 
vi/...  the  severity  of  the  crush  j  the  extent  of  the  comminution  ;  injury  to  the  nerves  or  to 
both  arteries,  as  evidenced  by  the  condition  of  the  fool  :  and  the  age  or  the  vitality  of 


Anterior  tibial  recurrent . 


Posterior  tibial 


Tibia 


Fig.  421. 

Diagram  of  the  colla- 
teral branches  and  arte- 
rial communications  in 
the  leg  and  at  the  ankle. 
(MacCormac.) 


Internal  malleolar 

Internal  calcanean 

Posterior  internal  malleolar 

Internal  plantar 

External  plantar 

Scaphoiil  bone 


Popliteal. 


I  iliial. 

Post  ei  lor  tibial  recurrent 
Supei  lor  fibular. 


Fibula. 


.   Peroneal. 


Anterior  peroneal. 
Posterior  peroneal. 

Communicating. 


External  malleolar. 

Astragalus. 

External  calcanean  branch. 

Calcaneum. 


the  patient.  In  most  of  these  cases,  as  an  attempt  to  find  the  vessel  involves  great 
difficulty  and  danger,  and  the  probabilities  of  success  diminish  as  the  interval  between 
the  infliction  and  treatment  of  the  injury  increases,  ligature  of  the  femoral  would  be 
less  hazardous  than  any  interference  with  the  wound.  But  amputation  will  frequently  be 
nee  led.  The  above  remarks  apply  to  compound  fractures  ;  an  instance  of  successful  ligature 
S. VOL.  II.  63 


994 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


Inside. 

Vena  comes. 
Posterior   tibial   nerve 
(above). 


of  a  lacerated  femoral  co-existing  with  a  compound  fracture  of  the  leg  is  given  at  p.  921. 
ii.  Small  traumatic  aneurysms,  iii.  The  posterior  tibia]  may  be  tied  low  down,  together 
with  the  dorsalis  pedis,  for  certain  wounds  of  the  sole  or  for  some  vascular  growths  of 
the  foot. 

Line  and  Guide. — Aline  drawn  from  a  point  at  the  lower  part  of  t lie 
centre  of  the  popliteal  space  to  one  midway  between  the  tendo  Achillis 
and  the  internal  malleolus. 

Relations. — These  differ  according  as  the  vessel  is  tied — (A)  in 
the  middle  of  the  leg,  (B)  in  the  lower  third  of  the  leg,  (C)  at  the  inner 
ankle. 

A.  Relations  in  the  Middle  of  the  Leg  ; 

Superficial. 
Skin ;  fascise  ;  branches  of  saphenous  veins  and  nerves. 
Gastrocnemius  ;  soleus  ;  plantaris. 
Special  fascia  ;  transverse  branches  of  vense  comites  ; 
tendinous  origin — arch — of  soleus  (above). 

Outside. 

Vena  comes. 
Posterior  tibial  nerve 

which   has    crossed  Posterior  tibial. 

above      from      the 

inner  side. 

Beneath. 

Flexor  longus  digitorum. 
Tibialis  posticus. 

B.  Relations  in  Lower  Third  of  Leg  ; 

Superficial. 
Skin  ;  fascias  ;  superficial  veins  and  nerves. 
Outside.  Inside. 

Vena  comes.  Vena  comes. 

Posterior  tibial  nerve.  Posterior  tibial. 

Tendo  Achillis. 

Beneath. 
Flexor  longus  digitorum. 
Tibia. 

C.  Relations  at  Inner  Ankle  : 

Superficial. 
Skin ;    fasciae ;    branches   of  internal  saphena  vein 

and  nerve. 
Internal  annular  ligament. 

Outside. 


Vena  comes. 

Flexor  longus  hallucis. 

Posterior  tibial  nerve. 


Posterior  tibial. 

Beneath. 
Internal  lateral  ligament. 


Inside. 

Vena  comes. 

Flexor  longus  digi- 
torum ;  tibialis 
posticus. 


LIGATURE   OF   THE   POSTERIOR   TIBIAL   ARTERY.         995 

Operation  in  Middle  of  Leg  (Figs.  422  and  423). 

The  parts  having  been  sterilised,  the  knee  flexed,  and  the  limb  sup- 
ported on  its  outer  side,  the  surgeon,  standing  or  sitting  on  the  inner 
side,  makes  an  incision  three  and  a  half  inches  long,  parallel  with  the 
centre  of  the  inner  border  of  the  tibia,  and  half  or  three-quarters  of  an 
inch  behind  it,  according  to  the  size  of  the  limb.     This  incision  divides 


Fig.  422. 


Ligature  of  the  posterior  tibial  artery.     (Heath.) 

A,  Incision  for  ligature  of  the  artery  in  the  leg. 

B,  Incision  for  ligature  of  the  artery  at  the  inner  ankle. 

1,  Gastrocnemius.     2,  Flexor  longus  digitorum.     3,  Soleus.     4,  Tibialis  posticus. 
5,  Posterior  tibial  artery.     7,  Posterior  tibial  nerve.     9,  Tendo  Achillis. 

skin  and  fasciae.  If  the  internal  saphenous  vein  is  met  with,  it  must 
be  drawn  aside  with  a  strabismus-hook  ;  any  of  its  branches  may  be 
divided  between  two  ligatures.  The  deep  fascia  is  then  freely  slit  up, 
and  the  inner  edge  of  the  gastrocnemius  defined  and  drawn  backwards. 
This  will  expose  the  soleus,  the  tibial  attachment  of  which  is  to  be  cut 
through,  any  sural  artery  being  at  once  secured.  The  incision  through 
the  soleus  (Fig.  422)  should  be  three  inches  long  and  quite  half  an  inch 

63—2 


996  OPERATIONS    ON    THE    LOWEB    EXTREMITY. 

from  the  tibia;  as  the  fibres  are  divided,  the  central  membranous  tendon 
will  come  into  view,  and  must  Dot  be  confused  with  the  special  deep 
fascia  or  intermuscular  septum  over  the  deep  flexors.  Usually,  before 
this  comes  into  view, some  additional  fibres  have  to  be  divided.  When 
this  is  done,  the  above  Bpecial  fascia  must  be  identified,  stretching 
between  the  bones.  The  wound  must  be  carefully  dried,  well  opened 
out  with  retractors,  and  exposed  with  a  good  light  at  this  stage.  The 
deep  fascia  being  opened  carefully,  the  nerve  usually  comes  into  view 
first,  the  artery  Lying  a  little  deeper  and  more  external.  The  vens 
<•.. mites  should  be  separated  as  far  as  possible,  but  rather  than  puncture 
them  and  cause  haemorrhage  at  this  stage,  or  waste  time,  the  Burgeon 
should  tie  them  in.  The  needle  should  be  passed  from  the  nerve.  To 
facilitate  this,  the  knee  should  be  well  flexed,  and  the  foot  also  flexed 
downwards  so  as  to  relax  the  muscles  thoroughly.  The  ligature  will 
lie  below  the  peroneal  artery. 

Fig.  423. 


Ligature  of  the  posterior  tibial  at  the  middle  of  the  calf.  The  inner  head  of 
the  gastrocnemius  is  drawn  backwards  by  retractors.  The  loft  index  raises 
the  anterior  lip  of  the  wound  while  the  soleus  is  divided  perpendicularly  to  its 
surface.     (Farabeuf.) 

Operation  in  Lower  Third  of  Leg. — The  limb  and  the 
operator  being  in  the  same  position  as  before,  an  incision  two  and  a 
half  inches  long  is  made  through  skin  and  fascia?,  parallel  with  the 
inner  border  of  the  tibia,  and  midway  between  it  and  the  tendo 
Achillis  ;  after  the  deep  fascia  has  been  opened  another  layer,  tying 
down  the  deep  flexor  tendons,  will  require  division.  The  artery  here 
lies  between  the  flexor  longus  digitorum  and  pollicis,  surrounded  by 
vense  comites.  The  needle  should  be  passed  from  the  nerve,  which 
lies  to  the  outer  side.  If  the  incision  is  made  too  high,  some  of  the 
lowest  fibres  of  the  soleus  will  require  detaching  from  the  tibia;  if 
too  low,  the  internal  annular  ligament  would  be  opened.  The 
sheaths  of  the  flexors  (their  synovial  investment  commences  about 
an  inch  and  a  half  above  the  internal  malleolus)  should  not  be 
interfered   with. 

Operation  at  the  Inner  Ankle  (Fig.  422). — The  limb  and  operator 
being  placed  as  before,  a  curved  incision,  two  inches  long,  is  made, 
three-quarters  of  an  inch  behind  the  internal  malleolus.  Skin  and 
fascia?  being  divided,  any  branches  of  the  internal   saphena  vein  tied, 


LIGATURE   OF   THE   ANTERIOR   TIBIAL.  997 

the  internal  annular  ligament  is  divided,  and  the  artery  found  closely 

surrounded  by  its  veins.  The  nerve  lies  externally,  and  the  needle 
should  be  passed  from  it.  The  artery  is  so  superficial  here  that  the 
veins  can  he  easily  separated.  The  nerve  has  occasionally  bifurcated 
higher  up. 

LIGATURE    OF    THE    ANTERIOR    TIBIAL. 

Indications. — These  are  very  few,  and  resemble  so  closely  those 
already  given  for  the  posterior  tibial — viz.,  wounds  and  traumatic 
aneurysm — that  there  is  no  need  to  go  into  them  again  here. 

In  the  course  of  1887,  I  had  occasion  to  tie  the  anterior  tibial  in  its 
lower  third  for  profuse  haemorrhage  from  a  compound  fracture,  not 
arrested  by  pressure. 

There  was  a  compound  comminuted  fracture  of  the  right  leg,  in  the  lower  third,  from 
a  fall  of  4  cwt.  upon  the  limb.  The  upper  end  of  the  artery  was  found  with  some 
difficulty,  owing  to  the  pulped  condition  of  the  soft  parts.  Having  failed  to  find  the  lower 
end,  I  was  about  to  expose  the  dorsalis  pedis,  and  trusting  to  antiseptic  precautions,  trace 
this  up  to  the  anterior  tibial,  when,  an  urgent  strangulated  hernia  being  admitted,  I 
plugged  the  wound,  all  the  undermined  parts  being  previously  laid  freely  open.  No 
recurrence  of  bleeding  took  place,  and  the  man  (aged  44)  made  an  excellent  recovery, 
aided  by  his  temperate  life  and  patience,  and  the  freedom  with  which  the  wound  was 
laid  open. 

Dr.  Shepherd,  of  Montreal  (Ann.  of  Surg.,  No.  1.  p.  7),  gives  another, 
but  more  difficult,  case  in  which  the  compound  fracture  was  about  the 
junction  of  the  middle  with  the  upper  third  of  the  leg. 

The  bleeding  was  first  arrested  by  pressure.  On  the  fourth  day  a  traumatic  aneurysm 
appeared.  The  artery  was  exposed  with  difficulty,*  and  found  partly  divided;  two 
ligatures  were  applied,  and  the  patient  made  a  good  recovery. 

Line  and  Guide. — From  a  point  midway  between  the  head  of  the 
fibula  and  the  outer  tuberosity  of  the  tibia  to  the  centre  of  the  front  of 
the  ankle-joint;  the  outer  edge  of  the  tibialis  anticus. 

Relations  : 

Superficial. 

Skin  ;    fasciae ;    cutaneous    branches    of   saphenous 

veins  and  nerves,  and  (below)   musculocutaneous 

nerve. 
Tibialis    anticus    and    extensor    longus    digitorum 

(above),  overlapping. 
Tibialis  anticus  and  extensor  longus  hallucis  (below), 

overlapping. 

*  Dr.  Shepherd  points  out  that,  the  injury  to  the  vessel  being  just  in  front  of  the 
place  where  it  pierces  the  interosseous  membrane,  if  the  artery  had  been  completely  torn 
through  it  would  have  retracted  through  the  opening,  and  ligature  would  have  been 
impossible.  Mr.  F.  Page  {Lancet,  1887,  vol.  i.  p.  522)  gives  a  case  of  traumatic  aneurysm 
of  ten  weeks'  duration,  after  a  stab,  at  the  junction  of  the  middle  and  lower  thirds  of  the 
leg.  The  swelling  had  been  poulticed  and  opened,  with  the  result  of  haemorrhage. 
Mr.  Page,  on  clearing  out  the  clots  and  opening  up  the  swelling,  was  unable  to  find  the 
anterior  tibial  artery.  Haemorrhage  recurring,  the  leg  was  amputated.  The  patient 
recovered. 


998 


OPERATIONS   ON   THE    LOWEB    EXTREMITY. 


Outside.  Anterior  tibial  artery.  Inside. 

Extensor  longua  digitoram  (above).  Tibialis  anticus. 

Extensor  longus  hallucis  (below).  Vein. 

Anterior  tibial  nerve. 
Vein. 

Beneath. 
Interosseous  membrane 

Operation  at  the  Junction  of  the  Upper  and  Middle  Thirds  of 
Leg  (Figs.  424,  425). — The  knee  being  flexed  and  the  limb  supported 
npon  its  inner  side,  the  surgeon  having  defined,  if  possible,  the  outer 
edge  of  the  tibialis  anticus,*  sits  or  stands  on  the  outer  side  of  the 
patient,  and  makes  an  incision  about  four  inches  long  in  the  line  of  the 
artery,  beginning  about  two  inches  below  the  head  of  the  tibia.  This 
incision  should  lie  (if  the  edge  of  the  muscle  has  not  been  marked  out) 


Fig.  424. 


Ligature  of  the  anterior  tibial  artery  at  the  junction  of  the  middle  and 
upper  thirds;  division  of  the  deep  fascia  an  a  director  (p.  1000).  The  leg  is 
generally  flexed.     (Farabeuf.) 

three-quarters  to  one  inch — according  to  the  size  of  the  leg — from  the 
crest  of  the  tibia,  and  should  expose  the  deep  fascia  carefully,  so  that 
the  white  line  which  marks  the  desired  intermuscular  septum  may  be 
looked  for.  This  line  is  often  whitish-yellow,  and  varies  much  in  dis- 
tinctness. If  there  is  any  difficulty  in  finding  it,  any  bleeding  points 
must  be  secured,  and  the  deep  fascia  slit  up  over  the  line  of  the  artery,  and 
the  finger-tip  inserted  to  feel  for  the  sulcus  between  the  muscles.  A 
third  aid  is  almost  constant,  and  that  is  a  small  muscular  artery t  which 
comes  up  between  the  tibialis  and  the  extensor  longus  digitorum.  The 
sulcus  being  found  between  the  muscles  (without  tearing  them),  they 
are  separated  with  the  handle  of  a  scalpel  or  a  Bteel  director,  and 
retractors  inserted,  the  outer  one  being  hooked  over  the  fibula.  If  the 
limb  is  a  very  muscular  one,  the  deep  fascia  should  be  nicked  trans- 
versely at  the  upper  and  lower  extremities  of  the  wound,  and  the  parts 
more  relaxed  by  bending  the  knee  more  and  pressing  the  foot  upwards. 

*  The  patient  may  put  this  into  action  just  before  the  anaesthetic  is  taken. 
t  This  was  pointed  out  by  Mr.  C.  Heath  (Oper.  dttrg.,  p.  47).     I  have  found  the  same 
fact  most  helpful  in  the  ligature  of  the  ulnar  in  the  middle  third  of  the  forearm. 


IJOATlllK    OK   TIIK    ANTERIOB    TIBIAL. 


999 


The  finger,  now  directed  towards  the  interosseous  space,  feels  for  the 
artery  deep  down  in  the  bottom  of  the  wound.     The   nerve  should  be 


Fig.  425 


Ligature  of  the  anterior  tibial  artery.     (Heath.) 

A  and  B,  Incisions  for  ligature  of  the  anterior  tibial  artery. 

C,  Incisions  for  ligature  of  the  dorsalis  pedis  artery. 

1,  Extensor  longus  digitorum.     2,  Anterior  tibial  vessels  and  nerve.     3,  Extensor 

proprius  hallucis.      4,  Tibial  anticus.      5,  Peroneus  tertius.      6,  Anterior  tibial 

nerve.     7,  Dorsalis  pedis  artery. 

drawn  to  the  outer  side.    If  much  trouble  is  met  with  in  separating  the 
venae  comites,  they  may  be  included. 

In  a  case  which   still  presents  difficulties  the  following  directions  of 


iooo  OPERATIONS   ON   THE    LOWEB    EXTREMITY. 

M.  Farabeuf  may  be  useful  (Man.  Oper.}  p.  89):  The  two  lips  of  the 
wound  having  been  separated,  the  deep  fascia  is  opened  close  to  the 
inner  lip  and  the  grooved  director  introduced  beneath  it,*  and  pushed 
across  gently  until  its  tip  is  arrested  by  the  firsl  intermuscular  interval 
and  septum,  that  between  the  tibialis  anticus  and  the  extensor  digi- 
torum.  If  the  operator  pushes  it  too  far  it  will  be  arrested  by  the 
better-marked  septum  between  the  peromei  and  extensors.  In  cutting 
upon  it  the  operator  will  have  crossed  the  desired  interval. 

Operation  at  the  Junction  of  the  Lower  and  Middle  Thirds  of  Leg 
(Fig.  425,  n). — An  incision  about  two  inches  and  a  half  long  is  made  in 
the  line  of  the  artery;  in  the  upper  part,  this  incision  will  be  about  one 
inch  from  the  tibia.  The  white  line  and  the  interval  between  the 
tibialis  anticus  and  the  extensor  proprius  hallucis  are  both  looked  and  felt 
for.  The  deep  fascia  being  divided  and  the  muscles  relaxed  and  retracted, 
the  artery  is  found  surrounded  by  its  ven?e  comites.  The  needle  must 
be  passed  from  without  inwards. 

LIGATURE   OF  THE   PERONEAL  ARTERY. 

Indications. — As  these  are  extremely  few,  and  as  in  the  case  of  a 
wound  of  the  vessel  (which  is  very  rarely  met  with)  the  best  course 
would  be  to  enlarge  the  wound,  any  formal  operation  for  its  ligature 
need  only  be  very  briefly  described. 

Relations. — The  peroneal  artery  comes  off  from  the  posterior  tibial 
about  one  inch  below  the  popliteus,  descends  at  first  parallel  with  this 
artery  but  separated  from  it  by  the  posterior  tibial  nerve  ;  it  then  passes 
outwards  towards  the  fibula,  and  runs  down  between  this  bone  and  the 
flexor  longus  hallucis.  In  the  upper  part  of  its  course  it  lies  upon  the 
tibialis  posticus,  and  is  covered  by  the  soleus. 

Operation. — To  tie  the  artery  when  no  wound  is  present  to  guide  the 
surgeon,  an  incision  three  inches  long  should  be  made  along  the  posterior 
border  of  the  fibula,  with  its  centre  at  the  junction  of  the  upper  and 
middle  thirds  of  the  leg.  The  gastrocnemius  being  drawn  aside,  and 
the  soleus  separated  from  its  attachment  to  the  fibula,  the  special  deep 
fascia  is  slit  up  and  the  artery  sought  for  close  to  the  fibula. 

AMPUTATION   OF   THE  LEG. 

Different  Methods  (Figs.  426 — 432). 

1.  Lateral  Flaps  (Figs.  426 — 429).  2.  Teale's  Rectangular  Flaps 
(Figs.  430 — 432).  3.  Antero-posterior  Flaps  of  Skin.  4.  Antero- 
posterior Flaps,  Anterior  of  Skin,  Posterior  by  Transfixion  of  Muscle. 
5.  Circular. 

I  shall  only  describe  the  first  two,  as  they  will  be  found  adapted  to  all 
emergencies,  and  to  be  devoid  of  the  disadvantages  of  the  others. 

1.  Lateral  Skin  Flaps,  with  Circular  Division  of  the  Muscles,  &c. 
— This  is,  I  believe,  a  method  not  well  known  beyond  Guy's  Hospital  and 
those  who  have  been  taught  there.  It  will  not  only  be  found  most  con- 
venient at  the  time,  but  it  also  gives  very  satisfactory  results  afterwards. 

*  Though  in  Fig.  424  M.  Farabeuf  figures  the  director  introduced  from  without,  he 
directs  that  it  be  passed  as  described  above  and  figui'  .mother  illustration. 


AMPUTATION    OF   THE    LEG. 


IOOI 


The  blood-supply  is  well  and  equally  distributed  to  the  lateral  flaps, 
one  can  be  conveniently  cut  longer  than  the  other,  and  they  are 
more  easily  shaped  and  disse-ted  up  than  antero-posterior  skin-flaps, 
while  no  mass  of  QlUScle  is  left  to  drag  away  from  and  expose  the  bones, 
as  in  the  antero-posterior  flaps,  with  the  anterior  of  skin  and  the 
posterior  by  transfixion. 

Operation  (Figs.  426 — 429). — The  femoral  artery  having  been  com- 
manded, the  leg  brought  over  the  table,  and  the  damaged  or  diseased 
parts  bandaged  in  sterilised  towels — so  as  to  give   the  assistant  a  firm 


Fia.  427. 


Amputation  of  the  leg  by  lateral  flaps. 
(Farabeuf.) 


Amputation  of  the  leg  by  lateral 
flaps.  The  muscles  are  being  severed 
with  circular  sweeps  of  the  knife. 


hold  and  also  to  prevent  his  soiling  the  flaps  later  on — the  opposite 
ankle  is  tied  to  the  table.  The  surgeon,  standing  to  the  right  of  the 
limb,  places  his  left  index  on  the  crest  about  an  inch  below  the  tubercle, 
and  his  thumb  at  a  corresponding  point  behind  in  the  centre  of  the 
limb.  Looking  over,  he  inserts  his  knife  close  to  the  thumb,  and  cuts 
on  the  side  of  the  limb  farthest  from  him  a  lateral  flap  broadly  oval  in 
shape  and  three  inches  long,  ending  at  the  index  finger,  from  which 
point,  without  removing  the  knife,  a  similar  flap  is  marked  out  ending 
on  the  back  where  the  first  began.*     Flaps  of  skin  and  fascia  are  now 

*  If  the  condition  of  the  soft  parts  demand  it,  not  only  can  one  lateral  flap  be  shaped 
longer  than  its  fellow,  but  antero-external  and  postero-internal  flaps  can  be  employed. 


1002 


OPERATIONS    ON    Till".    LOWEB    EXTREMITY. 


dissected  up,  and  tlie  muscles  all  cut  through  with  a  circular  swoop  of 
the  knife  at  the  intended  point  of  bone-section,  this  sweep  being 
repeated  two  or  three  times  till  the  soft  parts  are  all  cleanly  severed. 
The  posterior  muscles  should  be  cul  a  little  longer  than  those  in  front, 
owing  to  their  greater  retraction  (Figs.  428,  429).  The  interosseous 
membrane  is  next  divided,  so  that  it  shall  not  he  frayed  by  the  saw, 
and  with  one  final,  firmly  drawn,  circular  sweep  the  periosteum  is 
grooved  lor  the  saw.*  This  is  then  applied  with  the  following 
precautions.  The  position  of  the  fibula  behind  the  tibia  and  its  much 
smaller  size  must  he  remembered,  lest  it  he  splintered.  This  may  be 
avoideil  by  rolling  the  leg  well  over  on  to  the  inner  side,  and  placing 
the  saw  well  down  on  the  outer  side  so  as  to  start  the  section  of  the 
hones  simultaneously,  and  thus  ensure  complete  division  of  the  fibula 
before  the  tibia.  This  object  may  also  he  effected,  if  the  leg  is  held 
in  the  ordinary  position,  by  applying  the  saw  to  the  tibia,  and  remem- 
bering, when  this  hone  has  been  sawn  half  through,  to  depress  the 
handle,  and  thus  complete  the  section  of  the  bones  simultaneously.     In 


Fig.  428. 


Fig.  429. 


Amputation  of  thelegat  the  scat  of  election 
by  lateral  flaps,  .1  good  stump  resulting. 
(Farabeuf.) 


Amputation  of  the  leg  by  lateral 
flaps  at  tlie  seat  of  election.  The 
posterior  muscles,  cut  too  high, 
have  retracted  greatly,  and  an  agly 
conical  stump  is  the  result.  (Fara- 
beuf.) 


either  case  the  saw-  should  be  used  lightly  and  quickly,  with  the  whole 
length  of  the  blade,  and  without  jamming.  As  the  sharp  projecting 
angle  of  the  crest  tends  to  come  through  the  anterior  angle  of  the  flaps, 
this  may  be  sawn  off  obliquely  after  the  hones  are  sawn. 

Bier's  Osteoplastic  Method  of  Amputation. — 'The  following 
advantages  are  claimed  for  this  procedure  by  the  inventor  (Centr. 
f.  Chir.,  1897,  Hft.  31,  S.  834),  J.  H.  Pringle,  of  Glasgow  (Lancet, 
November  18,  1905),  and  Moscowitz,  of  New  York  (Med.  News,  February, 
1901)  : — (1)  The  patient  can  bear  his  whole  weight  on  the  stump, 
whether  this  has  been  made  through  the  bones  of  the  leg  or  the  femur, 
as  well  as  a  patient  can  do  so  after  a  Syme's  amputation.  (2)  He  can 
wear  an  artificial  limb  earlier.  Thus. Mr.  Pringle  writes:  "At  the  end 
of  four  weeks,  as  a  rule,  I  fix  a  wooden  pin-leg  to  the  stump  by  plaster 
of  Paris  bandages,  and  get  the  patient  up."  The  disadvantages  are: 
(1)  that  the  raising  the  bony  part  of  the  flap  is  not  easy:  a  suitable  saw, 

vaiiays.  with  modern  precautions,  tlie  old  need  of  periosteal  flaps — viz..  to  keep 
pus.  &c,  out  of  the  diplbe  and  medullary  canal —is   no    longer    present.      Furthermore, 
-■■  flaps  arc  very  difficult  to  raise,  unless  inflamed,  especially  in  the  thin  periosteum 
of  adults. 


WIIM  TATION    OF    TIIK    LK(I. 


r  <)«».{ 


e.g.,  a  small  one  of  the  keyhole  pattern  or  a  Gigli's  saw  set  in  a 
frame,  must  be  al  hand.  (2)  This  (hip  may  necrose  and  cause  trouble. 
i  |)   Longer  time  is  obviously  required. 

Oporation. — To  take  the  ease  of  the  leg,  flaps  are  marked  out  as 
before,  a  large  antero-internal  or  antero-external  being  preferred  by 
Bier.  Whatever  flaps  are  employed,  great  care  must  be  taken  not  to 
injure  the  periosteum  on  the  inner  side  of  the  tibia.  The  next  step 
is  the  raising  of  the  osteoplastic  flap.  A  rectangular  flap  of  periosteum 
is  marked  out  on  the  inner  side  of  the  tibia.  This  must,  be  large 
enough  to  cover  easily  the  sawn  surfaces  of  the  tibia  and  fibula,  and 
care  must  be  taken  to  cut  the  periosteum  longer  than  the  bone,  both 
at  the  sides  and  margin  of  the  flap,  so  that  it  can  be  sutured  in  place 
later  without  any  tension  on  the  pedicle  of  periosteum  which  remains 
attached  to  the  tibia.  The  cut  edges  of  periosteum  having  been  suffi- 
ciently raised,  a  thin   bony  flap  is  then  cut  out  from  the  inner  surface 


of  the  tibia  partly  with  one  of  the  saws  mentioned  above,  partly  with 
a  chisel.  Its  base  must  be  either  snapped  through  or  divided  with  a 
saw  or  chisel.  Its  pedicle  must  be  carefully  preserved  intact.  The 
soft  parts  are  next  divided,  the  bones  sawn  and  the  vessels  secured  at 
the  base  of  the  flap  or  flaps,  great  care  being  taken  not  to  injure  the 
flap  of  bone  and  periosteum.  This  is  now  carried  across  the  sawn 
surfaces  of  tibia  and  fibula  and  kept  in  place  by  sutures  of  sterilised 
silk  which  take  up  the  cut  fasciae,  tendons  and  periosteum  of  tibia  and 
fibula.  If  the  flap  be  not  large  enough  to  cover  the  cut  surface  of  the 
fibula,  this  bone  should  be  divided  again  at  a  slightly  higher  level. 
Actual  bony  union  does  not  appear  to  be  absolutely  essential  for  a  perfect 
functional  result. 

Teale's  Amputation  by  Rectangular  Flaps  (Figs.  430 — 432). — This  method  is  rarely 
employed.  In  hospital  practice,  where  amputation  of  the  leg  is  usually  called  for,  amputa- 
tion at  "the  seat  of  election,"  so  that  the  patient  can  bear  his  weight  on  parts  used  to 
pressure,  is  always  preferable,  and  lateral  flaps  give  here  the  best  results,  at  the  least 
expense  of  tissue,  and  in  the  shortest  time.  In  the  better  ranks  of  life,  where  the  patient 
can  afford  and  use  comfortably  a  well-moulded  leather  socket,*   a  longer  stump  may  be 

*  Hospital  patients  occasionally  ask  for  and  get  together  the  money,  on  the  first 
occasion,  for  one  of  these  expensive  legs.  The  well-moulded  socket  on  which  the  bearing 
of  the  weight  comfortably  depends  is  quite  unfitted  for  the  hard  wear  and  tear,  perspira- 
tions, &c,  to  which  it  will  be  submitted. 


ioo4 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


made,  here  also  by  lateral  flaps,  as  the  pressure  will  now  not  be  taken  on  the  face  of  the 
stamp,  bu1  distributed  over  the  socket. 

Advantages. — i.  The  covering  for  the  bones  is  ample,  and  the  Haps  come  together 
without  tension.*  2.  The  way  in  which  the  Haps  arc  united  favours  drainage  during  healing, 
and  provides  a  scar  well  out  of  the  way  of  pressure.     3.  The  stump  hears  pressure  well. 

Disadvantages. — 1.  It  is  an  expensive  method,  involving  a  high  section  of  the  bones. 
2.  The  long  anterior  flap  may  slough.  3.  If  performed  with  the  accuracy  of  its  introducer, 
it  involves  more  time  than  that  by  lateral  flaps  (tide  supra),  and  is,  thus,  not  suited  to 
cases  of  shock. 

Operation. — The  preparatory  steps,  and  the  position  of  the  operator  and  patient,  are 

Fig.  431. 


Fig.  432. 


Tcale. 


as  at  p.  1001.  The  surgeon  having  measured  the  circumference  of  the  limb  at  the  spoi 
where  he  intends  to  saw  the  bones,  and  placing  here  his  left  index  and  thumb  on  the  tibia 
and  fibula,  traces  ou(  a  Long  rectangular,  anterior  flap  which  is  to  be,  both  in  its  length 
and  breadth,  equal  to  half  the  above  circumference. f     In  tracing  this  Hap  the  incision 

stalls  from  the  index   finger,  runs  down  along  the  bone  farthest  from  the  BUrgt for  four 

inches  and  a  half  (if  the  circumference  at  the  site  of  bone-section  is  nine  inches),  then 

*  Save  when  infiltrated.    The  ditlieulty  of  getting  the  anterior  flap  into  position  is  then 
often  considerable. 

I    In  the  lower  third,  where  the  leg  tapers  quickly,  care  must  lie  taken  to  keep  this 
flap  of  the  same  width  heluw  as  it  is  ahove. 


SKtjUESTIlOTOMY.  1005 

crosses  the  limb,  cutting  all  the  structures  down  to  t lio  bones — this  end  of  the  flap  b 
also  four  inches  and  a  half  wide — and  then  travels  up  along  the  opposite  bone  to  the 
Burgeon's  thumb.  The  anterior  flap  is  then  dissected  up  partly  with  the  knife  r.v  .  on 
the  inner  side,  where  the  scanty  coverings  must  be  raised  as  thick  as  possible  and  without 
scoring,  partly  with  the  knife  and  partly  with  the  Auger  on  the  outer  aspect,  where  the 
extensors,  anterior  tibial  vessels,  and  nerve  must  be  stripped  up,  uninjured,  from  the 
interosseous  membrane  (Fig.  431).  The  posterior  Hap,  which  has  been  previously  marked 
1  .lit  fully  one-third  in  length  of  the  anterior,  is  now  made  by  the  surgeon  looking  over  the 
limb  and  passing  his  knife  beneath  it,  and  cutting  everything  down  to  the  hones.  It  is 
next  raised  as  high  as  the  point  where  the  hones  are  to,  he  s-awn.  The  interosseous 
membrane  and  the  hones  are  then  attended  to   with  the  precautions  given  at  p.  1002. 

The  vessels  being  secured  and  drainage  provided,  the  anterior  flap  is  folded  over  the 
bones  (can;  being  taken  not  to  double  it  too  sharply),  its  cut  end  stitched  to  the  cut  end 
of  the  posterior  (lap,  and  the  portion  folded  below  the  bones  stitched  to  that  folded  above 
them  (Fig.  432). 

SEQUESTROTOMY. 

As  the  removal  of  necrosed  bone  is  most  frequently  required  in  the 
leg,  the  above  operation  will  be  described  here. 

Indications. — The  question  will  often  arise  as  to  whether  the  case  is 
ripe  for  operation.  The  chief  points  bearing  upon  this  and  the  loose- 
ness of  the  sequestrum  are — (1)  The  time  that  has  elapsed  since  the 
beginning  of  the  illness  ;  thus,  two  to  three  months  will  probably  be 
required  in  the  case  of  the  tibia,  but  more  likely  six  in  that  of  the 
femur.  (2)  The  age  and  general  health*  of  the  patient.  The  younger 
the  patient,  and  the  more  vigorous  his  vitality,  the  more  rapidly  will 
the  sequestrum  become  detached.  (3)  The  size  of  the  sequestrum.  The 
larger  and  more  tubular  the  sequestrum,  the  slower  will  be  the  process. 
(4)  The  feel  of  the  sequestrum.  When  steel  probes  announce  this  to  be 
dry,  hard,  and  ringing,  exploration  is  justified,  especially  if  the  seques- 
trum can  be  felt  to  be  loose  or  depressed  by  the  probe.  (5)  The  size  and 
amount  of  the  new  shell  of  bone.  The  more  distinct  this  is,  the  more 
probable  is  it  that  the  process  of  separation  is  complete. 

Operation.! — This  should  be  always  conducted  with  strict  antiseptic 
precaution  throughout,  for  these  reasons — (a)  to  prevent  any  risk  of 
setting  up  infective  osteo-myelitis  ;  (b)  to  diminish  the  amount  of  sup- 
puration, and  so  the  risk  of  necrosis  after  the  interference  with  the 
periosteum  which  is  entailed  by  the  operation. 

The  limb,  having  been  rendered  evascular  by  vertical  elevation  while 
the  patient  is  taking  the  anaesthetic,  and  the  application  of  Esmarch's 
bandages,  is  firmly  supported  on  sand  bags,  steel  probes  are  placed  in 
the  cloacae  which  mark  the  limit  of  the  disease,  and  with  a  strong- 
backed  scalpel  the  surgeon  makes  an  incision  between  them  on  the 
inner  surface  of  the  tibia  down  to  the  bone.  If  only  one  sinus  is 
present,  this  will  probably  be  taken  as  the  centre  of  the  incision.  This 
incision  should  be  made  to  surround  the  sinus  or  sinuses  so  that  the 
edges  of  these  are  removed.  The  soft  parts  being  reflected,  with  every 
care  of  the  periosteum,  partly  with  the  finger,  partly  with  a  blunt  dis- 
sector, the  new  sheath  of  bone,  spongy  and  vascular,  is  thoroughly 
exposed.     This  is  then  cut  into  and  sufficiently  removed  with  a  chisel 

*  Freedom  from  syphilis  and  phthisis  will  be  noted. 

f  It  is  supposed  here  that  the  sequestrum  is  one  of  considerable  size. 


ioo6 


(MIRATIONS    ON    THE    LOWER    EXTREMITY. 


and  mallet,  to  expose  its  cavity  completely  from  end  to  end.*  The 
sequestrum  is  now  removed  with  sequestrum  forceps,  or  prised  out  with 
an  elevator.  If  too  large,  it  must  he  divided  with  cutting  forceps. 
The  hed  of  ill-formed  granulation-tissue  in  which  the  sequestrum  lay 
is  then  carefully  examined  for  any  small  hit  which  may  he  concealed, 
and  this  tissue,  together  with  that  lining  the  sinuses,  is  all  scraped 
away  with  a  sharp  spoon,  and  the  cavity  left  thoroughly  cleansed,  e.g., 
with  formalin  solution  (i  in  250),  or  pure  carholic  acid.  The  resulting 
cavity    is    then   carefully   plugged    with   sterilised    gauze   dusted   with 


Fig.  433. 


Flap  method  of  sequestrotomy.     (Tillnianns.) 

iodoform,  the  dressings  heing  handaged  firmly  on  while  the  limb  is 
elevated,  and  not  till  then  is  the  Esmarch's  bandage  removed.  If  the 
handage  is  removed  hefore  the  dressings  are  applied,  such  free  venous 
oozing  takes  place  that  the  plugs  are  at  once  loosened  and  rendered 
inefficient,  and  the  wound  has  to  he   re-dressed  shortly.     The  limb  is 

*  Sir  H.  Howse  (Jirif.  Med.  Joitrn.,  1874,  V01-  '•  P«  475^  hiys  greal  stress  <<n  the  need  of 
this.  The  new  bone  should  be  removed  as  far  as  the  probe  can  be  passed  upwards  or 
downwards  inside  it,  so  as  to  make  the  whole  easily  granulate  up  from  the  bottom. 
Otherwise,  the  part  that  is  not  laid  open  will  very  likely  persist  with  a  sinus.  Further- 
more, laying  the  whole  cavity  open  not  only  ensures  its  granulating  Dp  from  the  bottom, 
but  also  allows  of  the  removal  of  all  ill-formed  and  infective  material. 


SEQUESTROTOMY.  1007 

kept   raised  on  a  back  splint  and  an  injection    of  morphia  given,  if 
Deeded. 

In  order  to  curtail  the  period  of  after-treatment,  which  is  extremely 
prolonged  and  tedious  owing  to  the  slowness  with  which  healing  takes 
place  in  the  large  cavity  left,  an  attempt  has  been  made  by  German 
surgeons  to  raise  a  flap  which  includes  the  anterior  portion  of  the 
involucrum,  as  shown  in  Fig.  433.  The  flap  bacd  is  first  marked  out 
by  skin  incisions  passing  down  to  the  bone,  and  the  latter  then  divided 
along  the  lines  of  incision  with  a  sharp  chisel  or  osteotome.  This 
having  been  done,  the  flap  is  prised  up  sufficiently  to  expose  the  cavity 
in  which  the  sequestrum  lies,  and  the  latter  then  removed.  All  the 
granulation  tissue  lining  the  cavity  and  the  sinuses  is  now  thoroughly 
removed  with  a  sharp  spoon,  and  the  skin  forming  the  margins  of  the 
sinuses  excised.  The  cavity  in  the  bone,  the  sinuses,  and  the  surround- 
ing skin  are  now  thoroughly  cleansed,  the  flap  replaced  and  sutured,  and 
the  wound  dressed.  In  a  few  cases  thus  treated,  where  the  attempt  at 
rendering  the  wound  aseptic  has  been  successful,  rapid  healing  by 
organisation  of  blood-clot  may  take  place. 

As  the  formation  of  sequestra  is,  nowadays,  very  largely  preventible,  I 
shall  take  an  opportunity  here  of  making  a  few  practical  remarks  on 
the  disease  which  is  largely  responsible  for  necrosis  of  long  bones, 
infective  juxta-epiphysialosteo-periostitis.  i.  Anatomy  of  the  jiarts  first 
affected:  its  bearing  on  the  disease,  (a)  In  a  young  patient,  the  juxta- 
epiphysial  area  contains  growing  cellular  tissues  of  much  activity,  delicate, 
complicated  and  unstable,  with  an  equilibrium  which  is  easily  disturbed, 
and  a  resistance  which  is  often  small ;  (b)  hosts  of  vessel-loops  are  also 
present,  imperfect  in  their  embryonic  structure,  communicating  freely  and 
unable  to  expand  ;  (c)  at  this  age  the  richly  cellular  periosteum  divides  at 
the  above  area  into  two  layers,  one  continuous  with  it,  the  other  descend- 
ing to  blend  with  the  cartilage  of  the  joint.  In  the  above  tissues  some 
slight  injury,  exposure  to  cold  or  an  exanthem  leads  to  the  arrest  of 
the  ordinary  pyo-cocci  which,  if  not  present  in  the  patient,  abound 
universally  wherever  men  congregate.  Results  of  such  arrest  are  violent 
inflammation,  haemorrhages,  thrombosis,  suppuration  with  different  lines 
ready  for  this  to  travel  along,  necrosis,  and  many  possibilities  of  auto- 
inoculation,  ii.  As  the  diagnosis  is  sometimes  far  from  eas}r,  and  as  this 
most  grave  disease  is  liable  to  be  mistaken  for  acute  rheumatism,  cellulitis, 
or  an  exanthem,  one  absolute  ride  should  always  be  remembered  in  acute 
2>yrexias  of  doubtful  origin  in  young  subjects,  and  that  is  to  remember  the 
•presence  of  juxta-epiphysial  areas,  iii.  With  regard  to  the  nature  of  the 
early  interference  which  is  always  imperatively  called  for,  there  are  two 
camps  of  opinion  as  to  whether  the  periosteum  is  ever  affected  alone,  i.e., 
without  the  medulla.  In  nry  experience  it  certainly  is  so  in  the  early 
stage. 

This  is  a  question  very  largely  affected  by  the  surroundings.  A 
surgeon  with  a  well-equipped  hospital  at  his  back  is  very  differently 
placed  from  a  general  practitioner  in  the  country.  The  latter  may  feel 
confident  that  a  free  incision  may  be  safely  made  down  to  the  bone,  in 
the  case  of  the  femur  in  either  of  the  sites  given  at  p.  943.  The 
following  would  be  indications  to  my  mind  for  exploring  and  endeavouring 
to  disinfect  the  medulla  itself:  (1)  gravity  of  the  general  symptoms 
from  the  first ;    (2)   obscurity  of  the  local  symptoms ;    (3)  failure    of 


ioo8  OPERATIONS   ON   THE    LOWEB    EXTREMITY. 

relief  after  free  incision  of  the  periosteum;  (4)  a  soft  condition  of  the 
bone  when  cut  down  upon,  to  the  finger  or  director. 

Two  more  questions  connected  with  the  above  disease  require  to  be 
alluded  to  ;  viz.,  those  of  amputation  and  the  performance  of  early  sub- 
periosteal resection — i.e.,  as  soon  as  the  bone  is  dead,  and  before;  any 
new  shell  has  formed  around  it.  The  following  are  some  of  the  conditions 
in  which  the  question  of  amputation  will  arise  :  failure  of  the  above  treat- 
ment, especially  if  initiated  late  ;  involvement  of  joints,  especially  if 
drainage  of  both  knee  and  ankle  has  failed;  presence  of  chronic  septi- 
caemia or  pyaemia  and  the  existence  of  other  pyemic  lesions  ;  a  patient 
with  a  vitality  so  low  as  to  render  him  unequal  to  meet  further  calls 
upon  it. 

Early  sub-periosteal  resection. — This  is  so  simple  an  operation  in 
the  case  of  the  tibia,  and  its  advantages  over  the  expectant  treatment  are, 
at  first  sight,  so  great,  that  it  has  frequently  been  performed.  (1)  Thus 
it  removes  what  may  be  the  source  of  dangerous  infection,  and  (2)  it 
avoids  the  need  of  any  operation  for  the  removal  of  a  sequestrum,  and 
the  tediousness  of  waiting  and  of  the  after-convalescence.  The  very 
serious  disadvantage  of  shortening  of  the  limb  which  has  occurred  in 
the  majority  of  cases,  though  the  fibula  is  present  to  act  as  a  stay 
between  the  knee-  and  ankle-joints,  more  than  outweighs  the  above 
advantages.  This  shortening  has  occurred  even  when  the  periosteum 
has  been  carefully  preserved  and  even  portions  of  the  ends  of  the 
diaphysis  left  to  ensure  portions  of  the  epiphysial  cartilages  persisting. 
While  I  am  aware  that  successful  cases  have  been  reported,  we  hear 
nothing  of  the  unsuccessful  ones.  The  results  are  extremely  uncertain 
owing  to  causes  at  present  not  definitely  known.  Where  regeneration 
of  bone  has  not  taken  place  the  limb  is  an  extremely  useless  one 
(p.  1009).  Nowadays,  early  diagnosis  and  early  operation  should 
render  these  cases  of  necrosis  extremely  rare.  Where  they  occur,  it 
is  possible  that  the  Rontgen-rays  by  the  information  they  may  give  as 
to  the  thickness  of  the  periosteum  and  the  involucrum  will  very  likely 
enable  the  sequestrum  to  be  removed  at  an  earlier  date. 


BONE-GRAFTING.       FILLING    UP    OF    BONE-CAVITIES. 

The  subject  of  bone-grafting  to  replace  the  results  of  necrosis  has 
been  referred  to  at  some  length  in  Vol.  I.,  at  p.  159,  where  Sir  W. 
Macewen's  success  in  building  up  the  shaft  of  a  humerus  with  pieces  of 
bone  removed  during  osteotomies,  and  at  p.  455,  where  Mr.  Watson 
Cheyne,  C.B.,  restored  the  nose  with  pieces  of  a  bone  of  a  rabbit,  are 
related  in  some  detail.  Two  other  methods  have  been  employed  in 
recent  years. 

Friedrich,  of  Griefswald  (Germ.  Congr.  of  Surg.,  April,  1904),  reported 
rapid  healing  and  good  functional  results  in  two  cases  in  which  the 
diaphysis  of  the  tibia  and  femur  had  been  removed  and  replaced  by  the 
corresponding  shaft  from  another  human  being,  the  bone  used  being 
first  deprived  of  its  marrow  and  sterilised  by  boiling.  In  a  girl,  ret.  8, 
in  which  the  entire  shaft  of  the  femur  had  been  removed  for  an  endos- 
teal sarcoma,  a  child's  tibia  was  used.  Healing  was  rapid,  and  the 
child  was  able  to  run  with  the  help  of  a  splint  and  cane.     In  another 


BONE-GRAFTING.  1009 

child  14  ctin.  of  the  femur  were  replaced  by  part  of  the  femur  from  a 
woman  who  had  died  of  gastric  cancer. 

A  modification  of  grafting  which  may  be  termed  bone-transference 
may  be  usefully  employed  in  the  case  of  two  contiguous  long  hones. 

Dr.  Huntingdon,  of  San  Francisco,  drew  attention  to  tins  common- 
Bense  and  useful  principle  (Ann.  of  Surg.,  Feb.  1905,  p.  249),  with 
a  successful  case,  though  his  paper  is  lacking  in  details  of  technique, 
where  these  are  most  needed.  Dr.  Donald,  of  Paisley  (Brit.  Med.  Journ., 
May  12,  1906)  successfully  employed  the  same  principle  in  a  boy  of 
five.  As  in  Dr.  Huntingdon's  case,  sub-periosteal  resection  of  the  tibia 
had  been  performed  for  infective  osteo-periostitis,  and  in  each  case  the 
limb  was  useless.  "  An  incision  was  made  in  the  original  scar  in  its 
lower  half  and  the  deeper  tissues  retracted  so  as  to  form  a  suitable 
furrow  for  the  reception  of  the  bone-graft.  Another  incision  was  made 
over  the  lower  third  of  the  fibula  and  the  superficial  structures  separated 
from  the  bone  and  periosteum.  A  segment  of  bone,  about  two  inches  long, 
composed  of  half  the  thickness  of  the  fibula  with  its  attached  periosteum, 
was  split  off  by  a  chisel,  and  laid  in  the  prepared  furrow."  When  the 
dressings  were  first  changed  at  the  end  of  two  weeks,  the  wound  was 
found  to  be  suppurating.  Small  crumbs  of  bone  came  away,  but  the 
wound  gradually  healed  well.  About  nine  weeks  after  the  operation  the 
tibia  was  rigid  in  its  whole  length,  and  abnormal  movements  could  no 
longer  be  performed.  Skiagraphs  taken  at  intervals  showed  increasing 
thickness  and  density  of  the  tibia.  Seven  months  after  the  trans- 
ference of  bone,  the  boy  was  able  to  walk  quite  well,  although  there 
was  some  shortening  of  the  leg.  This  method  deserves  extensive  trial. 
Two  points  especially  need  attention  :  (1)  Thorough  sterilisation  of  the 
bed  for  the  graft ;  (2)  attention  to  the  position  of  the  foot  and  support 
to  the  tibia,  while  this  is  solidifying. 

Filling  up  of  bone-cavities. — The  following  methods  are  available 
here.  In  all  it  is  absolutely  essential  that  the  cavity  be  devoid  of 
infection  of  any  kind.  The  circumjacent  area  must  be  regularly 
re-sterilised  from  time  to  time. 

1.  By  detaching  flaps  of  skin  and  soft  parts  and  so  "papering" 
the  cavity  which  must  be  first  carefully  freshened.  This  method  may 
be  aided  by  skin-grafting.  It  has  been  alluded  to  at  p.  962.  If  any 
portion  of  a  muscle  has  formed  part  of  the  soft  tissues  used,  adhesion  of 
this  to  the  cavity  and  subsequent  interference  with  its  action  must  be 
prevented  by  passive  and  active  movements  being  begun  two  or 
three  weeks  later.  The  limb  should  not  be  used  until  six  or  eight 
weeks  have  elapsed. 

2.  By  the  use  of  decalcified  bone.  The  cavity  having  been  carefully 
refreshed,  and  the  periosteum  if  possible  detached,  the  cavity  is 
entirely  filled  up  with  the  decalcified  fragments  over  which  the  perios- 
teum  and  soft  parts  are,  separately,  drawn  together,  if  this  be  possible. 

3.  By  various  "  fillings."  Most  of  these  have  proved  failures.  The 
following  account  of  the  method  of  v.  Mosetig  inserted  by  the  editors, 
Dr.  W.  T.  Bull  and  Dr.  J.  B.  Solley,  in  the  third  volume  of  their 
translation  of  v.  Bergmann's  System  of  Surgery,  p.  703,  is  worth}'  of 
careful  attention.  "  The  method  as  reported  by  v.  Mosetig  (Munch. 
Med.  Woch.,  1903,  No.  2)  before  the  Gesellschaft  fur  Aertze,  in  Vienna 
in  January  of  the  same  year,  and  which  he  had  used  during  the  previous 

s. — vol.  11.  64 


Toio  OPERATIONS   ON    THE    LOWEB    EXTREMITY. 

three  years,  in  over  a  hundred  cases  of  caries  and  necrosis,  was  as 
follows:  Under  application  of  the  Esmarch  and  with  Btrict  antisepsis 
the  periosteum  was  lifted  off  and  all  diseased  tissue  removed  thoroughly 
with  sharp  spoon,  &C.,  until  positive  that  the  cavity  was  aseptic.  The 
result  depended  upon  the  latter  condition  and  the  sterility  of  the 
tilling.  The  filling  consisted  of  iodoform,  6o-o ;  spermaceti  and 
oleum  sesami,  aa  4CO,  heated  slowly  to  ioo°  (.'.  in  a  flask  on  a  water- 
hath;  kept  at  this  temperature  for  fifteen  minutes;  then  removed  and 
allowed  to  cool  and  solidify,  while  shaking  constantly.  Before  using, 
it  is  melted  and  heated  to  500  C.  in  a  thermostat.  After  the  cavity 
has  heen  cleansed  of  all  diseased  tissue,  it  is  washed  out  thoroughly 
with  a  I  per  cent,  solution  of  formalin,  dried  out  with  swabs  and  then 
with  hot  air  and  filled  with  the  melted  mixture.  The  periosteum  ami 
skin  are  then  sutured  without  drainage  and  a  dressing  applied.  In 
fourteen  days  the  dressing  is  changed  and  the  skin  sutures  removed. 
The  course  is  almosl  afebrile,  and  there  is  never  iodoform  intoxication. 
The  hardened  filling  is  gradually  replaced  by  granulations  and  new 
bone  as  demonstrated  by  the  X-ray  (llolzknecht).  The  patient  can 
be  about.  The  size  of  the  cavity,  according  to  Silbermacb  [Munch. 
Med.  Woeh.,  1903,  No.  20)  is  no  contraindication,  in  some  instances 
two-thirds  of  the  shaft  having  been  removed  and  replaced  by  the 
filling.  The  same  author  emphasises  (Centr.  f.  Chir.,  1903,  No.  25) 
the  importance  of  absolutely  checking  all  bleeding  and  drying  out  the 
cavity  with  hot  air,  and  describes  the  electrical  hot-air  apparatus  used 
in  v.  Mosetig's  clinic  (Deut.  Zeitseh.  f.  Chir.,  Bd.  lxvi.,  p.  589). 
To  check  the  oozing  of  blood  even  more  surely,  Damianos  (Centr.  f. 
Chir.,  1904,  No.  6)  swabs  out  the  cavity  with  adrenalin  pledg 
after  thorough  cleansing  and  drying  with  hot  air.  He  cites  150 
cases  treated  successfully,  and  attributes  the  results  to  extreme  care 
in  the  technic  and  in  determining  the  time  of  operation.  According 
to  Damianos,  v.  Mosetig  prefers  a  flap  section  to  direct  incision.  In 
chronic  osteo-myelitis  the  cavity  can  be  plugged  at  once,  hut  in  acute 
cases  not  until  several  weeks  after  the  onset." 

SARCOMA   OF  FEMUR  AND   TIBIA. 

The  myeloid  mid  endosteal  variety  has  been  referred  to  in  Vol.  I., 
p.  91,  in  the  surgery  of  the  bones  of  the  forearm.  In  that  region 
resection  was  the  chief  operation  in  question,  here  it  is  amputation 
or  scooping  out  of  the  growth. 

In  the  femur,  when  the  sarcoma  is  periosteal,  amputation  at  the 
hip-joint  by  skin  flaps  and  division  of  all  the  soft  parts  as  high  as 
possible  is  usually  the  only  operation  available.  It  is  possible  that 
the  use  of  the  Rontgen-rays  may  by  rendering  an  earlier  diagnosis 
possible,  improve  the  prognosis  which  is  at  present  so  grave  owing  to 
the  probable  existence  of  metastases.  In  the  endosteal  variety  affecting 
one  condyle,  scooping  out  of  the  growth,  resection  of  the  hone  affected 
and  excision  of  the  knee  have  all  heen  performed,  but  the  risk  of 
reappearance  of  the  disease  and  the  doubtfulness  as  to  the  utility  of 
the  limb  render  amputation  which  is  usually  sufficient  if  performed 
high  up  in  the  thigh  with  careful  inspection  of  the  medullary  canal,  a 
preferable  step.     But  here,  again,  the  Etontgen-rays  if  employed  early, 


SARCOMA    OF    FEMUR    AND    TIBIA.  ion 

and  aided  by  a  free  exploratory  incision  made  without  delay,  may 
increase  the  possibility  of  saving  the  limb. 

In  the  tibia  and  fibula,  where  the  sarcoma  is  endosteal,  from  the 
presence  of  two  bones  and  the  somewhat  simpler  access,  resection 
of  the  bones  and  scooping  <>nt  of  the  growth  have  to  be  considered  as 
well  as  amputation.  Mr.  Morton  has  resected  the  knee  joint  in  two 
cases  (Brit.  Med.  Journ.,  1898,  vol.  ii.  p.  228).  The  after  use  of  the 
limb  was  good.  As  stated  in  Vol.  I.,  p.  92,  long  duration,  slow  pro- 
gress of  the  growth,  uniformity  of  expansion,  no  evidence  of  increased 
size  of  the  shaft,  indicating  extension  along  the  medulla,  or  of  escape 
of  the  growth  into  the  soft  parts  are  amongst  the  chief  points  to  bear 
in  mind  when  any  of  the  less  radical  operations  are  performed.  The 
llontgen-rays  may  not  only  be  of  assistance  in  clearing  up  early  a 
doubtful  case,  but  also  in  showing  the  degree  of  thickness  of  the  bony 
capsule  as  indicated  by  a  darker  zone  contrasting  with  the  adjacent 
lighter  area,  and  whether  the  growth  has  perforated  externally. 
Egg-shell  crackling  and  pulsation  are  more  often  talked  of  than  seen. 

In  the  operation  for  scooping  out — it  is  rarely  an  enucleation — the 
following  points  may  be  of  service.  The  parts  having  been  duly 
sterilised,  and  the  hemorrhage  controlled  by  an  Esmarch's  bandage, 
the  growth  is  exposed  by  a  sufficient  flap  or  longitudinal  incision  on 
the  aspect  which  gives  the  best  access.  If  the  periosteum  be  not 
infiltrated,  it  should  be  raised,  care  being  taken  not  to  rupture  the 
capsule.  With  stout  scissors  or  a  chisel  this  is  next  freely  opened.  If 
it  be  possible  the  growth  is  now  enucleated  entire.  But  its  friability 
and  its  adhesions  render  this  rarely  possible.  The  only  mode  of 
removal  is  usually  that  by  sharp  spoons.  During  their  use  the  capsule 
must  not  be  perforated,  and  cavities  accessory  to  the  main  one  should 
be  looked  for.     Haemorrhage  now  may  cause  much  trouble. 

In  a  case  operated  upon  by  Dr.  J.  C.  Bloodgood  (John  Hopkins  Hosp.,  Bull.,  May 
1903,  p.  134),  the  shell  was  found  to  be  perforated  by  25  or  30  vessels  as  large  as  the 
temporal  artery.  Each  of  these  openings  was  plugged  with  Horsley's  wax.  No  return  of 
bleeding  took  place,  but  it  was  two  weeks  before  all  the  wax  was  removed.  The  history 
of  the  case  is  only  carried  up  to  three  months  after  the  operation. 

Where  the  result  of  the  scooping  out  appears  doubtful,  the  cauteiy, 
pure  carbolic  acid,  or  a  strong  solution  of  formalin  should  be  tried. 
The  wound  is  plugged  with  strips  of  gauze.  The  long  process  of 
healing  of  the  cavity  where  this  is  large  ma}'  be  hastened  by  one  of  the 
steps  given  at  p.  1009. 

Even  where  there  is  no  local  reappearance,  the  above  operation  may 
fail  owing  to  metastases,  or  to  the  shell  left  being  too  weak  to  support 
the  leverage  of  the  parts  below  or  the  weight  above.  Where  a  free 
exploratory  incision  has  proved  that  the  endosteal  sarcoma  is  a  mixed 
one — and  these  growths  are  by  no  means  always  myelomata-— amputation 
through  the  knee-joint  or  the  lower  third  of  the  thigh  is  the  only 
course.  Owing  to  the  aggravated  disappointment  which  attends  a 
local  reappearance  after  an  amputation,  I  prefer  the  latter  step.  And 
this  operation  is  the  only  one  in  periosteal  sarcomata  of  the  bones  of 
the  leg. 


64 — 2 


ioi2  OPERATIONS    ON    THE   LOWER    EXTREMITY. 


TREATMENT    OF   COMPOUND    FRACTURES.* 

The  following  special  points  for  consideration  arise  here — viz.,  (i) 
The  treatment  of  the  wound  ;  (2)  The  reduction  of  protruding  frag- 
ments and  the  treatment  of  splinters;  (3)  Complications;  (4)  The 
question  of  amputation. 

(1)  In  the  treatment  of  the  wound  the  one  great  object  is  to  convert 
the  fracture  as  soon  as  possible  into  a  simple  one.  In  a  few  cases, 
sealing  a  small,  clean  cut  wound,  the  skin  having  been  carefully 
sterilised,  at  once  with  dry  gauze,  and  collodion  and  iodoform,  or 
tinct.  benz.  co.,  may  be  sufficient.  But  where  the  surgeon's  sur- 
roundings admit  of  it,  and  where  there  is  reason  to  be  suspicious  about 
the  soil  at  the  spot  where  the  injury  took  place,  it  will  be  better  to 
make  an  incision  and  disinfect  the  ends  of  the  bones.  In  those  cases, 
common  enough  in  large  hospital  practice,  where  the  wound  is  exten- 
sive and  lacerated,  and  accompanied  by  great  contusion  of  the  soft 
parts,  with  abundant  blood  extravasation,  with  much  comminution  of 
fragments  and  injury  to  the  periosteum,  or  where  the  fracture  is  com- 
plicated with  a  dislocation,  the  following  method  will  be  found  to  give 
the  best  results. 

(2)  Protrusion  of  Fragments. — It  is  usually  the  upper  one  which 
protrudes.  The  difficulty  of  reduction  is  in  proportion  to  the  obliquity 
of  the  fracture,  the  length  of  the  protruding  bone,  and  the  amount  of 
spasm.  The  wound  having  been  freely  enlarged,  an  attempt  must  be 
made  by  manipulations  to  bring  the  fragments  into  accurate  apposi- 
tion. This  will  often  be  facilitated  by  means  of  a  strong  elevator 
inserted  between  the  fragments,  and  used  as  a  lever.  Division  of  the 
tendo  Achillis  or  possibly  of  other  tendons  may  also  be  found 
necessary  before  satisfactory  reposition  can  be  accomplished.  Failing 
all  these,  part  of  the  bone  must  be  removed  with  a  narrow-bladed  saw, 
care  being  taken  to  separate  the  periosteum  first,  and  to  protect  the 
soft  parts  with  a  blunt  dissector  passed  under  the  bone  and  by 
retractors.  If  the  bone  is  splintered,  some  judgment  is  required  as 
to  what  pieces  to  remove.  Those  which  are  still  adherent  by  their 
periosteum  should  be  left.  Those  completely  torn  away  must  be 
removed,  whether  they  carry  their  periosteum  or  not.  As  to  a  third 
set  partly  adherent,  partly  not,  these,  as  a  rule,  partially  die  in  pro- 
portion to  the  injury  to  their  periosteum,  and  keep  up  for  a  long  time 
irritation,  and  delayed  union  with,  perhaps,  suppuration,  &c.  They 
must,  therefore,  as  far  as  practicable,  be  removed.  If  after  reduction 
it  is  found  that  there  is  any  considerable  tendency  to  the  reproduction 
of  the  deformity,  the  fragments  must  be  tixed  either  by  means  of 
silver  wire,  steel  screws,  &c,  as  suggested  by  Mr.  W.  A.  Lane 
(vide  p.  1017),  the  choice  between  these  methods  depending  upon  the 
conditions  present  and  the  practice  of  the  surgeon  operating. 

While  an  anaesthetic  is  given, I  the  parts  are  widely  and  thoroughly 
cleansed  with  turpentine  or  liquor  potassse.hot  soap  and  water,  and  warm 
1  per  cent,   lysol   solution.      In   the   case  of  the   leg,  the    razor  and 

*  From  the  frequency  with  which  these  occur  in  the  leg  this  subject  will  be  treated 
here. 

t  Nu  probing  or  other  examination  is  to  be  made  until  the  limb  has  been  cleansed. 


TIJKATMKNT    <>K    (!()M  1'oHNI)    KliACTl'UKS.  1013 

nail-brush  should  be  used  from  the  toes  to  above  the  knee.  Any  skin 
which  is  much  damaged  or  into  which  dirt  lias  been  ground  is  first  cut 
away.  The  wound  having  been  freely  enlarged  and  all  recesses  well 
opened  up,  the  blood-clot  is  washed  away  and  the  whole  surface  of  the 
wound  thoroughly  sponged  over  with  swabs  (of  gauze,  not  wool), 
soaked  in  hot  carbolic  acid  solution  (1  in  30)  or  biniodide  of  mercury 
(1  in  2000).  Where  many  recesses  exist,  especially  if  out  of  sight,  one 
of  the  above  solutions  wanned  should  be  introduced  gently  with  a 
syringe,*  a  sterilised  gum-elastic  catheter  and  short  piece  of  tubing 
and  funnel.  An  additional  source  of  safety  may  be  the  use  of  pun' 
carbolic  acid  to  any  infected  tissues  or  the  bones  themselves.  Where 
dirt  has  been  ground  into  the  fragments,  this  must  be  gouged  out  or 
shaved  off  with  a  stout  knife.  The  fragments  are  now  reduced  (care  being 
finally  taken  that  nothing  intervenes)  and  fixed,  if  needful,  as  described 
at  p.  1020,  and  counter-openings  made  for  drainage  as  may  be  found 
necessary.  The  Esmarch's  bandage  should  not  be  removed  until  there 
has  been  time  for  the  antiseptics  used  to  soak  into  the  parts  ;  all  haemor- 
rhage being  now  arrested,  and  any  torn  nerves  pared  and  sutured,  the 
recesses  of  the  wound  are  well  dried  out ;  sterilised  iodoform!  is  then 
dusted  in,  sterile  dressings  applied  or  a  boracic  acid  fomentation  accord- 
ing to  the  confidence  which  the  surgeon  is  able  to  feel  in  the  disinfection 
of  the  wound,  and  the  limb  put  up  either  in  a  back  and  two  side  splints 
with  any  needful  interruptions,  or,  according  to  Mr.  Croft's  directions,  in 
plaster  of  Paris.  Another  excellent  means  of  using  plaster  of  Paris  is 
in  combination  with  metal  strips  so  as  to  easily  provide  good  access  to 
the  injury.  A  sterile  bandage  is  first  applied  below  and  above  the 
wound,  two  to  four  strips  of  thin  malleable  metal  are  then  applied 
antero-posteriorly  and  laterally  as  well  if  needful,  bent  outwards  over 
the  area  adjacent  to  the  fracture,  their  extremities  being  embedded  in 
the  plaster  of  Paris  bandages  as  these  are  applied.  Of  the  above  I 
prefer  the  first  and  the  third,  in  severe  cases,  for  the  first  week ; 
infrequent  dressings,  wherever  practicable,  are  most  essential.     But  in 


*  Vigorous  introduction  of  fluid  may  drive  infected  blood  clots  or  dirt  deeper  in. 

t  This  most  valuable  drug  is  not  sufficiently  used  in  these  cases.  1  may  briefly 
mention  three  cases  in  which  limbs  were,  I  think,  saved  by  it.  One  was  a  very  severe 
compound  fracture  of  the  femur  in  a  man,  aged  46,  who  fell  twenty-two  feet  on  to  the 
banks  of  the  Thames,  striking  a  stone  buttress  as  he  went  down.  I  saw  him  about  an 
hour  after  the  accident.  The  fragments  were  much  displaced  and  overlapping,  the  lower 
one  being  also  split  vertically,  but  not  so  far  as  the  knee-joint.  The  ends  of  both  were 
bare,  and  the  vastus  externus  and  hamstrings  were  lacerated,  the  injury  having  been 
made  greater  by  the  patient  having  been  lifted  off  the  mud  on  to  which  he  fell  into  a 
boat,  and  then  into  a  cab.  Ether  having  been  given,  the  external  wound,  through  which 
the  vastus  externus  protruded,  was  freely  enlarged,  and  its  recesses  well  washed  out  with 
1  in  30  carbolic  acid  solution,  as  advised  above.  About  5J  of  iodoform  was  then  carried 
down  right  between  the  fragments  by  means  of  the  finger  and  a  narrow  spatula,  and  two 
large  drainage-tubes  inserted.  An  aseptic  result  was  secured  from  the  first  and  maintained, 
throughout,  by  the  dresser  (Mr.  J.  H.  Lister),  the  man  making  an  excellent  recovery.  The 
second  case  was  that  of  a  compound  comminuted  fracture  of  the  leg,  with  wound  of  the 
anterior  tibial  artery  (mentioned  at  p.  997).  The  third  occurred  in  a  boy  with  compound 
separation  of  the  lower  epiphysis  of  the  tibia,  in  which  two  inches  of  the  protruding 
diaphysis  were  removed.  The  case  did  so  well  after  the  introduction  of  iodoform  and  the 
other  precautions  already  given,  that  the  first  dressings  were  not  removed  till  the  eighth 
day,  and  the  lad  recovered  with  an  excellent  limb. 


1014  OPERATIONS   ON    THK    LOWEB    EXTREMITY. 

trying  to  secure  this  end,  the  risk  of  shutting  in  infection  must  not  be 
forgotten. 

(3)  Complications. — My  space  will  only  allow  me  to  enumerate  tin  ae. 
They  are  local  and  general.  The  former  include  pruritus,  vesicles, 
ecchymosis,  suppuration,  odeum,  phlebitis,  gangrene,  osteitis,  caries, 
necrosis,  muscular  spasms,  dislocations,  and  implication  of  a  neigh- 
bouring joint.  The  general  complications  are  such  as  are  common  to 
all  injuries — viz.,  traumatic  fever,  delirium,  erysipelas,  septicaemia, 
pyaemia,  hectic,  tetanus,  jaundice,  and  retention  of  urine;  in  older 
patients  a  tendency  to  hypostatic  congestion  and  broncho-pneumonia, 
and  finally,  in  a  few  cases,  pulmonary  fat-embolism. 

(4)  Question  of  Amputation. — The  following  are  amongst  the  condi- 
tions requiring  primary  amputation:  (1)  When  a  limb  is  torn  off  by 
a  cannon-ball,  a  portion  of  shell,  or  by  machinery.  (2)  When  the 
division  of  the  soft  parts  is  nearly  complete,  except  in  the  case  of  a 
clean  cut  across  the  phalanges,  metacarpus,  or  metatarsus  ;  even  the 
forearm  may  occasionally  be  saved  under  similar  circumstances. 
(3)  When  there  is  much  actual  loss  of  soft  parts,  as  when  one  side  of 
a  limb  is  torn  away,  or  the  skin  is  extensively  peeled  off.  (4)  When, 
with  or  without  great  comminution  of  the  bones,  there  is  much  bruising 
and  laceration  of  the  soft  parts,  with  protrusion  of  muscular  bellies, 
and  extensive  tearing  up  of  deep  planes  of  areolar  tissue.  (5)  In  some 
cases  when  the  principal  artery  and  nerves  of  the  limb  are  both  divided  ; 
thus,  in  the  case  of  the  lower  limb,  primary  amputation  will  usually 
be  required.  (6)  In  certain  cases  of  severe  haemorrhage,  primary  or 
secondary.  On  this  subject  I  must  refer  my  readers  to  the  remarks 
already  made  at  p.  992.  (7)  Some  cases  of  compound  fracture  of 
large  joints — viz.,  when  one  bone  is  shattered  or  more  than  one  is 
broken  ;  when  there  is  much  laceration  of  the  ligaments  ;  when,  in 
addition  to  comminution  of  the  bones,  there  is  much  contusion  of  the 
soft  parts,  especially  if  complicated  with  division  of  an  artery  ;  when  the 
foreign  body  which  has  caused  the  fracture  remains  in  the  joint,  or,  pro- 
jecting into  it  from  its  bed  in  the  bone,  cannot  easily  be  removed,  or  when 
there  is  much  damage  to  the  articular  surfaces.  It  will  be  understood 
that  all  these  forms  of  injury  are  most  fatal  when  affecting  the  knee  or 
hip  ;   in  dealing  with  other  joints  much  greater  latitude  may  be  allowed. 

Finally,  before  deciding  on  amputation,  the  surgeon  must  take  into 
consideration,  in  addition  to  the  above  points  which  concern  the  fracture 
itself,  any  general  information  to  be  gained  about  the  patient  himself. 
Thus,  the  age,  constitution,  habits,  any  sign  of  visceral  disease,  and 
the  appearance  of  the  patient,  are  all  points  of  material  importance  in 
coming  to  a  decision  between  amputation  and  an  attempt  to  save  the 
limb.  Thus,  to  make  my  meaning  clearer,  there  are  no  more  anxious 
cases  than  severe  compound  fractures  in  dwellers  in  large  towns,  who 
are  past  middle  life,  flabbily  fat,  with  dilated  venules  about  the  cheeks 
and  nose,  whose  conjunctiva'  are  slightly  jaundiced,  the  urine  of  low 
specific  gravity  and  perhaps  albuminous.*  The  surgeon  must  here  bear 
in  mind  that  saving  the  patient's  life  is,  after  all,  of  more  importance 
than  the  preservation  of  his  limb. 

Note  will  also  )>.-  taken  of  the  occupation,  as  in  brewers'  draymen  and  commercial 
travellers. 


OPERATIVE   TREATMENT   OF   SIMPLE    FRACTURES.      1015 

In  performing  amputation  in  these  cases  of  compound  fracture  it  is 
always  to  be  remembered  that  the  injury  is  not  so  localised  as  would 
appear  from  the  surface  (footnote,  p.  935)  ;  thus,  in  compound  fracture 
of  the  leg  there  is  often  extensive  loosening  of  the  skin  from  the  deep 
fascia,  and  extravasation  of  Mood  into  the  deep  planes  of  connective 
tissue  for  some  distance  ahove,  the  knee-joint  being  perhaps  full  of 
blood,  and  its  cartilages  bruised.  In  such  cases,  if  amputation  be 
performed  jusl  ahove  the  injury,  sloughing  and  separation  of  the  Hups 
will  inevitably  follow.  On  the  other  hand,  in  cases  of  severe  com- 
pound fracture  of  the  thigh,  where  amputation  is  required  high  up,  it 
will  be  found  better  practice  to  amputate,  in  part  at  least,  through 
injured  tissues.* 

If,  in  addition  to  the  fracture,  there  are  serious  injuries  to  other 
organs,  immediate  amputation  is  useless  or  injurious.  The  only 
chance  of  recovery  here  is  afforded  by  secondary  amputation  after  the 
early  dangers  are  past. 

Secondary  amputation  may  be  required  for  profuse  suppuration  with 
hectic,  for  gangrene,  or  uncontrollable  haemorrhage.  The  decision 
must  here  be  made  according  to  the  needs  of  each  case.  The  surgeon 
must,  if  possible,  wait  till  the  infective  fever  and  constitutional 
disturbance  are  subsiding,  till  the  temperature  has  begun  to  fall, 
and  till  all  redness,  erysipelas,  and  sloughing  have  ceased.  On  the 
other  hand,  if  the  operation  be  deferred  till  the  powers  of  the  patient 
are  running  down  from  profuse  suppuration  and  hectic,  and  till  con- 
firmed asthenia  has  set  in,  the  period  of  performing  it  will,  very 
probably,  have  passed  away. 

At  a  still  later  period  the  operation  may  be  desired  by  the  patient,  if, 
in  consequence  of  non-union,  incurable  deformity,  or  tedious  bone 
disease,  the  limb  has  become  an  encumbrance  to  him.  Some  of  these 
conditions  may,  of  course,  be  treated  by  resection,  osteotomy,  &c. 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES. 

The  wider  adoption  of  this  step  has  been  strongly  advocated  by  Mr. 
W.  A.  Lane  (Clin.  Soc.  Trans.,  vol.  xxvii.  ;  Clin.  Joum.,  July  1897,  and 
elsewhere),  on  the  grounds  chiefly  that  (1)  it  is  perfectly  safe  nowadays, 
(2)  that  otherwise  the  results  are  often  bad  and  very  frequently 
disabling,  and  (3)  that  it  is  a  saving  of  time. 

(1)  At  the  present  date  the  opinion  of  most  surgeons  is  that  it  is  only 
in  a  small  proportion  of  cases  of  fracture  of  the  leg  and  Pott's  fracture 
— conditions  which  will  be  considered  separately — that  operative 
interference  is  justifiable,  for  the  following  reasons.  The  value  of  any 
treatment,  especially  in  a  very  common  injury,  must  be  estimated  by 
the  extent  to  which  it  is  available  by  the  great  majority  of  those  called 
upon  to  ernploy  it,  or  to  put  the  matter  in  Sir  W.  Bennett's  words 

*  Thus,  in  the  case  of  a  young  railway  porter,  whose  thigh  was  smashed  by  a  railway 
accident  at  Epsom,  I  performed  amputation  at  the  level  of  the  lesser  trochanter,  in  pre- 
ference to  the  hip-joint.  The  damaged  flaps  sloughed,  as  I  expected,  but  the  patient 
made  a  good  recovery,  after  the  removal  of  some  dead  bone.  All  the  precautions  which 
may  be  taken  against  shock  before,  during,  and  after  the  amputation,  will,  of  course,  be 
adopted  in  these  cases. 


ioi6  OPERATIONS   ON    THE    LOWEB    EXTREMITY. 

(Treatment  of  Simple  Fractures,  p.  16;  ami  Brit.  Med.  Journ.,  Oct.  7, 
1900)  :  "It  is  quite  impossible — and  this  is  a  fact  that  cannot  be  too 
strongly  insisted  upon — to  estimate  the  value  of  any  method  of  treat- 
ment upon  the  evidence  of  the  report  of  the  successful  cases  only.  It 
is  equally  impossible  to  gauge  the  general  value  of  any  method  of 
treatment  upon  the  experience  of  a  few  individuals.  Although  a 
certain  number  of  surgeons  may  be  able,  from  the  circumstances  in 
which  they  work,  or  from  special  aptitude  in  operating,  to  produce 
results  which  are  practically  ideal,  it  does  not  necessarily  follow  that 
the  same  result  can  be  achieved  by  the  general  body  of  those  who 
attempt  the  same  method."  1  need  not  point  out  that  while  the  skin 
in  these  cases  of  simple  fracture  of  the  leg  is  unbroken,  it  is  very 
often  in  a  condition  which  renders  it  impossible  to  say  that  operative 
interference  is,  even  nowadays,  without  risk.  At  the  usual  site  of 
fracture  it  is  thin  and  of  little  vascularity,  its  vitality  is  diminished  by 
the  injury;  blebs  and  extravasation  may  be  present.  The  needed 
thoroughness  of  the  sterilisation  can  only  be  secured  at  the  risk  of 
further  damage.  Moreover,  the  patients  are  often  habitually  inattentive 
to  cleanliness,  and  drunken  habits  may  be  a  further  complication. 

(2)  In  my  opinion  the  proportion  of  cases  in  which  the  use  of  the 
limb  has  been  permanently  impaired  and  the  wage-earning  capacity  of 
the  patient  seriously  diminished  has  been  much  exaggerated.  To 
get  at  the  truth,  I  consider  it  essential  that  in  such  cases  the  patient 
should  be  examined  as  to  the  accuracy  of  his  statements  by  the 
surgeon  himself.  Written  reports  from  patients  have  little  value  in 
my  eyes.  The  patient's  powers  have  to  be  tested  by  experienced  and 
watchful  eyes,  and  the  influence  of  club-money  and  expected  remunera- 
tion from  actions  at  law  to  be  duly  weighed.  That  the  real  disabilit}' 
is  small  is  confirmed  by  such  results  as  Sir  W.  Bennett  (he.  supra  cit., 
p.  22)  obtained  from  his  enquiries  amongst  practitioners  in  mining  and 
collieiy  districts,  and  those  who  had  to  do  with  sailors  in  large  numbers 
who  have  suffered  from  fractures  at  sea  and  under  other  disadvantageous 
circumstances.  On  this  point  Sir  William  speaks  as  follows  : — "  The 
result  of  my  enquiries  in  this  respect  is  that  1  find  the  real  disability 
following  upon  fracture  is  not  so  great  as  one  would  be  led  to  suppose 
from  recent  writings  on  the  subject."  ..."  The  fact  of  the  matter 
is,  I  believe,  as  follows.  In  spite  of  what  may  be  said  to  the  contrary, 
the  disability  following  upon  fracture  is  much  more  frequently  due  to 
matting  of  the  parts  about  the  fracture  and  about  the  joints  imme- 
diately concerned  than  to  faulty  union  of  the  bones  themselves."  .  .  . 
"  I  believe  that  if  in  cases  of  fracture  early  passive  movements  were 
methodically  used  so  that  all  chance  of  adhesion  of  the  parts  is 
prevented,  very  much  less  would  be  heard  about  the  disabilities  in 
such  cases  than  we  hear  now."  Mr.  R.  W.  Murray,  Surgeon  to  the 
Northern  Hospital  at  Liverpool  in  a  paper  on  "  The  Ultimate  Results 
of  Eighty-eight  Cases  of  Fracture  of  the  Tibia  and  Fibula  "  (Brit. 
Med.  Journ.,  Oct.  10,  1903)  writes,  "In  the  vast  majority  of  the  cases 
of  oblique  fracture  the  men  were  able  to  resume  their  former  work." 
While  the  subject  of  the  function  of  the  limb  is  being  referred  to,  I 
would  remind  my  readers  that  though  the  functional  results  of  non- 
operative  treatment  may  be  excellent  the  Rontgen-rays  may  reveal  the 
persistence    of    a    marked    deformity.      As  to  the    gain    of   time   by 


OPERATIVE   TREATMENT   OF   SIMPLE    FRACTURES.      1017 

operative  treatment  in  simple  fracture  of  the  leg  this  is  certainly  not 
so  marked  as  in  fracture  of  the  patella.  The  screw,  while  an  excellent, 
menus  of  holding  the  fragments  together,  frequently  requires  removal, 
ami  in  future  as  the  early  use  of  passive  movement,  which  Sir  W. 
Bennett  has  advocated  so  strongly,  becomes  more  general,  the  time 
required  before  the  patient's  employment  is  renewed  will  be  materially 

shortened. 

Indications  for  Operative  Interference  in  Simple  Fractures. — 
A.  Those  cases  of  spiral  or  oblique  fracture  in  which  careful  attempts 
guided  by  radiography  have  failed  to  satisfactorily  reduce  the  displace- 
ment; or  where  reduction  is  effected,  but  on  the  patient's  recovering 
from  the  anaesthetic  the  fragments  slip  apart.  In  the  rare  cases  where 
crepitus  is  noticed  to  be  absent,  a  suspicion  of  intervening  soft  parts 
would  arise,  justifying  exploration.  B.  Some  cases  of  Pott's  fracture. 
The  general  health,  vitality,  and  habits  of  the  patient  must  be 
satisfactory,  and  the  surroundings  such  as  to  ensure  an  aseptic  result 
being  secured. 

A.  Operation. — The  entire  leg,  foot  and  toes  are  most  carefully 
prepared  (p.  1012).  Any  blebs  should  be  incised,  and  pure  car- 
bolic  acid   applied.       The  exposed    surface   should    be    dusted   with 

Fig.  434. 


m&mmmm 


sterilised  aristol  while  the  compress  is  on.  The  sterilisation  should  be 
carefully  repeated  when  the  patient  is  anaesthetised.  The  fragments 
are  best  exposed  by  a  longitudinal  incision  over  the  superficial  aspect  of 
the  tibia  :  a  flap  is  more  likely  to  further  interfere  with  the  vitality  of  the 
parts  (p.  1016).  Any  intervening  blood  clot  or  muscle  or  fascia  having 
been  removed,  the  fracture  is  reduced,  often  a  matter  of  much  difficulty. 
While  extension  and  counter-extension  are  made  by  assistants,  the 
surgeon  prises  the  fragments  into  their  correct  position  by  means  of 
a  strong  elevator  and  lion-forceps,  any  comminuted  fragments  which 
admit  of  it  (p.  1012)  being  accurately  fitted  into  place.  If  it  is 
necessary  to  remove  part  of  either  fragment  the  periosteum  must  be 
detached  ;  otherwise  this  membrane  is  left  carefully  in  situ. 
While  the  corrected  position  is  maintained  by  lion-forceps,*  or 
extension  and  counter- extension,  the  fixation  is  carried  out.  Mr. 
Lane's  screws  (Fig.  434)  are  an  excellent  means  of  effecting  this. 
They  are  of  silvered  steel,  long,  and  practically  of  the  same  width 
throughout :  the  thread  is  a  wide  one  and  the  head  small,  so  that  a 
small  cavity  in  the  bone  suffices  for  its  reception.  A  series  of  drills  or 
bradawls  should  be  at  hand,  and  the  one  selected  should  be  slightly 

*  Peter's  modification  of  these  which  allow  of  screws,  fee.,  being  passed  through  the 
jaws  while  these  are  holding  the  fragments  firm  are  most  useful. 


1018  OI'KUATIONS    ON    TIIK    fOVVKR    EXTREMITY. 

smaller  than  the  screw.  Both  fragments  are  then  drilled  obliquely 
and  together,  and  when  this  is  done  the  holes  should  be  sufficiently 
far  from  the  ends  of  the  fragments  to  prevent  any  splitting  of 
the  hone.  As  a  further  precaution  against  this  the  upper  part  of  the 
drill-hole  should  be  enlarged  with  a  reamer  (Fig.  435)  of  the  same 
size  as  the  shank  of  the  screw.  A  cavity  should  also  he  made  with  a 
small  gouge  or  burr  to  receive  the  head  of  the  screw.  As  this  is 
finally  driven  home  it  should  he  felt  to  draw  the  fragments  together 
and  to  lock  them  firmly.  Other  means  of  fixation  are  referred  to  in 
the  next  section.  The  wound  is  then  thoroughly  dried  out:  the 
amount  of  drainage  and  the  number  of  sutures  indicated  depend  on 
the  condition  of  the  soft  parts,  superficial  and  deep.  And  the  same 
factors  in  the  case  will  decide  whether  dry  dressings  or  a  horacic  acid 
fomentation  are  employed.  As  screws,  after  fulfilling  their  function, 
are  liable  to  cause  trouble  such  as  localised  suppuration,  sinuses  and 
necrosis,  it  may  be  after  a  long  interval,  it  is  well  to  remove  them 
about  six  weeks  after  the  insertion.  If  secure,  they  require  to  be 
unscrewed. 

B.  Pott's  Fracture. — The  occasional  severely  crippling  and  disabling 
deformity  of  pes  valgus  which  may  follow  eversion-fractures  is  well 
known,   and    certainly   calls  for  remedy  by   operation.      But  if  these 

Fig.  435. 


injuries  were  only  treated  with  "brains,"  if  the  nature  of  a  Pott's 
fracture  were  remembered  with  the  displacement  of  the  foot  backwards 
as  well  as  outwards,  the  rapid  and  large  effusion,  the  parts  implicated 
thereby,  and  the  tendency  to  look  upon  these  injuries  as  severe 
sprains,  the  need  for  such  interference  would  arise  very  rarefy 
indeed. 

Owing  to  the  calls  on  mjr  space  cases  of  recent  origin  and  those  of 
longer  standing  will  be  considered  together.  For  compound  fractures 
or  separation  of  the  lower  epiphysis  of  the  tibia  the  remarks  at  p.  1012 
should  be  referred  to. 

Operation. — It  is  only  in  recent  cases  up  to  about  the  third  week 
that  forcible  correction,  by  manipulations  aided  by  a  wrench  will  be  of 
any  avail.  Where  this  fails  to  place  the  foot  in  an  over-corrected 
position,  a  point  as  essential  as  in  talipes,  some  modification  of  osteotomy 
may  suffice.  Thus  the  fibula  is  exposed  by  a  longitudinal  incision 
over  its  lower  part,  and  the  bone  either  refractured  or  better  divided 
transversely  with  a  chisel,  care  being  taken  of  the  periosteum.  If 
correction  is  impossible  a  curved  incision  is  made  freely  over  the 
internal  malleolus,  the  tibia  exposed  by  separation  of  the  periosteum 
and  soft  parts,  and  a  wedge,  the  size  of  which  is  proportionate  to  the 
deformit}',  cut  out  with  a  chisel,  the  bone  not  being  completely  divided. 
By  fracturing  the  remaining  portion  over-correction  can  generally  be 
effected.  Furthersteps  whichmay  be  needed  are  division  of  adhesions 
about  the  internal  malleolus,  or  removal   of  this   process  or  redundant 


UNUNITED  FRACTURES.  1019 

callus  where  mal-union  has  taken  place.  If  any  equinus  position 
persist,  the  tendo  A  chillis  should  he  divided.  In  some  cases  an  oblique 
osteotomy  of  the  fibula  is  preferable  to  a  transverse  one,  by  allowing 
better  of  shifting  of  the  fragments,  and  the  same  step  with  a  similar 
objecl  may  occasionally  replace  the  cuneiform  osteotomy  of  the  tibia. 
Removal  of  the  lower  end  of  the  fibula,  while  facilitating  greatly  the 
needful  inversion  is  never  permissible  in  patients  of  the  age  at  which 
this  fracture  occurs :  the  after-stability  of  the  foot  and  secure  walking 
are  liable  to  be  seriously  interfered  with.  Drainage  should  always  be 
employed,  and  most  of  the  sutures  inserted  should  be  left  untied  for 
the  first  few  days.  Back  and  side  splints  are,  in  my  opinion,  greatly 
preferable  to  plaster  of  Paris  at  the  first,  if  the  right-angled  position  of 
the  foot  is  to  be  maintained. 

The  patient  must  be  prepared  to  take  his  just  share  of  the  responsi- 
bility as  to  the  result  by  helping  in  the  needful  passive  movements 
and  massage,  early,  and,  as  soon  as  the  union  is  sufficiently  firm,  by 
undertaking  those  of  an  active  kind. 


UNUNITED     FRACTURES. 

Recent  years  have  shown  that  operative  interference  has  made  here 
no  real  advance  as  to  certainty  of  result  which  is  proportionate  to  the 
progress  of  modern  surgery.  The  methods  of  fixation  have  increased 
in  number.  But  while,  theoretically,  these  are  full  of  promise,  in 
practice  failure  is  still  common.  The  chief  addition  to  our  knowledge  is 
the  information  which  the  Rontgen-rays  may  give  as  to  the  condition 
of  the  ends  of  the  bone  or  bones,  the  direction  of  the  line  of  the  fracture, 
whether  oblique  or  transverse,  how  far  they  are  symmetrical,  the 
amount  of  separation,  and,  especially,  how  far  they  are  normal  or 
expanded,  or  atrophied.  By  the  information  thus  gained  the  surgeon 
is  aided  in  his  selection  amongst  the  different  methods  of  fixation. 

Operation. — While  the  following  remarks  have  been  inserted  here 
for  the  sake  of  convenience,  they  apply  not  only  to  the  bones  of  the 
leg,  but  also  to  the  humerus  and  femur.  It  may  be  useful  to  refer  to 
the  best  mode  of  access  to  the  humerus  (Vol.  I.,  p.  160),  and  that  to 
the  femur  {supra,  p.  943).  AVhile  the  tibia  offers  a  subcutaneous 
surface  on  its  inner  aspect  which  invites  attack,  its  outer  aspect  can  be 
safely  reached  by  working  within  the  detached  periosteum.  While 
this  hint  applies  to  other  bones  with  important  structures  lying  on 
one  aspect  it  must  not  be  taken  to  sanction  needless  detachment  of  the 
above  membrane.  The  limb  must  be  emptied  of  blood  and  an 
Esmarch's  bandage  applied.  In  making  his  incision  the  surgeon  will 
be  guided  by  the  information  given  by  the  rays.  If  a  flap  be  preferred, 
the  objections  given  at  p.  1016  to  this  method  do  not  apply  so  strongly 
here,  where  the  vitality  of  the  parts  is  better  and  thorough  sterilisation 
more  easily  secured.  A  free  longitudinal  incision  usually  suffices.  The 
remarks  at  p.  1017  apply  to  the  exposure  of  the  fragments.  These  are 
next  sufficiently  refreshed  by  the  removal  of  any  scar  tissue,  &c,  with  a 
chisel  and  mallet  or  bone-forceps  ;  a  thin  slice  is  then  removed  from 
each  fragment,  and  if  they  lend  themselves  to  mortising  or  stepping 
(vide  infra),  they  are  shaped  accordingly.  They  are  now  brought  in 
apposition,  especial  precaution  being  taken  as  to  faulty  rotation  of  the 


1020 


ol'KKATloXs    (>N    TIIK    LOWER    EXTREMITY. 


L.wcr  fragment,  partly  by  extension  and  counter-extension,  partly  by 
manipulation  with  powerful  elevators  or  forceps.  Much  difficulty  may 
be  met  with  where  one  fragment  is  depressed  and  firmly  embedded  in 
the  soft  part-,  and  the  needful  disturbance  of  these  may  be  great  in 
spite  of  much  ingenuity  and  patience.  Any  tense  hands  which  interfere 
with  the  replacement  must  be  detached  or  divided,  after  due  examina- 
tion of  their  possihle  contents.     Thus  in  the  case  of  the  humerus  the 

Fig.  436. 


A.  An  oblique  fracture. 


B.  A  transverse  one.     (Cheyne  and  Burghard.) 


musculo-spiral  nerve  must  be  remembered.     To  retain   them  in  place 
the  following  methods  oj f fixation  are  available. 

1.  Soncs. — The  use  of  these,  especially  indicated  where  the  fracture 
is  known  to  be  an  oblique  one,  has  been  described  at  p.  1017. 

2.  Wire  (Fig.  436). — While  this  material  does  not  give  a  hold  as 
firm  as  does  a  screw,  and  while,  if  used  in  the  ordinary  way.  it  involves 
more  complete  exposure  of  the  fragments,  it  is  the  material  with  which 


Fig.  437. 


Fig.  43S. 


the  majority  of  surgeons  are  most  familiar;  it  is  always  available,  and, 
if  it  gives  after-trouble,  it  is  more  easily  removed  than  a  screw.  When 
its  use  is  preceded  by  drilling,  Figs.  436  and  437  illustrate  useful 
methods  in  the  case  of  an  oblique  fracture,  and  Fig.  436  that  when 
the  fracture  is  transverse.  In  the  latter  case  the  use  of  two  wires 
when  practicable  is  always  advisable.  While  this  step  is  not  essential, 
where  it  has  not  been  employed  greater  care  i>  always  needed  in  the 
application  of  splints  or  plaster  of  Paris  (p.  1013).  I  do  not  consider 
the  use  of  drilling — always  the  most  difficult  and  prolonged   part  of  the 


CM  XNT.h    K It Af TURKS.  102 1 

operation — as  necessary.  One,  or  better  two,  encircling  wires  will 
often  suffice  (Fig.  43ft).  To  give  an  additional  hold  the  bone  maybe 
notched  as  there  Bhown.  Tlu:  wire  is  more  easily  embedded  if  it  be 
passed  outside  the  periosteum.  In  three  cases  of  fracture  of  the 
humerus,  the  use  of  a  single  wire  led  to  an  excellent  result ;  while  in 
one,  when  1  last  saw  the  patient,  union  was  not  complete,  the  patient 
had  resumed  his  work  as  a  miner.  However  the  wire  is  employed,  its 
ends  Bhould  be  cut  short,  after  the  twisting,  and  embedded.  The  wire 
should  be  soft.  The  most  useful  sizes  are  Xos.  5  and  6,  French 
gauge.  By  some  iron  wire  is  preferred,  but  I  have  seen  nothing  to 
lead  me  to  believe  that  troublesome  after-effects  are  influenced  by  the 
material  of  the  wire  employed. 

3.  Ivory  Pegs. — The  objection  to  these  is  that  they  soon  work  loose. 
According  to  Watson  Cheyne,  C.B.  and  Burghard  (Man.  of  Surf/. 
Treat.,  pt.  iii.  p.  52)  this  can,  to  some  extent,  be  avoided  by  using  square 
]>■  gs.  Care  must  be  taken  in  driving  them  home  not  to  damage  the 
soft  parts  or  break  off  the  peg. 

4.  Senn's  Bone  Ferrules. — (Amer.  Journ.  Med.  Sei.,  1893,  vol.  ii. 
p.  125).     These  are  theoretically  ideal.     They  not 

only  hold  the  fragments  well  in  place,  but  afford  Fig.  439. 

a  scaffolding  along  which  reparative  material  may 
travel.  They  are  not  always  available,  and  diffi- 
culty in  satisfactorily  ensheathing  the  second  frag- 
ment is  liable  to  occur. 

5.  Aluminium  Perforated  Collars  or  Plates.—  Gussenbauer-S  stapie 
These  are  recommended  by  Messrs.  v^  atson  (v  Ber^mann's  Sur- 
Cheyne,   C.B.   and    Burghard    (loc.   supra  cit.)   in     gcry'). 

cases  where  lateral  displacement  is  a  marked 
feature,  or  where  a  tendency  of  the  lower  fragment  to  rotate  is  difficult 
to  meet.  If  the  bone  be  cylindrical  a  partial  collar  encircling  about 
three-fourths  of  the  circumference  is  employed ;  in  other  cases  two 
narrow  plates  are  insei'ted,  one  on  either  side  of  the  bone.  In  either 
case  they  are  secured  with  nickelled  tin-tacks. 

6.  Dovetailing  or  Mortising  the  Fragments. — Very  occasionally,  the 
condition  in  which  these  are  found  lends  itself  to  cutting  them  into 
step-like  shape,  or  zig-zag  fashion,  so  as  to  secure  better  interlock- 
ing. They  are  thus  secured  with  a  screw  or  peg  passed  horizontally  or 
vertically,  a  ferrule  or  aluminium  plate. 

7.  Gussenbauer's  Staple  (Fig.  439). — This  very  simple  method 
deserves  a  wider  knowledge  in  this  country.  If  any  sinus  form,  and 
the  staple  give  evidence  of  becoming  loose,  the  adjacent  skin  must  be 
kept  sterile. 

8.  Bone-Grafting. — This  subject  has  been  referred  to  at  p.  1009. 
Here  the  graft  is  best  taken  from  the  bones  themselves.  In  the  case 
of  a  single  bone  a  portion  covered  with  and  still  connected  with  its 
periosteum,  if  possible,  is  chiselled  off  and  jammed  in  between  the 
freshened  fragments.  This  fixity  is  essential  as  no  wire,  &c,  can 
usually  be  employed.  In  the  case  of  two  bones,  where  the  intact  con- 
dition of  one  prevents  the  approximation  of  the  fragments  of  the  other, 
the  graft  is  best  taken  from  the  unbroken  bone  (p.  1009).  In  other  cases 
the  bone  has  been  taken  from  a  distance,  as  in  Sir  W.  Macewen's  case 
(Vol.  I.   p.    159),   where  the   wedges   removed   in   osteotomies   were 


1022  OPERATIONS    ON   THE   LOW  Ki;    EXTREMITY. 

employed.  As  the  method  of  bone-grafting  is  chiefly  indicated  in  the 
less  promising  cases  where  the  ends  are  much  atrophied  or  widely 
separated,  too  much  must  not  be  expected  from  it.  Scheuer  has  me1 
the  difficulty  with  brilliant  success  in  a  severe  case  of  pseudarthrosis  of 
the  humerus  in  a  boy  aged  four.  After  refreshing  the  cuds  of  the  bone 
he  implanted  a  flap  from  the  thorax  containing  a  piece  of  the  fifth  rib. 
Bony  union  followed,  and  the  pedicle  was  divided  fourteen  days  later 
(v.  Bergmann's  Sj/st.  of  Sun/., .  1  mer.  Trans.,  vol.  iii.  p.  138).  In  the  case 
of  the  lower  extremity,  it  might  be  possible  to  follow  this  example  by 
taking  the  bone  from  the  opposite  limb. 

As  before  stated,  the  question  of  drainage,  and  the  extent  to  which 
it  is  advisable  to  close  tbe  wound  at  once  with  sutures,  must  depend 
on  the  amount  of  disturbance  inflicted  on  the  parts.  Complete  closure 
of  the  wound  looks  admirable  at  the  time,  but  may  well  entail  too 
much  risk.  From  his  knowledge  of  anatomy  and  the  size  of  any  vessels 
divided  the  surgeon  should  decide  as  to  whether  it  is  safe  to  leave  the 
removal  of  the  Esmarch's  bandage  until  the  dressings  are  in  situ  (p.  959), 
a  course  always  to  be  followed  if  possible. 

EXCISION   OF  VARICOSE  VEINS. 

This  method,  as  old  as  the  times  of  Celsus,  and  one  which  fell  into 
disuse  from  the  risks  of  pyaemia,  &c,  was  revived  with  safety  some 
years  ago  by  Mr.  Davies-Colley  (Guy's  Hasp,  lie]).,  1875,  p.  431), 
when  Lord  Lister  had  shown  how  the  old  dangers  might  be  avoided. 

Indications. — Safe  as  this  operation  has  been  made,  it  is  to  be 
recommended  with  caution  owing  to  the  great  risk  of  recurrence.  If 
this  operation  is  largely  employed,  and  the  cases  are  carefully  watched, 
it  will  be  found  after  some  years  that  the  amount  of  permanent  benefit 
ensured  is,  in  many  cases,  very  small.  I  allude  especially  to  opera- 
tions performed  below  the  knee  only  {vide  infra),  or  to  those  cases, 
often  of  markedly  diffuse  varicosity,  where  small  multiple  incisions, 
thirty  to  fifty,  are  made  on  the  two  limbs. 

Operative  interference  here  requires  more  discrimination  than  it  has 
received  either  by  surgeons  or  patients.  The  public  look  upon 
operation  here  as  not  onty  absolutely  safe,  but  as  equally  certain  to 
bring  about  a  cure.  Any  surgeon  wishing  to  maintain  a  character  for 
honesty  will  consider  this  claim  to  be  a  most  harmful  exaggeration. 
AYbile  operation  in  well  chosen  cases  will  remove  many  discomforts 
and  certain  sources  of  danger,  it  is  extremely  rare  that  it  enables  the 
patient  to  dispense  entirely  with  the  need  of  further  attention  to 
his  veins. 

Before  the  varices  are  removed  it  must  be  ascertained  that  the  better 
supported  deep  veins,  through  which  it  is  intended  that  the  blood  shall 
largely  return  after  the  superficial  ones  are  obliterated,  are  healthy.* 
The  cases  best  suited  for  operation  are:  (1)  "Where  only  one  vein- 
trunk  is  involved,  at  one  or  two  definite  parts  of  its  course.  (2)  Where 
both  saphenous  veins  are  involved,  but  again  definitely  and  locally. 
The  more  the  varices  are  longitudinal,  the  more  they  lie  in  the  lines 

*  A  full,  tumid  condition  of  the  calves,  with  cramp-like  pains  here,  [mints  to  a 
varicose  state  of  the  sural  veins,  and  is  against  operation;  so  too  are  any  tendency  to 
oedema,  or  increase  in  the  size  of  the  liml>. 


EXCISION    OF    VARICOSK    VKINS. 


1023 


Fig.  440. 


of  the  trunk,  the  more   longitudinal   incisions  will  suffice,  the  more 
satisfactory  the  operation  and  the  better  and  more  lasting  the  results. 
On  the  other  hand,   where  the  enlargement  is  bilateral  and  general, 
where  numerous  communicating  veins  between  the  trunks  are  enlarged, 
where  the  venous  radicles  are  becoming  dilated  and  their  ramifications 
plexiform,  the  more,  in  short,  that  the  disease  shows  signs  of  being  a 
general  one,  the  more  will  the  result  be  disappointing.      Finally,  the 
soft  parts  near  the  varices  should  be  in  a  healthy  condition,  free  from 
dermatitis,  and  thus  capable  of  being 
rendered  aseptic,  and  of  uniting  quickly 
afterwards.     In  a  few  cases,  though  the 
conditions  given  above  as  essential  for 
success  are  absent  operation  is  still  in- 
dicated.    (3)   Where  many  varices  exist, 
but    one   is   especially  troublesome,   as 
where  a  very  thin- walled  vein   crosses 
the   tibia   in  an  exposed   position  in  a 
young  adult,  to  whom  playing  football, 
&c,    means   very    much ;    or    where    a 
varix  is  the  cause  of  an  ulcer  trouble- 
some to  heal,  and,  perhaps,  already  the 
source  of  dangerous  bleeding  (Fig.  440). 
(4)  In  some  cases  of  thrombosis.   Where 
a  patient  is  the  subject  of  thrombosis 
in  "the  dangerous  area"    (vide   infra) 
and  the  thrombus  is  creeping  upwards 
a    surgeon   who    can   rely   on   the   case 
running  an  aseptic  course  is  quite  justi- 
fied in  placing  a  ligature  on  the  proximal 
side  of  the  thrombus  with  the  view  of 
preventing  its  reaching  the  large  trunks. 
How  far  it  is  wise  for  him  to  go  further 
and  remove  the  thrombus  at  the  same 
time   or   later   with  the  object  of  pre- 
venting implication  of  the   deep  veins 
and  a  recurrence  of  the  thrombus  must 
depend  on  the  individual  case.     Sir  W. 
Bennett    ("  Varix    and    Thrombosis," 
p.  49)  goes  further  and  considers  that 
in  a  certain  number  of  cases  of  throm- 
bosis followed   by  embolism  "incalcu- 
lable good  can  be  done  by  surgical  means  provided  that  action  is  taken 
speedily  and  boldly."     Thus  if  a  thrombus  in  the  "dangerous  area" 
(vide  infra)  shows  signs  of  softening,  if  one  or  two  attacks  of  cardiac 
pain  and  dyspnoea  have  occurred,  removal  of  the  source  of  the  emboli, 
or  interruption  by  ligature  of  the  channel  by  which  they  have  reached 
the  central  parts,  and  by  which  the}'  may  produce  another  and  a  fatal 
attack  is  called  for. 

I  shall  describe  two  operations.  (1)  That  by  which  the  "dangerous 
area"  of  Sir  W.  Bennett  is  removed;  (2)  that  of  Trendelenberg.  I 
have  used  the  first  largely  and  my  experience  justifies  ni}r  saying  that 
I  consider  it  to   be   the  one  most  suitable  to  the  largest  number  of 


Case  of  varicose  internal  saphena 
vein  with  dermatitis  and  ulceration 
below.  From  the  ulcer  severe  haemor- 
rhage had  occurred.  I  saw  the  woman 
three  years  after  the  operation  on 
the  varicose  veins,  and  she  remained 
well,  but  I  have  lost  sight  of  her 
since. 


1024  OPERATIONS    ON   THE    LOW K 11    KXTItKMITY. 

cases  in  which  an  operation  is  justified,  and  one  which  is  least  likely 
in  its  results  to  lead  to  disappointment.  Sir  W.  Bennett  (loc.  supra 
cit.,  p.  18),  has  given  the  term  "  dangerous  area  "  to  that  part  of  the 
inner  aspect  of  the  lower  limb  "which  is  marked  off  by  two  transverse 
lines,  one  about  the  middle  of  the  thigh,  and  another  three  inches 
below  the  knee-joint,  an  area  in  which  the  local  conditions  predisposing 
to  thrombosis  in  varix  are  present  in  a  remarkable  degree.  Cysts, 
often  of  great  size,  huge  dilated  tortuous  vessels,  valveless  and  with 
abrupt  bends  are  frequent,  and  are  constantly  being  subjected  to  the 
straining  movements  produced  by  flexion  and  extension  of  the  knee." 
A  little  later  Sir  William  writes:  "  Speaking  generally,  if  the  disease  is 
confined  to  the  leg,  operation  is  useless  ;  sometimes  it  is  harmful." 
And  again,  "operative  measures  confined  to  the  parts  below  the  knee 
in  general  varix  are  useless." 

Operation. — The  skin  of  the  limb  or  limbs  must  be  first  carefully 
sterilised,  and  if  the  operator  for  any  reason  is  likely  to  trench  upon 
the  back  of  the  limb,  this  area  with  its  thicker  skin  must  not  be 
forgotten.  This  step  having  been  completed,  the  patient  should  stand 
in  order  to  distend  the  veins,  the  outlines  of  which  are  then  marked  on 
the  skin  with  sterilised  carbolic  acid  fuchsin  solution  applied  either 
with  a  sterilised  camel-hair  brush  or  a  match-stick.  The  usual 
compress  is  then  applied.  When  the  patient  is  placed  on  the  table 
the  limb  should  be  allowed  to  be  dependant  while  the  anaesthetic  is 
given,  and  if  both  limbs  require  removal  of  the  "  dangerous  area"  this 
can  be  done  simultaneously  by  two  operators,  if  the  limbs  be  well 
abducted,  everted  and  rotated  outwards.  An  incision  is  made  from 
above  downwards  over  the  above  mentioned  area  starting  in  the 
middle  of  the  inner  aspect  of  the  thigh,  and  the  dilated  saphena  vein 
exposed  by  light  touches  of  the  knife.  Fine  sterilised  silk  having  been 
passed  by  an  aneurysm-needle  around  the  vein  in  the  upper  angle  of 
the  wound  and  Spencer  Wells's  forceps  applied  a  little  lower  down,  the 
ligature  is  secured,  cut  short  and  the  vein  divided.  Then  the  operator, 
dragging  gently  on  the  forceps,  exposes  the  vein  gradually  by  pro- 
longation of  the  longitudinal  incision  down  to  the  middle  of  the  leg, 
dissects  the  vessel  out  at  this  point,  where  another  ligature  is  applied  in 
the  lower  angle  of  the  wound,  and  the  varix  removed.  Any  branch-veins 
which  have  been  clamped  with  forceps  are  now  tied,  and  it  will  shorten 
a  prolonged  operation  if  when  the  upper  half  of  the  vein  has  been 
dissected  out,  a  trustworthy  assistant,  standing  above  the  operator 
and  on  the  opposite  side  of  the  limb,  begins  to  close  the  long  wound 
with  sterilised  gossamer  salmon-gut  sutures.  I  will  venture  to  draw 
the  attention  of  my  younger  readers  to  the  following  cautions, 
(i)  The  strictest  aseptic  precautions  will,  of  course,  be  taken  through- 
out by  all  concerned.  (2)  The  frequency  of  a  collateral  trunk  or  a 
double  internal  saphenous  vein  in  the  thigh  must  be  remembered. 
When  such  a  condition  is  present  the  vessel  usually  lies  superficial  to 
the  parent  trunk  ;  if  the  latter  be  healthy,  it  may  need  no  interference 
(Davies-Colley,  loc.  supra  cit.).  (3)  Every  bleeding  point  Bhould  be 
carefully  tied,  otherwise  tension  may  occur,  with  undermining  of  the 
edges  of  the  wound  with  blood  clot  and  delayed  healing.  (4)  The 
ligatures  should  be  of  the  finest  and  most  thoroughly  sterilised, 
otherwise  they  will  work  out  vexatioiisly,  a   result    rendered  the  more 


EXCISION   OF   VARICOSE    VEINS.  1025 

probable  it'  the  patient  persist  in  getting  about  too  early.  (5)  The 
close  proximity  <>f  the  nerve  trunks  below  the  knee  must  be  remem- 
bered. I  consider  it  quite  justifiable  to  resect  a  portion  of  one  of 
these  where  a  patient  complains  bitterly  of  the  pain  caused  by  a 
clump  of  plexiform  dilated  varices  about  either  malleolus,  and  where 
it  is  doubtful  if  the  removal  of  the  varicose  condition  ahove  will  relieve 
this.  Owing  to  the  multiple  distrihution  of  nerves  to  the  foot,  the 
numbness  over  the  area  affected  becomes  very  little  noticeable. 
(6)  The  patient  should  rest  ahsolutely,  in  bed  or  on  the  sofa,  for  at 
least  three  weeks.  (7)  Longitudinal  incisions  have  been  alone 
described  in  this  account  of  removal  of  the  "  dangerous  area  "  of  the 
internal  saphena,  and  the  upper  part  of  the  external  also.  In  removal 
of  some  dilated  clump,  e.g.,  one  lying  over  the  popliteal  space  or  one 
especially  troublesome  which  lies  off  the  parent  trunks,  a  flap  may 
appear  indicated.  Such  is  to  be  used  as  sparingly  as  possible,  as  the 
vitality  of  the  skin,  already  poor,  will  be  further  impaired.  (8)  If  the 
wound  becomes  infected,  a  boracic  acid  fomentation  should  be  applied 
at  once,  and  those  sutures  which  need  it  removed. 

Trendelenberg's  operation. — Here  about  two  inches  of  the  saphena 
vein  are  resected  just  below  the  saphenous  opening.  This  step  is  only 
indicated  in  those  cases  to  which  Trendelenberg's  test  applies.  The 
limb  having  been  raised  and  emptied  of  much  of  its  blood  the  saphena 
vein  is  compressed  and  the  limb  lowered.  If  the  blood  can  be  seen  to 
fill  the  empty  vein  immediately  after  the  pressure  is  removed 
Trendelenberg  considered  it  proved  that  in  such  a  case  there  was  a 
column  of  blood  reaching  from  the  right  side  of  the  heart  to  the  foot, 
unsupported  by  valves.  The  precaution  mentioned  at  p.  1024  must  be 
remembered  here.  Where  there  is  reason  to  suspect  that  the  deep 
veins  are  varicose  this  operation  should  not  be  performed.  The 
spine  of  the  pubes  having  been  identified,  a  line  three  and  a  half 
inches  long  is  drawn  from  this  point  and  an  incision  three  inches  long 
made  in  its  lower  half.  By  some  a  transverse  incision  is  preferred. 
Some  difficulty  may  be  met  in  finding  the  vein  in  fat  patients.  The 
saphena  having  been  isolated  for  two  inches,  this  portion  is  resected 
between  two  ligatures  of  sterilised  silk.  The  inner  lip  of  the  wound 
should  be  retracted  upwards  to  allow  of  the  upper  ligature  being 
applied  as  close  to  the  femoral  vein  as  is  possible.  I  need  not  insist 
upon  the  absolute  need  of  scrupulous  asepsis  here.  While  Trendelen- 
berg's operation  gives  good  results  in  those  cases  in  which  it  is 
especially  indicated,  I  prefer  that  to  which  I  have  given  Sir  W. 
Bennett's  name.  I  consider  that  this,  by  removal  of  the  "dangerous 
area,"  leaves  the  patient  in  a  safer  condition,  that  it  meets  the  needs 
of  a  larger  number  of  cases,  and  that  it  is  more  free  from  risk.  Either 
operation  may,  if  it  is  desired,  be  performed  with  local  analgesia 
(vol.  i.  p.  652). 


s. — vol.  11.  65 


CHAPTER   VII. 
OPERATIONS  ON  THE  FOOT. 

LIGATURE  OF  THE  DORSALIS  PEDIS.— SYME'S  AMPUTA- 
TION.— ROUX'S  AMPUTATION— PIROGOFF'S  AMPUTA- 
TION.—SUB-ASTRA  GALOID  AMPUTATION.— EXCISION 
OF  THE  ANKLE. — ERASION  OF  THE  ANKLE.— EXCISION 
OF  BONES  AND  JOINTS  OF  THE  TARSUS.— EXCISION 
OF  ASTRAGALUS.— EXCISION  OF  OS  CALCIS.— MORE 
COMPLETE  TARSECTOMY  FOR  CARIES.— REMOVAL 
OF  WEDGE  OF  BONE,  AND  OTHER  OPERATIONS  FOR 
INVETERATE  TALIPES.— CHOPART'S  AMPUTATION. 
— TRIPIER'S  AMPUTATION.— AMPUTATION  AT  META- 
TARSOPHALANGEAL JOINT.— AMPUTATION  OF  THE 
TOES. 

LIGATURE    OF    THE    DORSALIS    PEDIS    (Fig.  441). 

Indications. — Very  rare.  (1)  Wounds.  (2)  Together  with  the 
posterior  tibial  in  the  lower  third,  for  haemorrhage  from  punctured 
wounds  of  the  sole  resisting  other  treatment.  (3)  For  some  vascular 
growths  of  the  foot. 

Line. — From  the  centre  of  the  ankle-joint  to  the  upper  part  of  the 
first  interosseous  space. 

Guide. — The  above  line  and  the  adjacent  tendons  of  the  great  and 
second  toe. 

Relations  : 

In  Feont. 

Skin,  fascise  ;  branches  of  saphenous  veins,  and  of  musculo- 
cutaneous and  anterior  tibial  nerves. 

A  special  deep  fascia  continuous  with  the  sheaths  of  the 
adjacent  tendons. 

Extensor  brevis  (innermost  tendon). 

Outside.  Inside. 

Vein  Dorsalis  pedis       Vein. 

Anterior  tibial  nerve.  artery.  Extensor longushallucis. 

Extensor  longus  digitorum. 

Behind. 

Astragalus;  scaphoid;  middle  cuneiform. 


SYMK'Sj  AMPUTATION. 


1027 


Operation  (Fig.  441). — The  foot  having  been  cleansed,  an  incision 
about  an  inch  and  a  half  long  is  made  in  the  line  of  the  artery,  in  the 
lower  part  of  its  course,  commencing  about  an  inch  and  a  half  below 
the  ankle-joint.  Skin  and  fascise  being  cut  through,  and  any  super- 
ficial veins  tied  with  chromic  gut  or  drawn  aside,  one  of  the  long 
extensors  is  found  (its  sheath  is  not  to  be  opened),  and  the  strong 

Fig.  441. 


The  dorsalis  pedis  (too  much  of  the  artery  is  shown  cleaned)  is  seen  lying  between  the 
extensor  longus  hallucis  and  digitorum,  and  crossed  by  the  innermost  tendon  of  the  short 

extensor. 

fascia  given  off  from  them  opened.  If  the  extensor  brevis  cross  the 
artery  at  this  spot  it  must  be  drawn  aside.  The  ligature  should  be 
passed  from  without  inwards. 


SYME'S    AMPUTATION. 
(Figs.  442  and  443.) 

An  amputation  at  the  ankle-joint  by  a  heel-flap,  with  removal  of  the 
malleoli. 

Operation. — The  thick  skin  of  the  heel  requires  careful  sterilising. 
Haemorrhage  having  been  controlled,  any  sinuses  present  scraped  out 
and  disinfected,  and  the  foot  held  at  right  angles  to  the  leg,  the  surgeon, 
standing  a  little  to  the  right,  but  so  as  easily  to  face  the  sole,  marks 
out  the  points  mentioned  below  with  the  index  finger  and  thumb.  He 
then  makes,  with  a  short,  strong  knife,  an  incision  (in  the  case  ot  the 

65—2 


1028 


OPERATIONS    ON    THK    LOWKll    KXTUKMITY. 


left  foot)  from  the  tip  of  the  external  malleolus  to  a  point  half  an  inch 
below*  the  internal  one,  this  incision  not  going  straight  across  the  sole 
as  in  PirogofFs  amputation,  but  pointing  a  little  backwards  towards 
the  heel.t  The  horns  of  this  incision  are  then  joined  by  one  passing 
straight  across  the  joint,!  illl(t  severing  everything  at  once  down  to 
the  ankle-joint.  The  foot  being  now  strongly  bent  downwards,  the 
lateral  ligaments  are  severed,  and  the  joint  thus  fully  opened.  The 
foot  being  slightly  twisted  from  side  to  side,  the  tendons  and  soft  parts 
on  either  side  are  carefully  divided,  the  knife  being  kept  closely  in 
contact  with  the  bones.  Especial  precautions  must  be  taken  on  the 
inner  side  to  cut  the  posterior  tibial  artery  as  long  as  possible  (to 
ensure  getting  below  the  internal  calcaneal))  and  not  to  prick  it 
afterwards. 

As  the  operation  proceeds  the  flap   is  partly  pressed   back  by  the 

Fig.  442. 


Application    of    Lynn-Thomas's    forceps-tourniquet  (p.  878)    in    Byrne's  or    PirogofFs 

amputation. 

thumb,  partly  pulled  back  and  so  saved  from   damage  by  the   knife. 
The  chief  difficulty  is  met  with  at  the  prominence  of  the  heel. 

The  foot  being  still  more  depressed,  the  upper  non-articular  surface 
of  the  os  calcis  comes  into  view,  and  then  the  tendo  Achillis.  This  is 
severed,  and  the  heel-flap  next  dissected  off  the  os  calcis  from  above 
downwards,  special  care  being  taken  to  cut  this  flap  as  thick  as 
possible,  not  to  score  or  puncture  it,  but  rather  to  peel  it  off  the  bone 


*  The  directions  usually  given  are  to  go  behind  this  point  as  well  as  below  it,  but  by 
following  the  above  course  the  posterior  tibial  is  more  likely  to  escape  section  before  its 
time,  and  the  flap  will  be  found  sufficiently  symmetrical. 

t  If  the  foot  is  small,  and,  still  more,  if  the  parts  on  the  dorsum  are  damaged,  the 
plantar  incision  should  run  straight  across.  On  the  other  hand,  the  more  prominent  the 
heel,  the  more  should  the  Hap  point  backwards.  This  will  facilitate  turning  the  Hap  over 
the  heel. 

%  Or  with  very  slight  convexity.  If  anything  of  a  flap  is  made  here,  the  operator  is 
liable  to  get  away  from  the  joint  and  cut  into  the  neck  of  the  astragalus.  Moreover,  the 
parts  are  not  well  nourished,  especially  if  sinus-riddled  or  undermined. 


SYMK'S    AMPUTATION. 


1029 


Fig.  443. 


with  the  left  thumb-nail  kept  in  front  of  the  knife,  aided  hy  touches 
of  this.* 

The  foot  having  been  removed,  the  soft  parts  are  carefully  cleared  oft'  the 
malleoli,  and  a  slice  of  the  tibia  sufficiently  thick  to  include  these  pro- 
minences removed.  This  slice  should  in  any  case,  to  avoid  shortening, 
be  the  thinnest  possible.  Prof.  Macleodf  has  recommended  to  remove 
only  the  malleoli,  leaving  the  cartilage  on  the  under  surface  of  the 
tibia.  I  have  followed  his  advice  in  my  last  fifteen  cases — in  one,  a 
private  patient  of  63,  where  I  bad  not  the  carrying  out  of  the  after-treat- 
ment, the  cartilage  exfoliated.  In  one  of  the  others  active  secondary 
syphilis  was  present ;  in  all,  in  spite  of 
tuberculous  sinuses  in  three  which  required 
repeated  scraping  out  (Fig.  446),  no  ex- 
foliation took  place.  In  one,  an  elderly 
patient  with  very  numerous  sinuses,  the 
result  of  treatment  elsewhere,  the  operation 
failed  and  amputation  through  the  leg  was 
successfully  performed.  Prof.  Macleod's 
advice  entails  less  shortening  of  the  limb 
and  does  away  with  the  risk  of  infective 
phlebitis,  which  may  be  brought  about  by 
opening  the  cancellous  tissue.  If,  on  the 
other  hand,  the  lower  end  of  the  tibia  is 
diseased,  it  must  be  removed  and  the  sawn 
surface  gouged  or  treated  with  a  sharp 
spoon.  If  the  cartilage  is  only  slightly 
diseased,  it  may  be  sliced  off  with  the  knife, 
and  gouged  here  and  there. 

Tendons  are  now  cut  short,  sinuses 
thoroughly  scraped  out  and  disinfected, 
and  the  vessels  secured.  Free  oozing  is 
often  present  in  tuberculous  cases,  or 
wdiere  the  periosteum  has  been  left  in  the 
heel-flap.  It  is  best  treated  by  firm  pres- 
sure with  dry  dressings,  and  elevation  of 
the  stump.  Drainage  having  been  provided 
through  the  cup-like  heel-flap  if  no  sinuses 
are  conveniently  placed,  the  sutures  are 
inserted.  I  prefer  some  of  silver  wire  sufficiently  stout,  as  they  last 
longer  than  silk.  They  should  be  passed  at  such  a  depth  and  a  distance 
from  the  edge  of  the  heel-flap  to  ensure  their  holding  this  up  well. 
Where  many  sinuses  have  been  present  along!  the  line  of  the  incision, 
it  is  no  good  uniting  the  wound  closely. 


The  parts  in  a  Syme's  amputa- 
tion before  the  heel-flap  is  ad- 
justed (left  side).  The  bones  are 
shown  above  with  the  extensor 
tendons  and  the  anterior  tibial 
vessels,  and,  below,  the  tendo 
Aehillis.  On  the  inner  side  the 
flexor  tendons  and  the  plantar 
arteries  are  shown  cut  ;  on  the 
outer  side,  the  peronaei.  This 
figure  should  be  contrasted  with 
Fig.  448. 


*  If,  in  a  young  subject,  the  epiphysis  comes  away  in  the  heel-flap,  it  may  remain  there 
if  the  parts  are  healthy.  The  same  course  may  be  followed  with  the  periosteum,  if  it  is 
found  loose  and  peels  easily  away.  Mr.  Johnson  Smith,  when  amputating  both  feet  for 
frost-bite,  left  the  periosteum  on  one  side.  On  the  other  no  attempt  was  made  to  save  it. 
The  first  stump  was  much  larger  than  the  other,  harder,  and  more  rounded  ;  more  like 
that  of  a  Pirogoff  s  amputation. 

t  Brit.  Med .  Journ.,  1S69,  vol.  ii.  p.  239. 

%  Sinuses  which  have  been  scraped  out  will  give  good  drainage  if  enlarged.  If  any 
puncture  has  been  made  in  the  heel-flap,  it  should  be  utilised  for  the  same  purpose. 


1030 


OI'KKATIONS    ON    THK    LOWKI!     KXTKKM ITY. 


While  the  success  of  a  Syme's  amputation  depends  chiefly  on  the 
care  with  which  the  heel-flap  is  raised,  later  on  attention  must  be 
•41  \  t ■  1 1  from  the  first,  and  often  for  some  weeks,  to  apply  tin;  bandages  BO 
;i>  to  hold  the  heel-flap  up  well  and  meet  its  tendency  to  glide  down- 
wards, and  afterwards  to  hasten  the  moulding  of  it  into  good  shape. 
As  soon  as  the  stump  is  healed,  the  patient,  if  li is  occupation  require 
it,  can  get  about  on  a  knee-rest.  In  about  eight  weeks  he  will  be  able 
to  bear  weight  on  the  stump. 

Eoux's  Modification  of  Syme's  Amputation  (Figs.  444  and  445). — 


Eoux's  amputation  at  the  ankle-joint  by  an  internal  flap.     Below  is  shown  a'foot  upon 
which  the  operation  has  been  performed.     (Smith  and  Walsham.) 

In  cases  where  a  satisfactory  heel-flap  cannot  be  obtained,  an  efficient 
substitute  can  be  got  by  a  large  internal  flap. 

The  incision  is  commenced  at  the  apex  of  the  outer  malleolus,  and  carried  half  across 
the  front  of  the  ankle-joint,  from  whence  it  should  run  inwards  in  an  oblique  direction 
over  the  astragalo-scaphoid  joint,  then  pass,  in  a  curved  manner,  downwards  and  backwards 
to  the  middle  line  of  the  sole  of  the  foot,  and,  running  along  the  under  surface  of  the  heel, 
ascend  the  posterior  aspect  of  that  part,  and  terminate  at  the  outer  malleolus,  where  it 
commenced.  The  ankle-joint  should  be  opened  at  its  upper  and  outer  part,  the  os  calcis 
dissected  from  its  connections,  the  malleoli  and  a  slice  from  the  articular  surface  of  the 
tibia  removed,  and  the  operation  will  be  complete.  The  shape  of  the  flap  will  be  gathered 
from  the  appearance  of  a  foot  operated  upon  (Fig.  444). 

Causes  of  Failure  after  Syme's  Amputation. — (1)  Sloughing  of 
the  heel-flap.     This  is  nearly  always  due  to  faulty  operating,  to  scoring 

Where  a  diseased  foot  has  been  long  on  a  back-splint,  the  skin  over  the  tendo  Achillis 
may  be  so  thinned  that  it  is  advisable  to  make  a  counter-puncture  here  and  insert  a 
drain. 


PIROGOFFS   AMPUTATION.  1031 

or  "button-holing"  the  flap,  or  to  dividing  the  posterior  tibial  high 
up.*  (2)  Persistence  of  sinuses  and  tuberculous  disease.  If,  in  spite 
of  repeated  scraping  out  (Fig.  446)  with  tbc  aid  of  anesthetics,  this  con- 
dition recurs  inveterately  and  spreads  along  the  sheaths,  the  limb 
must  be  amputated  higher  up.  This  will,  however,  be  rarely  called 
for  with  perseverance  on  the  part  of  the  surgeon  to  treat  this  condition 
as  a  kind  of  malignant  disease.     If  one  or  two  sinuses  remain,  and 


Fig.  445. 


V  .- 


Roux's  amputation.     The  incisions  shown  from  the  outer  and  the  inner  side.       (Stimson.) 

look  likely  to  persist,   scraping  out  should  be  resorted,  to    at  once. 
(3)  Caries  in  the  tibia.     (4)   Death  of  the  tendo  Achillis. 

This  rare  sequela  occurred  to  me  in  1890.  The  patient  was  an  aged  inmate  of  the 
Camberwell  Infirmary.  A  bluish  undermined  patch  being  laid  open  on  the  back  of  the 
ankle  some  weeks  after  the  amputation,  the  tendon  was  found  to  have  died  up  to  its 
junction  with  the  calf  muscles.    After  its  removal  the  parts  healed  soundly. 

PIROGOFF'S    AMPUTATION. 

(Figs.  447-452). 

An  amputation  at  the  ankle-joint,  in  which  the  posterior  part  of  the 
os  calcis  is  retained  and  united  to  the  sawn  surface  of  the  tibia. 

Question  of  the  Value  of  this  Operation  especially  as  compared 
with  Syme's  Ajnputation. — Disadvantages :  These  have  been  put 
prominently  forward  by  Scotch  surgeons.  1.  The  amputation  is  not 
suited  for  cases  of  disease,  except  of  distinctly  traumatic  origin  in  young 
healthy  subjects.  2.  Occasionally  the  sawn  os  calcis  fails  to  unite, 
causing  either  a  kind,  of  movable  joint  or  necrosis.  3.  It  is  said  by 
some  that  the  stump  is  more  difficult  to  fit  with  an  artificial  foot.f 
The  first  two  objections  are  undoubted,  but  I  think  that  they  are  quite 
outweighed  by  the  Advantages  :  1.  No  dissection  of  the  heel-flap  is 
needed.     2.  The  blood-supply  is  less  interfered,  with.     3.  The  stump 

*  If  possible,  the  cut  ends  of  the  two  plantar  arteries  should  always  be  seen,  and  not 
the  single  mouth  of  the  posterior  tibial.  In  the  former  case  the  surgeon  is  certain  that  the 
main  vessel  is  divided  below  the  internal  calcanean  branch. 

t  Prof.  Macleod  thinks  that  the  presence  of  the  heel  is  here  "  a  great  drawback,  and 
that  the  back  of  the  heel,  not  the  firm  plantar  pad,  is  what  comes  in  contact  with  the 
ground."     See  the  remarks  p.  1034. 


1032  OPERATIONS    ON    THE    LOWER    EXTREMITY. 


Fig.  446. 

."■'I^'Wft 


is  firmer  and  more  solid.  4.  The  stump  is  longer  by  one  inch  or  one 
inch  .Hid  a  half,  often  more.*  5.  The  stump  does  not  go  on  wasting, 
as  is  the  case  after  a  Syme's  amputation. t  6.  Dr.  Hewson  (Amer. 
Joiini.  Med.  Sri.,  1864,  pp.  121,  129)  has  pointed  out  that,  in  a 
PirogofiFs  amputation  the  origin  and  insertion  of  the  gastrocnemius 
being  both  intact,  the  combined  movements  of  the  knee  and  ankle 
are  preserved,  as  in  running,  &c. 

Operation. — The  position  of  the  patient's  foot  and  the  surgeon 
being  as  at  p.  1027,  an  incision  is  made,  straight  across  the  sole,  from 
the  tip  of  the  external  malleolus  to  a  point 
half  an  inch  below  the  internal  one. I  This 
incision  goes  right  down  to  the  bone.  Its 
horns  are  then  joined  by  a  transverse  cut  across 
the  front  of  the  ankle.  The  lateral  ligaments 
are  now  severed,  care  being  taken  to  cut  inside 
the  malleoli  and  to  divide  the  posterior  tibial 
artery  as  long  as  possible — i.e.,  below  its  origin 
into  the  two  plantar — and  not  to  prick  it  after 
it  is  divided.  With  a  few  touches  of  the  knife 
at  either  side  of  the  astragalus,  aided  by  twist- 
ing of  the  foot  from  side  to  side  and  forcible 
bending  of  it  downwards,  the  non-articular 
part  of  the  upper  surface  of  the  os  calcis  comes 
into  view  (Fig.  447).  A  groove  is  now  cut 
through  the  tatty  tissue  and  the  periosteum, 
and  the  saw  applied  just  in  front  of  the  tendo 
Achillis,  obliquely  downwards  and  forwards 
(Fig.  449),  care  being  taken  to  bring  it  out 
through  the  incision  in  the  heel.  The  foot 
being  removed,  the  soft  parts  around  the  bones 
of  the  leg  are  carefully  cleared  to  a  level  just 
above  the  tibial  articular  surface  and  the 
malleoli,  where  the  saw  is  next  applied,  and 
the  bones  divided  with  a  similar  slight  obliquity, 
from  before  backwards  and  downwards. 

The  vessels,  the  tibials,  anterior  peronreal, 
and  perhaps  one  or  both  malleolar  having  been 
secured,  the  tendons  cut  square,  the  bony  sur- 
faces are  placed  in  contact,  and,  if  needful,  drilled  with  a  sterilised 
bradawl  and  united  with  wire.§ 


A  Syme's  stump  soundly 
healed  after  scraping  out  of 
sinuses  had  been  resorted 
to.  The  patient  was  sent 
to  me  by  Dr.  Frascr,  of 
Romford,  and  had  active 
secondary  syphilis  as  well 
as  extensive  caries  of  the 
tarsus. 


*  Dr.  Hewson  {Inc.  infra  tit.-)  gives  the  shortening  after  a  PirogofiPs  amputation  as 
from  one  to  two  Inches  ;  that  after  Syme's  operation  as  two  and  a  half  to  three  inches. 

t  The  continuance  of  this  wasting  is  shown  by  the  hospital  patient  being  for  some 
time  obliged  to  stuff  the  socket  of  his  elephant-boot  with  a  sock.  It  is  not  intended  by 
this  to  depreciate  the  value  of  a  Syme's  stump.  Every  surgeon  knows  how  much  good, 
Lifelong  work  the  heel-flap  is  capable  of,  however  much  it  shrinks,  so  long  as  it  has  healed. 

\   !.<-.,  not  pointing  backwards. 

§  If  the  patient  is  young  and  healthy,  and  if  there  be  no  tension  on  the  piece  of  os 

-  as  this  is  brought  forwards,  this  step  is  not  absolutely  needful.     I  would  recommend 

it  in  other  cases.     Thus  I   have  made  use  of  it  in   a   Pirogoff's  amputation   for  inveterate 

infantile  paralysis,  with  excellent  results.     The  wire,  cut  short,  should  be  well  hammer.  .1 

down  and  deeply  embedded. 


|>||;<><;<>IT'S    AMPUTATION. 


1033 


If  it  is  found  advisable  to  convert,  the  Pirogoff  into  a  Syme,  all  thai 
is  needed  is  to  divide  the  tendo  Aehillis  and  to  dissect  out  the  part  of 
the  os  cult-is,  keeping  the  knife  (dose  to  the  bone. 


Flo.  447. 


Fi< 


Compare  with  Fig.  443. 


Modifications  of  Pirogoff  s  Amputation. — One  of  the  chief  of  these  is  that  intro- 
duced by  Dr.  E.  Watson  (Lancet,  1859.  vol.  i.  p.  577).  He  claims — (1)  That  it  is 
shorter  and  easier,  the  trouble  of  disarticulation  being  avoided.  (2)  That  it  is  less  likely 
to  damage  the  posterior  tibial  artery.     (3)  That   it  does   away  with   one   of   the   chief 


Fig.  449. 


Division  of  the  os  calcis  in  Pirogoff  s  amputation. 

difficulties  in  a  Pirogoff's  amputation  for  injury — viz.,  the  want  of   purchase  over  the 
smashed  parts  while  the  os  calcis  is  being  sawn  through. 

Operation. — The  operator,  standing  as  before,  having  cut  across  the  sole  from  the  tip 
of  one  malleolus  to  the  corresponding  point  (p.  1032)  down  to  the  bone,  introduces  a  small 
Butcher's  saw,  or  oue  with  a  narrow  blade,  into  this  wound,  and  saws  off  the  posterior 


i»34 


OPERATIONS   ON    THE    LOWER    EXTREMITY. 


part  of  the  os  calcis  by  carrying  his  section  upwards  and  backwards.  This  and  the  heel 
being  now  retracted  by  an  assistant  (Fig.  450),  the  surgeon,  resuming  his  knife, 
upwards  behind  the  ankle-joint  between  the  sawn  bones.  The  ends  of  the  first  incision 
are  now  joined  by  one  passing  between  them,  the  skin  being  pulled  up  a  little  and  the 
tendons  and  vessels  severed  down  to  the  tibia  and  fibula  jus!  above  the  ankle-joint 
Lastly,  these  bones  are  sawn  through  in  a  slanting  manner  by  directing  the  saw  from 

Fig.  450. 


Pirogoffs  amputation  as  modified  by  Dr.  E.  Watson.     (Smith  and  Walsham.) 

before  backwards  and  downwards.*     While  the  bones  of  the  leg  are  being  sawn,  the  heel- 
flap  should  be  held  well  up  against  the  back  of  the  leg  to  keep  it  out  of  the  way. 

Modifications  by  Sfcdillot,  Gunther,  and  Le  Fort. — In  order  to  facilitate  the 
fitting  easily  of  the  sawn  surfaces  of  os  calcis  and  tibia  and  to  minimise  any  resistance  to 
this  step,  Sedillot  and   Gunther   have   advised  the  very  oblique  section  of  the  bones 


Fig.  451. 


Fig.  452. 


modifications  of  Pirogoff's  amputation  by  Sedillot  and  Gunther.     (Farabeuf.) 

shown  in  Figs.  451  and  452.  Pasquier  Le  Fort  goes  still  farther  and  saws  through  the 
03  calcis,  horizontally,  parallel  to  its  articular  surface,  the  bones  of  the  leg  being  also 
sawn  horizontally. 


*  It  will  be  noticed  that  the  direction  of  the  bone-section  here  given  by  Dr.  Watson 
is  contrary  to  that  usually  taught. 


si  I!  ASTRAGALOID    AMP!  TATION. 


1035 


From  my  experience  Pirogoff's  operation  gives  excellent  results  if 
performed  in  suitable  cases  where  the  os  calcis  and  the  soft  parts  are 
both  sound.  One  difficulty  may  be  met  with  in  cases  of  severe  injury 
where  the  parts  are  badly  smashed,  and  that  is  the  want  of  the  desired 
purchase  while  the  os  calcis  is  being  sawn  through.  The  modification 
of  Dr.  E.  Watson,  Fig.  450,  will  meet  this. 

Operators  sometimes  mala'  another  difficulty  for  themselves  by  leaving 
too  large  a  portion  of  the  os  calcis.  Tension  is  then  unavoidable  when 
the  fragment  is  brought  upwards  and  forwards. 


Fig.  453. 


SUB-ASTRA GALOID    AMPUTATION    (Figs.  453-455). 

This  operation  consists — the  soft  parts  being  divided  as  at  Fig.  453. 
— in  opening  the  astragalo-scaphoid  joint  from  the  dorsum,  and  the 
astragalo  -  calcaneal),  of  which  the 
interosseous  ligament  can  only  be 
divided  by  introducing  the  knife  point 
from  the  outer  side.  The  whole  foot 
is  then  removed  in  one  mass  with  the 
exception  of  the  astragalus,  which  is 
left  mortised  in  between  the  tibia  and 
fibula. 

This  amputation  has  been  rarely 
practised  in  England,  partly  because 
most  surgeons  have  found  that  those 
of  Syme  and  Pirogoff  give  good  results, 
partly  because  the  technique  of  the 
sub-astragaloid  method  is  more  com- 
plicated to  remember,  and  also  because 
this  method  requires  that  the  soft  parts 
of  the  sole  should  be  sound  as  far  for- 
wards as  the  base  of  the  fifth  meta- 
tarsal bone.  Finally,  Farabeuf,  a  high 
authority,  states  that  the  stump  is 
liable  to  be  pulled  up  by  the  tendo 
Achillis  taking  on  a  firm  attachment, 
which  brings  the  weight  of  the  body  upon  this  bone  and  the  neighbour- 
hood of  the  cicatrix. 

Mr.  J.  Hutchinson,  jun.,  in  a  paper  (Brit.  Med.  Journ.,  Oct.  20, 
1900)  which,  like  all  his  writings,  is  lucid  and  instructive,  strongly 
advocates  the  sub-astragaloid  method,  claiming  the  following  advantages 
over  that  of  Syme,  of  which  his  experience,  necessarily  a  large  one  at 
the  London  Hospital,  has  not  been  satisfactory : — (1)  The  stump  is 
some  two  inches  longer;  (2)  it  gives  a  broader  base  of  support; 
(3)  the  elasticity  due  to  the  ankle  movements  is  a  marked  advantage 
in  walking;  (4)  the  pad  at  the  end  of  the  stump  is  much  thicker; 
(5)  the  arterial  supply  is  better  and  runs  less  risk  during  the  opera- 
tion ;   (6)   an  artificial  foot  can  be  better  fitted  to  the  stump. 

Operation  (Figs.  453  to  455). — The  following  account  is  taken,  in 
part,  from  Dr.  Stimson's  Manual  of  Operative  Surgery,  p.  113.  The 
chief  guides  are  the  external  malleolus    and  head  of  the  astragalus. 


The  incisions  in  sub-astragaloid  ampu- 
tation.    (J.  Hutchinson,  jun.) 


1036 


OPERATIONS    ON    THK    LOVYKR    KXTRKMITY. 


The  parts  having  been  carefully  sterilised,  especially  the  thick  skin 
about  the  heel,  the  outside  of  the  foot  is  presented  to  the  surgeon  as 
at  Fig.  453.  The  incision  commences  at  the  outer  border  of  the 
tendo  Achillis  on  a  level  of  above  three-quarters  of  an  inch  below  the 
external  malleolus,  and  is  continued  straight  forwards  below  this 
prominence  to  the  base  of  the  fifth  metatarsal.  It  is  thence  carried 
across  the  dorsum,  slightly  convex  forwards,  to  the  base  of  the  first 
metatarsal.  It  next  passes  over  the  inner  side  of  the  foot  and  across 
the  middle  of  the  sole,  again  convex  forwards.  From  the  centre  of 
the  sole  it  is  carried  on  to  the  outer  border,  which  it  gains  just  behind 
the  base  of  the  fifth  metatarsal.  Some  operators  make  it  join  the 
first  incision  at  the  calcaneo-cuboid  joint,  others  carry  it  onwards  and 
backwards  over  the  outer  aspect  of  the  foot  as  far  as  the  outer  tuberosity 


Fig.  454. 


FlO.  455- 


Sub-astragaloid  amputation  (right  foot)  by  large 
internal  and  plantar  ilap.     (Farabeuf.) 


Sub-astragaloid  amputation 
(left  foot)  by  large  internal 
and  plantar  Hap.   (Farabeuf.) 


of  the  os  calcis,  whence  it  curves  upwards  over  the  back  of  the  heel  to 
join  the  first  at  the  tendo  Achillis. 

The  incision  is  made  throughout,  down  to  the  bones,  all  the  tendons 
met  with  being  severed  at  once.  The  soft  parts  are  separated  from  the 
os  calcis  and  cuboid  on  the  outer  side,  and  on  the  dorsum  dissected  back 
to  the  head  of  the  astragalus.  The  interosseous  ligament  is  then 
reached  by  depressing  the  front  of  the  foot,  passing  the  knife  between 
the  astragalus  and  scaphoid,  and  cutting  backwards  and  inwards  along 
the  under  surface  of  the  former.  The  soft  parts  are  next  separated 
on  the  inner  side  from  the  os  calcis,  injury  to  the  vessels  being  avoided 
by  keeping  very  close  to  the  bone,  the  foot  depressed,  and  the  tendo 
Achillis  divided.  The  posterior  tibial  nerve  should  be  dissected  out 
and  cut  short. 

M.  Farabeuf  advises  an  internal  and  plantar  Hap,  whose  nutrition 
is  guaranteed  by  a  very  large  base.  This  is  the  Hap  of  Rous 
-  444,  445  )• 


EXCISION    AND    ERASION    OF    THE   ANKLE.  1037 


EXCISION    AND    ERASION    OF    THE    ANKLE. 

These  may  be  considered  together.  The  operation  performed 
is  usually  a  combined  one,  and  is  not  very  often  called  for,  and  the 
principles  which  should  guide  the  surgeon  in  selecting  one  or  the 
other  have  been  fully  given  at  p.    948. 

Indications. — These  will  be  considered  chiefly  as  they  relate  to  cases 
of:  A.  Disease ;  more  briefly  under  the  heading  of  13.  Injury. 

A.  Disease. — The  ohjections  made  to  operations  on  the  ankle-joint 
are:  (1)  The  frequency  with  which  the  other  tarsal  bones  are  involved, 
the  depth  to  which  the  astragalus  itself  is  affected,  and  the  poor 
vitality  usually  present  in  the  patients.  As  regards  the  astragalus, 
the  whole  bone  should  always  be  removed,*  and  this  meets,  in  part, 
another  reason  brought  forward  by  Prof.  Syme  for  preferring  amputa- 
tion at  the  ankle-joint,  viz.,  the  fact  that  in  disease  of  the  astragalus 
the  joint  between    it   and    the  os  calcis  is  often  involved.      (2)   The 

Fig.  456. 


Mac  Cormac's  splint  for  excision  of  the  ankle.     The  shape  can  be  modified  by  bending 
the  wire,  and  the  limb  immobilised  by  plaster  of  Paris.     (Mac  Cormac.) 

difficulty  of  free  exposure  of  the  parts  to  be  dealt  with.  With  the 
advantages  of  modern  surgery  this  objection  has  lost  some  of  its 
weight.  (3)  Amputation  at  the  ankle-joint  affords  a  better  chance  of 
radical  cure,  and  also  a  most  excellent  stump.  This  may  be  imperilled 
by  previous  operations  on  the  ankle-joint.  It  is  only  in  patients  with 
good  reparative  power,  with  disease  limited  to  the  ankle-joint  and  the 
astragalus,  and  of  traumatic  origin,  e.g.,  following  a  sprain,  with  no 
evidence  of  other  tuberculous  disease  or  syphilis,  that  operations  on 
the  ankle-joint  are  to  be  preferred  to  amputation.  (4)  The  difficulty 
of  securing  a  splint  which  will  combine  (a)  sufficient  rest,  and  (b)  suffi- 
cient   exposure   for    the   needful   dressings.      These    will  be  met   by 

*  Mr.  Holmes,  whose  experience  of  this  operation  was  a  large  one,  advised  (Brit.  Med. 
Joum.,  1878,  vol.  ii.  p.  875)  that  the  whole  of  the  astragalus  should  always  be  removed, 
for  these  reasons — (i)  As  it  is  often  softened  to  a  considerable  depth,  mere  removal  of  its 
articular  surface  will  often  leave  disease  behind  ;  (2)  in  patients  of  poor  vitality  the 
violence  done  by  the  saw  may  prove  the  starting-point  of  renewed  caries  ;  (3)  the  bones 
of  the  leg  unite  sufficiently  firmly  to  the  exposed  cartilaginous  surfaces  of  the  os  calcis  and 
scaphoid  ;  (4)  the  shortening  is  not  appreciably  increased  ;  (5)  the  difficulty  of  the 
operation  is  lessened. 


1038  OPERATIONS    ON    THE   LOWEII    EXTREMITY. 

a  splint  on  the  lines  of  the  one  shown  in  Fig.  456,  which  can  be  cut 
away  at  spots  desired,  and  admits  of  easy  sterilisation.  A  far  simpler 
method  is  the  anterior  flat  bar  of  malleable  iron  moulded  to  the 
dorsum  of  the  foot  and  front  of  leg  and  knee-joint,  covered  with 
india-rubber,  supplied  with  hooks  for  suspension,  and  secured  by 
plaster  of  Paris.  This  gives  admirable  access,  and  saves  an^y  pressure 
on  the  heel.  The  fitting  of  this  splint,  which  can  be  done  on  the 
sound  limb,  requires  the  careful  attention  of  the  surgeon  himself 
beforehand,  especially  as  to  the  angle  over  the  instep  by  which  the 
foot  is  kept  in  right  position.  Another  method  is  that  with  plaster  of 
Paris  and  windows  (p.  1013).  When  the  patient  can  get  up  he  can  use 
a  leg-rest  for  some  months.  In  those  cases  where,  in  addition  to  a 
large  cavity  to  fill  up,  any  tendency  to  oedema  exists,  a  back  and  two 
side-splints — all  being  interrupted — may  be  preferable  for  the  first 
week  or  ten  days.     The  side-splints  should  be  boiled  after  removal. 

B.  Injury. — In  a  young,  healthy  patient,  where  the  vessels  and 
nerves  are  mainly  intact,  where  the  mischief  is  limited  to  the  ends  of 
the  bones,  an  attempt  to  save  the  limb  by  excision,  partial  or  complete, 
is  abundantly  justified.  The  steps  given  at  p.  1012  for  the  antiseptic 
treatment  of  compound  fractures  should  be  carefully  attended  to,  as  to 
the  preservation  of  periosteum,  the  due  providing  of  drainage,  &c. 

As  to  gunshot  injuries,  Dr.  Otis  (Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion, 
part  iii.  p.  610)  thought  that  "  the  substitution  of  excision  of  the  ankle-joint  for  amputation 
effected  no  saving  of  life,"  formal  excisions  being  rarely  successful.  The  experience  in 
later  wars  appears  to  be  similar.  Mr.  Makins,  C.B.  (Surgical  Experiences  in  South 
Africa,  1899-1900,  p.  239)  writes  :  "The  ankle-joint  maintained  the  undesirable  character 
which  it  has  always  held  as  a  subject  for  gunshot  injuries.  This  is  entirely  a  question 
of  sepsis,  and  in  great  measure  depends  on  the  fact  that  the  foot,  as  enclosed  in  a  boot, 
is  invested  with  skin  particularly  difficult  to  thoroughly  cleanse  ;  while  the  socks  are  an 
additional  source  of  infection  before  the  patients  come  under  proper  treatment.  Of 
seven  cases  of  suppurating  ankle-joint  of  which  I  have  notes,  only  two  retained  the  foot, 
and  one  of  these  after  a  very  dangerous  illness." 

Operation. — The  necessary  exposure  may  be  secured  either  by  two 
lateral  incisions  or  by  a  transverse  one,  dividing  the  tendons  in  front, 
some  of  which  are  sutured  afterwards.  Of  these  the  first  is  preferable, 
theoretically,  owing  to  the  smaller  injury  inflicted  upon  the  soft  parts. 
For  myself,  considering  that  a  stable  and  sound  foot  is  the  first 
desideratum,  and  that  in  most  hands  a  transverse  incision,  prolonged 
laterally  as  freely  as  is  needful,  gives  the  best  exposure,  and  thus 
facilitates  the  eradication  of  all  the  diseased  parts,  which  is  so  essential 
in  dealing  with  tuberculous  disease  (p.  953,  and  Vol.  I.  p.  717),  I  have 
generally  employed  this  method.  If  the  suturing  of  the  chief  tendons 
is  not  successful — and  this  is  a  matter  of  difficulty  with  the  usually 
small  tendons — the  subsequent  stiffness  of  the  toes  is  partly  made  up 
for  by  the  mobility  gained,  in  young  subjects,  at  the  medio-tarsal  joint. 

Lateral  Incisions. — There  are  numerous  modifications  of  these,  but 
the  chief  point  to  remember  is  to  make  them  freely  from  a  point  about 
two  inches  above  the  malleoli  to  one  about  the  centre  of  the  lateral 
aspects  of  the  foot.  The  parts  having  been  carefully  sterilised,  and 
an  Esmarch's  bandage  applied,  the  foot  is  laid  upon  its  inner  side,  and 
firmly  supported  by  a  sand  pillow.  A  slightly  angular  incision  is 
then  made  from  a  point  two  inches  above  the  external  malleolus  behind 


EXCISION    AND    K11AS10N    OF   THE   ANKLE.  1039 

this  prominence  to  one  within  an  inch  of  the  base  of  the  fifth  meta- 
tarsal.    The  external  saphena  vein  is  drawn  aside  or  secured  between 
two  ligatures.     The  two  peronffii  tendons  are  carefully  preserved.    The 
wound  being  protected  with  sterile    gauze,    the  foot   is    turned    over 
and  a  similar  angular  incision  is  made  on  the  inner  side  forwards  and 
downwards  as  far  as  the  projection  of  the  internal  cuneiform.     In  the 
centre  of  the  incisions  the  operator  should  work  down  to  the  capsule 
of  the  joint ;  the  ends  are  made  free  in  order  to  give  room,  and  also  to 
admit   of  identification  and  displacement  of  the   tendons.     Thus  the 
peronei    on    the    outer,  and    the  tibialis   posticus    and   flexor  longus 
digitorum  on  the  inner  side,  must  be  carefully  but  sufficiently  displaced 
from  their  connection  with  the  fibula  and  tibia,  or  difficulty  will   be 
met    with    in    adequately    displacing    the    foot  inwards    or    outwards. 
The  capsule  being   identified,   by  means  of  a  periosteal  elevator  the 
structures  in  front  of  the  joint,  tendons,  vessels  and  nerves  are  raised 
en  masse  by  pushing  inwards  and  outwards  from  the  lateral  incisions 
and  up  and  down  as  well.    As  much  of  the  anterior  part  of  the  capsule 
as  possible  is  then   snipped  away  in  one  piece.     The  next   step  is 
removal  of  the  astragalus.     The  joint  between  it  and  the  scaphoid  is 
first  opened,  and  its  connections  with  the  os  calcis  taken  next.     By 
alternate  eversion  and  inversion  of  the  foot  the  lateral  ligaments  are 
divided,  with  the  help  of  an  elevator  and  sequestrum-forceps  the  astra- 
galus is  raised  and  drawn  in  different  directions  as  the  ligamentous 
fibres  are  divided  with  strong   blunt-pointed  curved  scissors.      The 
interosseous  ligament  is  next  severed ;  if  disease  be  present   here  it 
must  be  thoroughly  treated  with  a  gouge.     The  difficult  removal  of 
the  astragalus  must  be  effected  gradually,  and  without  any  needless 
bruising  of  the  adjacent  bony  and  cartilaginous  surfaces.     The  pre- 
sence of  the  flexor  longus  hallucis,  posteriorly,  must  be  remembered. 
The  articular  surfaces  of  the  tibia  and  fibula  are  next  scrutinised,  by 
thrusting  them  through  one  of  the  lateral  incisions.     If  they  appear 
healthy  the  cartilage  should  be  well  rubbed  with  sterile  gauze  to  ensure 
the  removal  of  an}'  tuberculous  material.     An}'  disease  present  must 
be  removed  by  shaving  off  the  cartilages,  or  by  a  gouge.     Removal  of 
either  malleolus,  even  sub-periosteally,  and  in  a  young  subject,  is  likely 
to  interfere  with  the  after-stability  of  the  foot.     Free  access  having 
been  thus  attained,  any  remnants  of  the  synovial  membrane  at  the 
back,  and  postero-lateral  aspects  of  the  joint  are  removed,  and  steri- 
lised iodoform  or  emulsion  of  iodoform  and  glycerine  (10   per  cent.) 
applied  to  the  cavity  left.     As  this  must  in  any  case  be  a  considerable 
one,    I    recommend   that  the    needful    drainage    be    secured    by  only 
suturing  the  upper  extremities  of  the  incisions,  and  slinging  the  foot 
for  the  first  few  days  laterally,  so  that  one  of  the  incisions  is  kept  facing 
downwards.     After  the  deeper  dressings  have  been  secured  by  a  few 
figure-of-8  turns  the  bandage  should  be  carried  firmly,  beginning  at 
the  roots  of  the   toes   (this  area  having  been   sterilised)   from  below 
upwards,  so  as  to  prevent  any  cedema  of  the  foot.    As  the  only  arteries 
cut    are    small    ones,    branches   of  the    peroneal    and    malleolar,    the 
Esmarch's   bandage   need    not    be    removed  until  the  dressings  are 
in  situ. 

To  secure  a  good  result  much  care  is  needed  afterwards  to  meet 
the  tendency  to  displacement,  which  is  two-fold :   (a)  pointing  of  the 


1040 


OPERATIONS    ON    THE    LOWEB    EXTREMITY. 


foot  downwards;  (l>)  a  lateral  displacement.  While  here,  as  after 
other  erasionp,  it  is  not  always  needful  to  disturb  the  deepest  dressings, 
it  is  well  to  re-apply  the  bandage  ;it  short  intervals  to  promote  early 
consolidation  of  the  deeper  parts  of  the  wound,  and  aid  in  the  oblitera- 
tion of  any  infective  material.  After  three  weeks,  if  the  wound  he 
healed,  active  and  passive  movements  may  he  gently  begun.  No  weight 
is  to  be  borne  on  the  foot  for  two  months.  A  hoot  with  lateral  supports 
will  he  required  for  some  time. 

A.  Transverse  Incision. — After  the  full  account  given  ahove  it  is 
needless  to  go  into  details  here.  In  my  opinion  this  method  is 
especially  indicated  in  doubtful  cases,  where  the  surgeon  has  the  pro- 
bability of  amputation  being  required  strongly  before  him,  it  being 
now  very  easy  to  proceed  to  removal  of  the  foot  by  Prof.  Syme's 
method. 

The  parts  having  heen  sterilised  and  rendered  evascular  as  before, 
a  transverse  incision  hetween  the  malleoli  is  made  down  to  the  tendons. 
Before  these  are  severed  guiding  sutures  of  sterilised  silk  are  placed 
in  the  tibialis  anticus,  extensor  proprius  hallucis  and  digitorum,  and 
the  anterior  tibial  nerve.  All  the  structures  in  front  of  the  joint  are 
then  severed,  the  joint  opened,  and  the  operation  completed  on  the  lines 
already  given.  It  is  always  well  to  remove  the  astragalus,  in  order  to 
secure  better  access  to  the  diseased  structures. 

G.  A.  Wright,  of  Manchester,  who  gave  such  a  healthy  impetus  to 
erasion  of  joints,  thus  describes  a  case  operated  on  as  long  ago  as 
1882  (Diseases  of  Children,  Ashby  and  Wright,  p.  633). 

The  child  was  8  years  old.  The  joint  was  opened  by  a  transverse  incision  across  the 
front  of  the  joint,  dividing  all  the  extensors,  kc.  ;  tuberculous  synovitis  existed  with 
subchondral  caries,  all  the  diseased  tissue,  as  well  as  the  loosened  cartilage  were 
removed  as  far  as  possible.  The  tendons  were  stitched  together  with  catgut  and  the 
wound  closed.  No  attempt  was  made  to  unite  the  nerve;  the  anterior  tibial  artery 
was  twisted.  The  wound  was  very  slow  in  healing,  but  three  years  later  the  child's 
condition  was  as  follows  :  "  Foot  sound  and  well,  but  the  toes  are  somewhat  pointed, 
and  lie  'throws'  the  foot  in  walking.  He  gets  about  well  with  a  boot  and  without 
any  support.  A  good  deal  of  new  bone-formation  about  line  of  incision,  but  some 
mobility." 

Those  interested  in  erasion  of  this  joint  should  refer  to  a  paper  by 
Mr.  W.  A.  Lane  (Clin.  Soc.  Trans.,  vol.  xxvii.  p.  15),  in  which  a  very 
free  extension  of  the  transverse  incision  is  advocated  ;  and  one  by 
Mr.  Glutton  (Trans.  Med.  Chir.  Soc.,  vol.  Ixxvii.  p.  101),  in  which  four 
vertical  incisions  are  made,  one  in  front  and  one  behind  each  malleolus, 
and  the  tendons  and  ligaments  alike  avoided.  The  disease  is  removed 
by  the  sharp  spoon  and  irrigation,  aided  by  the  linger.  As  stated  by 
Mr.  Glutton,  an  exactly  similar  method  was  described  by  Bruns 
{Munch.  Med.  Woch.,  1891.) 

EXCISION"   OF  BONES  AND  JOINTS   OF  THE   TABSUS. 

Before  considering  these  separately,  I  would  invite  attention  to  the 
following  practical  points  : 

i.  Those  cases  are  the  least  hopeful  in  which  there  is  no  history  of 
injury,   in  which  there  is  evidence  of  a   tuberculous   constitution,  or 


EXCISION   OF    BONES   AND   JOINTS    OF    THE   TARSUS.    1041 


perhaps  of  disease  dating  to  an  exanthem  and  coupled  with  the  above 
constitution  ;  cases  in  which  the  patient  is  wan  and  sickly  with  long- 
lasting  pain  and  sleeplessness  ;  those  in  which  the  parts  are  much 
swollen,  dusky  red,  and  glossy,  with  sinuses  numerous  or  excavated, 
all  points  denoting  a  disease  that  is  not  limited  to  one  joint  or  to  few 
bones,  ii.  Mere  laying  open,  and,  still  more,  injection,  of  sinuses 
where  there  is  disease  of  the 
tarsus  is  absolutely  useless  in 
most  cases,  iii.  When  a  patient 
is  under  care  for  caries  of  the 
foot,  his  lungs  should  always 
be  carefully  examined  before 
operative  treatment  is  under- 
taken, iv.  When  the  amount 
of  disease  present  is  being  esti- 
mated, it  must  be  remembered 
that  patients,  especially  chil- 
dren, will  often  use  their  feet 
with  much  freedom,  limping, 
even  bearing  their  weight  on 
their  toes  with  the  aid  of  a 
crutch,  though  all  the  time 
extensive  disease  is  present. 
v.  That,  before  an  operation, 
the  parts  should  always  be  ren- 
dered absolutely  evascular  by 
the  use  of  Esmarch's  bandages, 
and  that  thus  the  limit  of  the 
disease  should  be  denned  as 
accui'ately  as  possible,  vi.  Sub- 
periosteal excision  is  in  my 
opinion  not  advisable  in  tuber- 
culous cases.  It  is  here  a  step 
full  of  risk  and  does  not  offer 
any  sufficiently  compensatory 
advantages,  vii.  Strict  anti- 
septic precautions  should  be 
made  use  of  wherever  this  is 
possible,  because  —  (a)  Pro- 
longed suppuration  will  exhaust 
a  patient  whose  powers  are 
already  sufficiently  handicapped 
by  disease  and  operation  ; 
(6)  Suppuration  will  cause  destruction  of  the  periosteum,  and  thus 
fresh  caries  and  necrosis ;  (c)  Interference  with  inflamed  bones  may, 
if  infection  result,  easily  cause  osteo-myelitis  and  pyaemia,  viii.  When 
the  question  arises  between  excision  and  amputation,  if  the  powers 
of  repair  have  been  duly  considered,  the  question  of  time  and  the 
rank  of  life  should  also  be  remembered.  Thus,  after  an  extensive 
excision,  six  months  will  probably  be  required  before  the  foot  can 
be  used,  but  only  three  months  after  an  amputation.  The  time  in 
the  first  case  may  after  all  be  wasted,  a  point  of  much  importance, 
s. — vol.  11.  66 


To  show  the  arrangement  of  the  tarsal  synovial 
membranes.     (Mac  Cormac.) 


1042 


OPERATIONS    «>N    Till]    L<>\\  K1S    EXTREMITY. 


when  the  question  of  schooling,  learning  a  trade,  &c,  have  to  be  con- 
sidered, ix.  No  use  of  a  foot  can  be  permitted  after  an  operation 
till  firm  consolidation  is  obtained,  x.  If  tuberculous  mischief  persist 
after  an  operation,  the  sharp  spoon  must  be  freely  used,  together  with 
laying  open  sinuses,  snipping  away  of  undermined  skin,  &e.  If  all 
carious  bone  has  been  removed,  the  above  steps  may  be  repeated 
here,  as  in  the  knee,  with  ultimate  success,  if  good  general  health  be 
maintained. 

EXCISION   OF  THE  ASTRAGALUS. 

Indications. — These  will  be  for  A.  Disease,  B.  Injury. 

A.  Disease. — (1)  Caries  of  the  bone,  especially  when  comparatively 
recent  and  of  traumatic  origin  in  a  young  and  healthy  patient,  and 
when  the  disease  is  found  to  be  limited  to  the  upper  surface.  (2)  In 
disease  of  the  astragalo-calcanean  joint,  where  it  is  thought,  from  the 
position  of  the  sinuses,  &c,  to  be  more  advisable  to  expose  this  joint 
by  removing  the  astragalus  than  the  os  calcis.  (3)  Talipes ;  in 
inveterate  resistant  cases  (p.  1049). 

B.  Injury. — (1)  Primarily,  (a)  In  simple  dislocation  of  the  astragalus 
not  reducible  with  the  aid  of  anaesthetics  and  tenotomy  of  the  tendo- 
Achillis  and  the  tibials  or  extensors,  if  it  seem  likely  that  the  skin  will 
slough,  (b)  In  compound  dislocation  of  the  astragalus  when  the  bone 
is  too  far  displaced  or  comminuted  to  admit  of  replacement,  and  when 
the  condition  of  the  soft  parts,  vessels,  and  tendons  does  not  call  for 
amputation.  (2)  Secondarily,  when  the  foot  is  useless  and  painful. 
In  these  cases,  especially,  strict  antiseptic  precautions  must  be  taken 
and  free  drainage  provided. 

Operation. — This  may  be  performed  by  two  lateral  or  a  transverse 
incision,  with  subsequent  suture  of  the  tendons,  as  already 
described  (p.  1038).  Another  mode  of  access  is  given  at  p.  1049.  But 
in  tuberculous  cases,  especially  where  amputation  may  be  found  needful, 
I  prefer  the  freest  exposure.  In  some  cases  where  a  sequestrum  is 
found  on  the  upper  surface,  the  removal  of  this  and  the  use  of  the 
gouge  is  all  that  is  required.  More  usually  the  bone  needs  removal 
and  its  articulation  with  the  scaphoid  and  the  os  calcis  requires 
attention.  The  necessary  steps  and  the  after-treatment  have  been 
fully  described  at  p.  1039. 

EXCISION   OF  THE   OS  CALCIS. 

Practical  Remarks. — Disease  here  is  not  very  infrequent,  and  often 
remains  limited  to  this  bone  for  a  long  time.  It  may  commence  in 
one  of  three  sites — viz.,  (a)  the  posterior  epiphysis,  which,  not 
appearing  until  the  tenth  year,  does  not  unite  till  between  the  fifteenth 
and  nineteenth  years ;  (b)  the  body  of  the  bone  ;  (c)  the  calcaneo- 
astragaloid  joint,  de  novo,  or  its  an  extension  from  the  astragalus.  The 
diagnosis  of  primary  disease  in  this  joint  is  often  difficult ;  thus  the 
swelling  and  position  of  the  sinuses  recall  disease  of  the  ankle-joint. 
The  pain  is  usually  greater  than  in  ordinary  disease  of  the  os  calcis 
itself,  and  the  foot  is  sooner  disabled.  With  an  anaesthetic,  the  ankle- 
joint  is  found  free,  and  probes  introduced  by  .sinuses  may  pass  towards 


KXCISION    OF    THE    OS   CALCIS. 


1043 


the  level  of  the  upper  surface  of  the  os  calcis  (known  hy  the  tubercle 
for  the  extensor  brevis). 

Operation. — The  parts  having  been  sterilised  and  rendered  evascular, 

and  the  foot  firmly  supported  on  its  inner  side  at  the  edge  of  the  table, 
an  incision*  is  made  with  a  strong-backed  scalpel,  commencing  at  the 
inner  edge  of  the  tendo  Achillis,  and  passing  along  the  upper  border 
of  the  os  calcis  (vide  supra)  at  the  outer  border  of  the  foot  as  far  as 
the  calcaneo-cuboid  joint,  which  lies  midway  between  the  outer 
malleolus  and  the  fifth  metatarsal  bone.  This  incision  should  go 
down  at  once  upon  the  bone,  so  that  the  tendon  should  be  felt  to  snap 
as  the  incision  is  commenced.  Another  incision  is  then  to  be  drawn 
vertically  across  the  sole,  commencing  near  the   anterior  end  of  the 


Fig.  458. 


Foot  two  years  after  removal  of  os  calcis  in  a  child.  The  foot  is  flat 
but  very  serviceable.  As  will  be  seen  from  the  state  of  the  calf,  the  tendo 
Achillis  has  taken  on  a  fresh  attachment  in  the  detached  periosteum,  and 
has  been  well  employed. 

first,  and  terminating  just  short  of  the  inner  surface  of  the  os  calcis, 
beyond  which  it  should  not  extend  for  fear  of  wounding  the  posterior 
tibial  vessels.  The  bone  being  now  exposed  by  throwing  back  the 
flap,  the  calcaneo-cuboid  joint  is  first  found  and  opened.  The 
peronei  must  be  dissected  out,t  and  drawn  aside  with  a  blunt  hook. 

*  The  above  incision  is  taken  from  Mr.  Holmes'  article  (Syst.  of  Surg.,  vol.  iii.  p.  771). 
A  still  better  one  is  that  advised  by  Farabeuf  (Man.  Oper.,  p.  759)  :— A  horseshoe-shaped 
incision  is  made  round  the  heel,  beginning  at  the  calcaneo-cuboid  joint,  dividing  the 
tendo  Achillis,  and  ending  on  the  inner  aspect  of  the  foot,  external  to  the  posterior  tibial 
vessels  and  nerves.  To  this  incision  a  short  vertical  one  is  added,  running  up  along  the 
outer  side  of  the  tendo  Achillis.  By  turning  aside  the  flaps  thus  marked  out  the  bone  is 
most  thoroughly  exposed. 

f  Mr.  Holmes  (loc.  supra  cit.)  says  that  he  has  always  divided  these  without  ill  effect. 
Care  must  be  taken  in  drawing  them  aside,  for,  if  this  is  done  too  vigorously,  one  may 
slough,  as  happened  to  me  in  one  of  my  cases. 

66—2 


1044  OPERATIONS   ON   THK    LOWEB    EXTREMITY. 

Tlie  astragalo-calcanean  joint  is  next  attacked  ;  and  the  close  con- 
nection between  the  bones  at  this  point  constitutes  the  principal 
difficulty  of"  the  operation,  unless  the  ligaments  have  been  destroyed 
by  disease.  This  difficulty  can  best  be  met  by  grasping  the  bone 
firmly  with  lion-forceps,  and  wrenching  it  backwards  and  outwards, 
aided  by  levering  movements  of  an  elevator,  and  a  knife-point  kept 
very  close  to  the  bone.  Especial  care  must  be  taken  on  the  inner 
side  to  avoid  the  vessels.  The  bone  being  removed,  the  gap  is  lightly 
plugged  with  gauze,  and  the  dressings  applied  before  the  Esmarch's 
bandage  is  removed. 

The  question  of  preserving  the  periosteum  has  already  been  referred 
to,  p.  1041.  Some  good  cases  of  excisions  of  tarsal  bones  are  recorded 
by  Mr.  Holmes,  Syst.  of  Surg.,  vol.  iii.  p.  769  et  seq. ;  and  Surg.  Treat. 
of  Children's  Dis.,  chap.  xxvi. 

OPERATIONS     FOR     MORE     COMPLETE     TARSECTOMY. 

It  is  scarcely  worth  while  to  give  directions  for  the  removal  of  other 
single  bones — e.g.,  the  scaphoid  and  cuboid — as  these  are  rarely  diseased 
alone,  and,  if  this  should  be  so,  their  removal  is  easy. 

The  operations  of  Mickulicz  and  of  Dr.  P.  H.  Watson  will  be 
described  to  meet  those  cases  where  more  extensive  disease  is  present, 
and  where  the  patient's  age  and  condition  justify  a  trial  of  these  severe 
operations  instead  of  amputation.  In  the  very  few  cases  which  call 
for  these  operations  Watson's  is,  in  my  opinion,  to  be  preferred,  as  it 
leaves  a  foot  at  right  angles  with  the  leg. 

Operation  of  Mickulicz.* — The  object  of  this  operation  is  to  procure  an  artificial 
pes  equinus,  and  to  preserve  the  toes  and  metatarsals,  these  being  brought  into  a  straight 
line  with  the  leg,  and  the  toes  bent  at  a  right  angle,  so  that  the  patient  walks  on  the  ends 
of  the  metatarsal  bones  covered  by  the  thick  pads  of  tissue  which  invest  them  ;  a  broader 
surface  of  support  is  provided  than  after  Syme's  or  Pirogoff's  amputations,  and  there  is 
some  elasticity  of  the  foot  left.  I  do  not  recommend  this  operation,  and  only  introduce 
the  account  from  my  respect  for  the  surgeon  whose  name  it  bears.  The  result  is  obtained 
at  far  greater  cost  and  risk  than  that  by  a  Syme's  amputation,  and  is,  in  my  opinion,  of 
very  doubtful  superiority.  It  is  fair  to  state  with  regard  to  this  opinion  and  the  result  in 
the  case  which  follows,  a  case  from  its  nature  unpromising  for  any  operation,  that  Ptof. 
Nasse  and  Dr.  Borchardt  (v.  Bergmann's  Syst.  of  Surg.,  Amer.  "Prans.,  vol.  iii.  p.  886) 
write  :  "  The  results  of  this  operation  are  generally  good.  Of  73  cases  collected  by 
Kohladds  in  1891,  56  could  stand  and  walk  well.''  Mr.  island  Sutton  {Lancet,  1893, 
vol.  ii.  p.  1513)  brought  before  the  Medical  Society  the  skeleton  of  a  foot  three  years  after 
the  performance  of  a  Mickulicz's  operation.  The  artificial  pes  equinus  had  been  produced 
by  Sir  W.  Mac  Cormac  in  a  girl,  aged  18,  the  subject  of  infantile  paralysis.  In  spite  of 
the  anatomical  success  of  the  operation  the  foot  was  of  little  ser\  ice  in  progression,  causing 
the  girl  much  pain  and  inconvenience,  and  Mr.  Sutton  removed  the  leg  by  amputating 
through  the  knee-joint. 

Sir  W.  Mac  Cormac's  patient  was  aged  15,  and  the  disease  dated  to  a  sprain  of  the 
ankle.  On  the  lad's  admission  the  swelling  and  sinuses  pointed  to  disease  of  the  os  calcis  ; 
later  on  the  ankle-joint  became  involved.  Amputation  being  refused,  Sir  W.  Mac  Cormac 
operated  thus  :  "The  patient  was  placed  in  the  prone  position.  If  it  be  the  right  foot, 
the  knife  is  introduced  on  the  inner  border  of  the  foot,  just  in  front  of  the  scaphoid 

*  The  account  of  this  is  taken  from  a  paper  of  Sir  W.  Mac  Cormac's  (Lancet,  May  5, 
1888),  four  figures  accompanying  this.  Mickulicz's  paper  will  be  found  in  Langenbeck's 
Arch.,  1881,  Bd.  xxvi.  S.  191. 


REMOVAL    OF    TARSAL    BONES.  1045 

tubercle,  and  a  transverse  incision,  extending  to  the  bone,  is  made  across  the  sole  to  a 
point  a  little  behind  the  tuberosity  of  the  fifth  metatarsal.  On  the  left  foot  the  direction 
of  this  incision  will  be  reversed.  From  the  inner  and  outer  extremities  of  the  wound 
incisions  are  prolonged  upwards  and  backwards  over  the  corresponding  malleolus,  and 
their  extremities  united  by  a  transverse  cut  across  the  back  of  the  leg,  down  to  the  bone, 
a<  the  level  at  which  it  is  to  be  sawn,  usually  immediately  above  the  joint  surface  of  the 
tibia.  In  cases  where  a  larger  removal  of  the  tibia  and  fibula  is  required,  the  lateral 
incisions  must  be  more  oblique,  and  the  posterior  transverse  cut  made  at  a  higher  level. 
The  ankle-joint  is  now  opened  from  behind,  the  disarticulation  completed,  and,  after 
Hexing  the  foot,  the  soft  parts  arc  carefully  separated  in  front  until  the  medio-tarsal  joint 
is  reached,  through  which  disarticulation  is  effected  as  in  Chopart's  amputation.  The 
heel  portion  of  the  foot,  consisting  of  the  astragalus,  calcis,  and  the  soft  parts  covering 
them,  is  thus  removed.  The  articular  surfaces  of  the  tibia  and  fibula,  with  the  malleoli, 
are  now  sawn  off,  as  well  as  those  of  the  cuboid  and  scaphoid.  The  anterior  portion  of 
the  foot  remains  connected  with  a  bridge  of  soft  parts.  The  blood-supply  appears  to  be 
ample,  for  almost  directly  after  the  operation  blood  issued  freely  from  the  distal  ends  of  the 
divided  plantar  arteries.  All  haemorrhage  having  been  arrested,  the  foot  was  brought  into 
a  straight  line  with  the  leg,  and  the  cut  surfaces  of  the  bone  were  sutured  together  with 
kangaroo-tendon.  The  attempt  to  discover  and  unite  the  divided  ends  of  the  posterior 
tibial  nerve  failed,  on  account  of  the  sodden  condition  of  the  soft  parts.  Suitable  dressings 
and  a  plaster-of-Paris  splint  were  applied,  the  toes  being  brought  into  a  position  of 
complete  dorsal  flexion." 

The  boy  made  an  excellent  recovery.  Firm  bony  union  took  place.  In  about  a 
month  sensibility  began  to  return  in  the  sole,  and  gradually  became  more  complete.  The 
toes  were  mobile.* 

Operation  of  "Watson. — This  is  adapted  to  cases  where  the  medio-tarsal  articulation 
is  involved,  the  importance  of  which,  from  the  number  of  bones  and  the  complicated 
synovial  membrane,  is  well  known  (p.  1041).  In  other  words,  the  disease  should  be 
situated  between  the  bases  of  the  metatarsal  bones  in  front  and  the  os  calcis  and  the 
astragalus  behind.  The  parts  being  rendered  evascular,  incisions  three  to  four  inches 
long  are  made,  on  the  outer  side  from  the  centre  of  the  os  calcis  to  the  middle  of  the  fifth 
metatarsal  bone,  and  on  the  inner  from  the  neck  of  the  astragalus  to  the  middle  of  the 
first  metatarsal.  The  soft  parts  are  carefully  dissected  off  from  the  dorsal  and  plantar 
aspects  of  the  foot  by  means  of  these  incisions,  the  left  thumb  being  kept  between  the 
point  of  the  knife  and  the  soft  parts.  With  a  curved  probe-pointed  bistoury  the  joints 
between  the  astragalus  and  scaphoid,  and  os  calcis  and  cuboid,  are  opened  up,  and,  a  saw 
being  passed  between  the  plantar  soft  parts  and  the  metatarsal  bones,  these  are  cut  through 
from  below  upwards.  The  diseased  bones  being  removed,  the  wound  is  firmly  plugged 
and  pressure  applied  with  gauze  pads  and  bandages  before  the  tourniquet  is  removed. 
That  this  operation,  though  little  known,  is  an  excellent  one  in  Dr.  Watson's  hands,  is 
shown  by  the  fact  that  five  out  of  his  six  cases  did  well.  It  must  be  remembered  that  it 
is  an  operation  in  the  dark,  and  one  that  may  involve  a  good  deal  of  damage  to  soft  parts, 
owing  to  the  amount  of  disease  which  has  to  be  removed  by  somewhat  limited  incisions. 


REMOVAL     OP     TARSAL     BONES     FOR     INVETERATE 

TALIPES. 

Indications. — Cases  which  deserve  the  above  epithet  of  inveterate, 
in  which  tenotomy,  syndesmotomy,  and  forcible  manipulation  f   have 

*  The  patient  was  shown  to  the  Medical  Society  more  than  a  year  after  the  operation. 
"  He  walked  up  and  down  the  room,  both  with  and  without  his  boot,  with  great  ease  and 
evident  satisfaction  to  himself.  The  union  is  quite  solid,  and  he  now  attends  to  his  daily 
work  without  any  inconvenience." 

t  Especially  by  the  aid  of  Thomas's  wrench.  An  excellent  account  of  the  use  of 
this— in  fact,  one  of  the  very  best  descriptions  of  the  treatment  of  talipes  in  the  English 


1046  OPERATIONS   ON    THE   LOWER   EXTREMITY. 

been  thoroughly  tried ;  cases  in  which  there  is  evidently  confirmed 
alteration  in  the  shape  of  the  bones — e.(j.,  in  talipes  equino- varus — 
such  rigidity  that  the  position  of  the  foot  cannot  be  possibly  altered, 
the  astragalus  projecting  outwards  on  the  dorsum,  and  the  scaphoid 
so  displaced  that  it  almost  touches  the  internal  malleolus;  where  the 
patient  walks  on  the  outer  border  of  his  foot,  and  large  bursae  have 
formed  over  the  cuboid  ;  and  where  the  patient  is  prevented  from  earn- 
ing his  livelihood.  Finally,  the  surgeon  must  feel  assured  as  to  his 
power  of  conducting  the  case  aseptically. 

I  am  of  opinion  that  the  following  operations  will  enable  the 
surgeon  to  deal  with  cases  of  resistant  or  inveterate  talipes  met  with 
nowadays,  and  further  that  these  methods  are  best  adapted  to  the  largest 
number  of  operators,  a  point  which  has  been  insisted  upon  several 
times  in  this  book.  In  order  of  selection  they  are  :  (i.)  Division 
of  tendons  and  other  existing  structures  by  a  flap  incision 
on  the  inner  side  of  the  foot  (Fig.  459) ;  (ii.)  Removal  of  the 
astragalus ;  (iii.)  Cuneiform  tarsectomy.  Before  they  are 
described  I  would  impress  most  strongly  upon  my  younger  readers 
the  cardinal  importance  of  the  following  :  (1)  Relapses  will  follow  after 
any  operation,  however  complete  and  severe  at  the  time,  unless  the 
patient  is  kept  under  observation  sufficiently  long  for  the  surgeon  to 
feel  certain  that  the  case  is  cured.  (2)  Relapses  depend  either  upon 
the  patient  being  too  soon  removed  from  supervision,  or  upon  the 
surgeon  saying  prematurely  that  the  cure  is  complete.  I  have  gene- 
rally laid  down  the  rule  to  the  parents  that  in  addition  to  regular 
supervision  by  the  surgeon,  daily  attention  will  be  required  on  their 
part  until  the  child  is  old  enough  to  realise  the  right  position  of  the 
foot,  and  sensible  enough  to  take  a  due  share  in  maintaining  it.  (3)  No 
cure  is  complete  until  the  patient  has  been  walking,  under  skilled 
observation  at  intervals,  for  a  sufficient  time.  It  is  quite  impossible 
to  lay  down  anj'  law  or  limit  here.  For  cases  before  puberty  many 
years  are  required,  for  adults  at  least  one  year  is  needed.  The  more 
severe  the  case  the  more  care  is  required  for  the  surgeon  to  be  abso- 
lutely certain  that,  when  walking  is  allowed,  the  body-weight  falls  on 
the  foot  in  the  right  position,  and  not  unduly  on  the  outer  side,  per- 
petuating, if  even  in  the  slightest  degree,  the  varus.  In  no  case  is 
there  more  need  of  the  surgeon,  before  he  undertakes  these  trouble- 
some cases,  ensuring  that  the  parents  realise  their  responsibility  in 
the  after-treatment.  This  point  is  frequently  overlooked.  (4)  While 
there  is  no  routine  method  of  operation  in  these  cases,  the  surgeon 
will,  of  course,  secure  the  best  results  from  that  operation  with  which 
he  is  most  familiar. 

Division  of  tendons  and  other  resisting  structures  by  a  flap-incision 
on  the  inner  side  of  the  foot  (Fig.  459). — Since  I  became  acquainted 
with  this  method  I  have  used  it  largely,  and  have  had  every  reason  to 
be  increasingly  satisfied  with  it.  While  the  incision  is  uncomplicated 
it  gives  sufficient  access.  It  is  very  easy  to  combine  the  operation 
with  the  use  of  the  wrench.     In  bilateral  talipes  equino-varus  both  feet 


language — is  given  by  Mr.  R.  Jones,  of  Liverpool,  and  Dr.  Bidlon,  of  Chicago,  in  the 
Medical  Annual  fur  1896,  p.  448.  Another  very  helpful  account  of  talipes  is  that  given 
by  Mr.  Tubby  in  his  work  on  Orthopaedic  Surgery. 


REMOVAL   OF   TARSAL    BONES.  1047 

can  be  dealt  with  ;it  one  operation.  I  shall  first  describe  it  in  the  words 
of  its  introducer,  Dr.  A.  F.  Jonas  (Ann.  of  Swrg.,  1899,  p.  449),  who 
had  employed  it  in  twenty-five  cases  with  satisfactory  results:  "An 

incision  is  made  beginning  slightly  below  the  margin  of  the  plantar 
fascia  on  the  inner  side  of  the  foot,  at  a  point  on  a  line  directly  below 
and  anterior  to  the  internal  malleolus,  extending  forwards  and  upwards 
to  a  point  * >  1 1  the  first  metatarsal  bone,  and  nearly  to  the  metatarso- 
phalangeal articulation.  A  second  incision  is  made  beginning  at  a 
point  over  the  astragalo-scaphoid  articulation,  extending  forwards  and 
slightly  downwards,  joining  the  first  incision  near  the  metatarso- 
phalangeal joint,  forming  a  V.  The  incisions  are  made  deep  so  as  to 
include  the  subcutaneous  tissue  and  fat.  The  flap  is  dissected  back- 
ward to  the  points  first  indicated.  "We  have  now  exposed  all  the 
shortened  soft  structures.  We  first  sever  diagonally  the  inner  fasciculus 
of  the  plantar  fascia.  The  diagonal  division  of  the  plantar  fascia  is 
done  so  that  after  correction  there  shall  not  be  left  a  defect  between 
the  divided  ends,  but  that  the  points  of  the  incised  fascia   still  come 


Fig.  459. 


in  contact,  thereby  lessening  the  tendency  to  contraction  of  this 
structure  when  repair  is  complete.  The  remaining  structures  are  now 
divided  successively  as  directed  by  Phelps,  until  the  astragalo-scaphoid 
capsule  is  reached.  Instead  of  dividing  this,  we  make  another  incision 
on  the  outer  side  of  the  foot,  over  the  head  of  the  astragalus,  pushing 
aside  the  tendons  and  soft  structures  and  exposing  the  neck  of  that 
bone,  and  then  cut  through  the  neck  with  a  chisel.  We  can  now  push 
the  forward  part  of  the  foot  outward  without  separating  the  astragalo- 
scaphoid  articulation  which  nearly  always  occurs  in  the  typical  Phelps' 
operation."  After  bleeding  has  been  arrested  the  wounds  are  closed 
and  the  limb  put  up  in  plaster  of  Paris. 

I  have  sometimes  found  it  well  to  make  a  vertical  flap  (not  encroaching 
upon  the  sole)  instead  of  the  more  horizontal  one  advocated  by  Dr.  Jonas 
(Fig.  459).  The  internal  saphenous  vein  can  be  drawn  out  of  the  way. 
The  tibialis  anticus  tendon  is  easily  found  above.  As  no  Esmarch's 
bandage  is  required,  the  pulsation  of  the  posterior  tibial  artery  is  a 
guide  in  the  division,  with  blunt-pointed  scissors,  of  the  tibialis  posticus 
and  flexor  longus  digitorum.  Believing  that  in  cases  at  all  advanced  the 
shortened  astragalo-scaphoid  capsule  is  an  important  element  in  keeping 
up    the    resistance,    I    have    divided  this,  the  foot  being  everted  and 


1048  OPERATIONS   ON   THE    LOWER    EXTREMITY. 

abducted.  This  step  while  it  has  not  appeared  to  weaken  the  foot  at 
all  afterwards  has  enabled  me  to  dispense  with  the  second  incision  and 
osteotomy  of  the  neck  of  the  astragalus  recommended  above.  In  cases 
where  the  skin,  in  addition  to  the  deeper  parts,  is  much  shortened,  I 
have  not  found  it  possible  to  secure  complete  suturing  and  primary 
union  of  the  wound,  whichever  incision  is  employed.  With  reference 
to  this  point  it  will  be  remembered  that  hero,  as  after  any  operation 
for  talipes,  the  foot  must  be  put  up,  whether  in  a  short  Dupuytren's 
sj)lint,  or  in  plaster  of  Paris,  in  the  over-corrected,  everted  position. 

Phelps'  Operation  by  Open  Incision.* — The  foot  having  been  cleansed  and  rendered 
evasculav  is  placed  on  its  outer  side,  and  a  line  is  drawn  from  the  tip  of  the  inner  malleolus 
to  the  tuberosity  of  the  scaphoid.  From  the  centre  of  this  line  an  incision  is  made  out- 
wards across  the  inner  third  of  the  sole,f  down  to  the  neck  of  the  astragalus  on  its  inner 
side.  Through  this  wound  the  plantar  fascia,  abductor  hallucis,  tibiales  posticus  and 
anticus,  the  long  flexors,  together  with  the  internal  lateral  and  calcaneo-scaphoid  ligaments, 
are  divided.  If  possible,  the  internal  plantar  vessels  and  nerve  are  spared.  Great  force 
is  then  used  to  rupture  the  deeper  ligaments  and  over-correct  the  foot.  Phelps  also  divides 
the  tendo  Achillis  at  the  same  time  ;  others  prefer  to  leave  this  step  till  a  later  occasion. 
The  wound,  partly  sutured,  is  put  up  without  drainage,  and  must  heal  partly  under  blood- 
clot,  partly  by  granulation.  The  foot  is  maintained  in  the  over-corrected  position  by 
plaster  of  Paris. 

This  operation  has  been  modified  in  various  ways  in  order  to  avoid  the  tendency  to 
recurrence  which  results  from  the  contraction  of  the  scar  left  on  the  inner  side  of  the  foot. 

Mr.  W.  A.  Lane  (Lancet,  Aug.  19,  1893)  puts  on  a  large  skin  graft  on  the  second  dayt 
in  order  to  promote  more  rapid  healing.  Mr.  T.  H.  Kollock  (Lancet,  March  30,  1895) 
partially  fills  the  gap  by  means  of  a  skin  flap  from  the  dorsum  of  the  foot.  Dr.  W.  Gardner, 
of  Melbourne,  quoted  by  Tubby  (Orthopedic  Sura.,  p.  435),  inserts  a  wedge  of  decalcified 
bone  between  the  scaphoid  and  astragalus,  "  to  which  bones  it  is  wired,  and  by  this  the 
lengthening  of  the  inner  side  is  maintained  until  the  plate  is  replaced  by  fibrous  tissue." 

Lane's  %  Complete  Subcutaneous  Section. — Mr.  W.  A.  Lane,  believing  that  the 
later  results  of  Phelps'  operation  are  very  unsatisfactory  owing  to  the  "absolute  loss  of 
continuity  of  all  the  soft  parts  in  the  sole  of  the  foot,"  advises  the  following  method  (Lancet, 
vol.  ii.  1893,  p.  432)  :  "An  india-rubber  bandage  is  applied  above  the  knee  to  control  the 
circulation,  so  as  to  prevent  the  free  bleeding  that  would  otherwise  occur,  and  then,  by 
means  of  a  strong,  long-bladed,  sharp-pointed  tenotomy-knife,  everything  beneath  the  skin 
that  opposes  the  placing  of  the  foot  in  a  position  of  moderate  abduction  upon  the 
astragalus  is  divided.  This  includes  the  several  divisions  of  the  plantar  fascia,  part  of  the 
internal  lateral  and  annular  ligaments,  the  superior  internal  calcaneo-scaphoid,  the  inferior 
calcaneo-scaphoid  and  the  long  and  short  plantar  ligaments,  together  with  the  tibialis 
anticus  and  all  the  tendons,  vessels,  and  nerves  in  the  sole  of  the  foot.  This  cannot  be  done 
satisfactorily  through  a  single  puncture  ;  but  I  do  not  hesitate  to  make  any  number  of 
punctures,  only  taking  care  that  the  knife  is  entered  in  such  a  direction  that  the  forcible 
fixation  of  the  foot  in  a  position  of  abduction  does  not  cause  the  wound  made  by  it  to  gape. 
This  is  a  matter  of  considerable  importance,  since  it  is  frequently  necessary  to  sew  up  the 
apertures  which  are  made  by  the  knife,  otherwise  arterial  blood  spurts  through  them  on 
removing  the  tourniquet.  By  spending  some  time,  and  by  exercising  a  moderate  amount 
of  skill,  it  is  possible  to  divide  all  the  soft  parts  opposing  abduction  of  the  foot  on  the 
astragalus  and  to  leave  the  skin  intact,  except  for  the  punctures  produced  by  the  tenotomy- 
knife.  After  this  has  been  done,  I  pass  a  knife  between  the  skin  and  tendo  Achillis  and 
divide   it.      If  the  foot  does  not  become  square  I  cut  all  the  soft  parts  except  the  peronei, 

•  Mr.  E.  Owen  strongly  advocated  this  operation  (Med.-Chir.  Trans.,  vol.  lxxvi.  p.  89). 

I  Phelps  originally  made  his  incision  two-thirds  across  the  sole,  but  modified  it  owing 
to  the  tender  scar  which  was  liable  to  result. 

{  A  somewhat  similar  operation  is  given  by  Buchanan  (Brit.  Med.  Journ.,  Oct.  27, 
If 


REMOVAL   OF   TARSAL    BONES.  1049 

carefully   dividing   the   posterior   ligament  of  the  ankle-joint,  which  often  opposes  free 
movement  of  this  articulation." 

With  regard  to  the  above  operations,  I  am  of  opinion  that  cases 
severe  enough  to  require  them  are  best  met  by  cuneiform  tarsectomy 
(ride  infra). 

Eemoval  of  Astragalus  (Lund.,  Brit.  Med.  Journ.,  Oct.  19,  1872). — 
This  is  indicated  in  cases  of  equino-varus  where  the  astragalus  is  the 
chief  cause  of  the  deformity,  where  the  equinus  is  more  marked  than  the 
varus,  and  especially  in  paralytic  talipes  equinus.  The  resisting  tendons, 
fasciae  and  ligaments  must  be  divided  as  well  and  the  muscle  thoroughly 
employed.  Even  after  this  step  has  been  taken  in  equino-varus  and 
the  astragalus  has  been  removed,  it  may  be  needful  in  order  to  secuie 
the  needful  over-correction  to  remove  the  scaphoid,  cuboid  and  anterior 
part  of  the  os  cahis.  The  late  Mr.  Walsham  advised  partial  division  of 
the  external  malleolus  with  bone-forceps  and  then  carrying  the  foot 
outwards,  bending  the  malleolus  backwards  and  outwards  also.  In  his 
words,  "  When  once  a  bone-operation  has  been  embarked  on,  it  is  no 
use  stopping  short  till  sufficient  bone  has  been  cleared  away  to  permit 
of  the  rectification  of  the  foot.  No  more  should,  of  course,  be  removed 
than  is  necessary,  but  to  take  away  too  little  is  to  my  mind  much  the 
graver  fault."  But  before  removing  other  bones  than  the  astragalus 
the  operator  should  be  certain  that  the  resistance  of  the  soft  structures 
it  entirely  overcome.  Several  incisions  have  been  employed.*  The 
following  will  suffice.  The  projection  of  the  astragalus  renders  its 
removal  easier  than  would  otherwise  be  the  case.  A  longitudinal 
incision  about  two  inches  long  and  gently  curved,  is  made  over  the 
most  projecting  part  of  the  head  of  the  astragalus  from  the  external 
malleolus  downwards  and  inwards,  between  the  outermost  tendon  of  the 
extensor  longus  digitorum  and  the  peroneus  tertius.  The  soft  parts 
on  either  side  of  the  incision  having  been  raised  with  an  elevator,  the 
ankle-  and  astragalo- scaphoid  joints  are  opened,  and  the  bone  is  loosened 
in  its  bed  with  an  elevator  while  its  ligamentous  attachments  are  divided 
with  blunt-pointed  scissors.  This  is  facilitated  by  drawing  the  bone  in 
different  directions  with  lion-forceps.  The  chief  difficulties  met  with 
are  :  (1)  the  closeness  with  which  the  bone  occupies  its  socket,  and  the 
consequent  readiness  with  which,  if  a  sharp  instrument  be  used  to  lever 
out  the  astragalus,  slices  of  cartilage  are  detached  from  the  scaphoid  or 
malleoli ;  (2)  division  of  the  ligaments,  especially  the  interosseous  and  the 
internal  lateral. 

In  those  advanced  cases  where  it  is  doubtful  if  removal  of  the  astragalus 
will  suffice,  I  generally  prefer  to  remove  a  wedge  at  once,  as  involving 
less  disturbance  of  the  parts  than  two  operations,  and  as  being  certain. 
Mr.  Walsham,  however,  prefers  beginning  with  removal  of  the  astragalus. 

Cuneiform  Tarsectomy. — This  operation  is  especially  indicated  in 
those  inveterate  or  resistant  cases  of  talipes  where  great  prominence  of 
the  astragalus  is  not  the  prominent  feature,  where  the  fixity  is  too 
great  to  be  overcome  by  the  removal  of  one  bone,  or  wThere  this  step 
has  been  used  and  failed.     Personally,  I  prefer  this  operation  in  every 

*  G.  A.  Wright  {Diseases  of  Children,  with  Dr.  Ashby,  p.  687)  advises  an  incision  over 
the  ankle-joint,  from  the  tibialis  posticus  to  the  anticus,  and  another  incision  at  right 
angles  to  the  first  along  the  inner  side  of  the  tibialis  anticus. 


1050  oiTJtATIONS    ()N    THK    LOWEB    EXTREMITY. 

case  which  is  beyond  the  remedy  of  judiciously  employed  "  wrenching, " 
and  the  operation  described  at  p.  1046.  "When  I  say  in  every  case,  I 
should  like  to  make  one  reservation.  1  am  referring  to  the  bulk  of  cases 
which  conic  before  b  hospital  surgeon.  Where  these  can  afford  time 
mid  expense,  where  the  parents  have  the  good  sense  to  be  patient  over 
the  time  which  is  required  to  secure  good  results — in  such  cases  milder 
methods  will  often  suffice.  But  with  the  great  majority  of  hospital 
cases  it  is  not  so.  Time  for  schooling,  apprenticing,  and  so  forth,  is 
urgently  needed,  perhaps  much  has  been  already  lost.  Even  moderately 
expensive  apparatus  is  difficult  of  attainment ;  intelligence  and  patience 
on  the  part  of  the  parents  or  patient  are,  very  often,  not  forthcoming  ; 
the  regular  attendance  which  is  absolutely  needful  is  broken  off  or 
interrupted,  thus  causing  the  inevitable  relapses  so  well  known  to  every 
surgeon  of  experience.  Looking  upon  treatment  here  as  mainly  a 
question  of  time,  not  only  to  fit  the  patient  to  play  his  part  in  life's  battle, 
but  because  the  longer  the  deformity  is  left  the  worse  is  the  habit  of 
walking  acquired,  I  generally  resort  to  tarsectomy  in  patients  as  young 
as  ten  or  eleven,  and  very  occasionally  even  younger.  I  admit  the 
foot  is  flat  and  shortened,  and  in  some  cases  stiff,  though  this  last  is  due 
to  imperfect  after-treatment  and  insufficient  manipulation  and  active 
and  passive  exercise  of  the  foot.  Though  flat  and  shortened,  the  foot  is 
square,  without  any  tendency  to  inversion,  after  a  ivell-managed  tarsectomy. 
This,  I  maintain,  is  the  chief  object  before  us  in  these  resistant  cases 
of  talipes,  and,  as  it  is  attained  most  speedily  and  certainly  by  tarsec- 
tomy, I  recommend  this  operation  strongly  in  poorer  patients  who  can 
least  afford  to  lose  time. 

With  regard  to  the  matter  of  age,  I  would  refer  my  readers  to  papers 
by  the  late  Mr.  Walsham  (Brit.  Med.  Journ.,  1893,  vol.  i.  p.  339)  and 
Mr.  Ewens,  Surgeon  to  the  Bristol  Children's  Hospital  {ibid.,  1891, 
vol.  ii.  p.  843).  Both  these  surgeons  advocate  resort  to  removal  of 
bone  at  an  earlier  age  than  is  usually  allowed  ;  both  consider  such 
operative  steps  justifiable,  in  special  cases,  in  children  only  three  years 
old.  In  Mr.  Walsham's  words  :  "  I  have  not  done  a  bone  operation 
on  these  patients  at  a  younger  age  than  two  or  three  3'ears,  but  at  that 
tender  age  I  have  found  that,  even  after  removal  of  the  astragalus,  the 
foot  in  some  instances  could  not  be  got  into  a  satisfactory  position 
until  further  portions  of  the  bones  had  been  excised."  Where,  with 
the  advantages  of  a  well-ordered  special  department,  skilled  assistants 
and  nurses,  and  ample  experience,  Mr.  Walsham  found  milder  methods 
fail,  other  surgeons — working,  perhaps,  under  less  happy  surroundings 
— need  not  fear  to  resort,  in  like  occasional  cases,  to  removal  of  bone. 

Operation. — The  parts  having  been  rendered  evascularwith  Esmarch's 
bandages,  are  duly  resterilised  and  supported  on  a  sand-bag.  A  T-shaped 
incision  is  then  made  with  the  horizontal  limb  along  the  outer  side  of 
the  foot  over  the  os  calcis  and  the  cuboid,  and  the  longitudinal  one 
at  a  right  angle  to  this  passing  across  the  dorsum  and  ending  over 
the  scaphoid.  The  flaps  thus  marked  out  are  turned  aside.  With  a 
periosteal  elevator  the  tendons  and  vessels  on  the  dorsum  are  now 
raised  <  u  masse,  so  that  sufficient  room  is  given  for  the  saw  to  pass 
between  them  and  the  bones.  With  a  retractor  on  the  outer  side  the 
peronei  tendons  are  held  out  of  the  way,  due  care  being  taken  of  their 
sheaths  to  avoid   the  risk  of  slouching.      With  a  narrow-ldaded  saw,  a 


REMOVAL   OF   TARSAL    BONES.  1051 

wedge  of  bone  of  sufficient  size  is  then  removed  b}r  two  cuts,  one 
above  and  one  below,  meeting  at  the  scaphoid.  The  upper  of  these 
will  pass  through  the  os  calcis  to  the  scaphoid,  the  lower  through  the 
cuboid,  through  the  joint  between  this  and    the  fifth  metatarsal,  or 

through  the  base  of  this  bone,  according  to  the  severity  of  the  case. 
While  these  sections  are  made,  a  blunt  dissector  should  be  pushed  under 
the  bones  very  (lose  to  their  plantar  surfaces,  so  as  to  protect  the  soft 
parts  beneath.  The  wedge  of  bone  is  then  removed  with  a  lion-forceps, 
or  by  levering  it  out  with  an  elevator,  care  being  taken  not  to  damage 
any  parts  used  as  a  fulcrum.  As  it  is  twisted  out,  a  few  attachments 
to  the  structures  in  the  sole  may  require  division  or  peeling  off.  If 
the  position  of  the  foot  cannot  be  rectified,  the  gap  may  be  widened 
by  removing  more  bone  either  with  a  saw  or  with  a  chisel  and  mallet; 
it  is  especially  towards  the  apex  that  this  must  be  done.  But  before 
lli is  step  is  taken  any  resistance  due  to  the  soft  structures  should  be 
overcome.  This  is  effected  by  prolonging  the  apex  of  the  incision 
over  the  inner  side  of  the  foot  and  dividing  the  tendons,  &c,  by  the 
steps  given  at  p.  1047.  When  the  foot  can  be  brought  into  good  position 
any  tendons  that  have  been  divided  are  united  with  carbolised  silk  or 
chromic  gut.  Any  vessels  which  can  be  seen  are  then  secured,  a 
drainage-tube  is  inserted,  and  the  wound  partly  closed  with  sutures. 
Sufficient  gauze  dressings  are  then  firmly  bandaged  on  before  the 
Esmarch's  bandage  is  removed.  The  foot  is  put  up  with  a  back  and 
two  side  splints,  or  on  an  external  splint  with  an  interruption,  the 
knee  being  flexed  and  the  limb  resting  on  its  outer  side.  Mr.  Davy 
has  devised  a  special  splint  to  secure  eversion.  Morphia  should  be 
given  freely  at  first  if  required.  In  six  or  eight  weeks  the  union 
should  be  firm. 

If  after  the  operation  the  foot  still  turns  in  because  the  whole  limb 
does  so,  osteotomy  of  the  femur  at  about  the  junction  of  the  middle 
and  lower  thirds  should  be  performed,,  and  the  leg  and  lower  fragment 
turned  somewhat  outwards. 

Great  care  must  be  taken  during  the  after-treatment  to  keep  the 
parts  aseptic.  (Edema,  &c,  are  of  very  likely  occurrence,  if,  owing 
to  an  insufficient  wedge  being  removed,  much  force  has  to  be  employed 
to  correct  the  inversion.  Occasionally  complete  closure  of  the  wound 
is  delayed  by  the  coming  away  of  a  scale  of  bone ;  the  ill-vitalised 
corns  and  bursal  tissues  may  show  some  signs  of  sloughing.  In 
those  very  severe  cases,  rarely  met  with  nowadays,  where  this  condi- 
tion of  the  skin  seriously  imperils  its  vitality7,  a  Pirogoff's  amputation 
may  be  the  wiser  step. 

Operative  Treatment  of  Fiat-Foot. — Numerous  methods  have  been 
employed  here.  I  am  only  familiar  with  that  of  Prof.  Ogston  (Lancet, 
1884,  vol.  i.  p.  152),  in  which  the  articular  surfaces  of  the  astragalo- 
scaphoid  joint  are  removed,  the  proper  position  of  the  foot  restored 
as  far  as  is  possible,  and  thus  retained  with  ivory  pegs.  Sir  W. 
Stokes's  operation,  in  which  a  wedge  is  taken  from  the  head  and  neck 
of  the  astragalus  (Brit.  Med.  Joitm.,  Dec.  I,  1894),  is  the  more  scientific 
one,  as  in  it  the  mediotarsal  joint  is,  theoretically,  left  untouched,  but 
in  practice  it  is  difficult  to  ensure  this. 

Ogston's  Operation. — The  site  of  the  displaced  astragalo-scaphoid 
joint  having  been  exactly  identified,  the  parts  most  carefully  sterilised 


1052  OPERATIONS   ON   THE   LOWER    EXTREMITY. 

and  an  Esmarch's  bandage  applied,  a  longitudinal  incision,  about  two 
inches  long,  is  made  over  the  joint  and  deepened  down  to  the  bones. 
If  it  be  j) referred,  the  incision  may  be  curved  or  a  rectangular  one, 
one  over  the  joint  and  the  other  at  right  angles  to  it  towards  the 
dorsum,  and  small  flaps  made.  The  ligaments  and  periosteum 
together,  having  been  carefully  raised  from  the  bones  to  the  needful 
extent,  and  to  this  only,  the  articular  cartilage  is  detached  on  either 
side  with  a  chisel,  the  bevelled  surface  of  which  is  tinned  towards 
the  scaphoid  and  away  from  the  astragalus.  Two  holes,  half-an-inch 
apart,  are  now  drilled  through  the  scaphoid  into  the  astragalus,  towards 
the  centre  of  its  head.  Sterilised  fine  ivory  pegs  are  then  driven  into 
the  holes  and  cut  short.  To  get  the  foot  into  the  best  possible  position 
before  the  joint  is  opened,  the  foot  should  be  strongly  moved  or 
wrenched  in  every  direction,  especially  in  those  of  adduction  and  inver- 
sion. While  all  surgeons  of  experience  are  familiar  with  the  very 
slight  reaction  that  follows  on  forcible  rectification  without  operation, 
it  is  another  matter  when  a  deep  wound  has  been  made.  Hence  the 
need  of  rigid  attention  to  asepsis  before,  during,  and  after  the  opera- 
tion. Wire  hammered  down  may  replace  the  pegs,  or  any  retaining 
material  may  be  dispensed  with  altogether  (Openshaw,  Clin.  Joimi., 
Dec.  12,  1894).  If  needful,  the  rectification  must  be  completed  a  week 
or  ten  days  after  the  operation.  The  patient  must  not  walk  on  the 
foot  for  a  period  of  two  to  three  months.  In  bilateral  cases  both 
feet   should  be  operated  on  at  the  same  time. 

Prof.  Ogston  found  that  in  those  cases  where  complete  restoration 
of  the  arch  was  impossible,  great  improvement  followed,  and  that  this 
improvement  was  lasting. 

Here,  as  in  all  cases  where  a  surgeon  once  embarks  on  removal  of 
bone  for  aggravated  deformity,  he  must  continue  until  sufficient  is  taken 
awa}'  to  permit  of  over-rectification.  Otherwise  relapse  is  certain. 
Thus  where  the  valgus  at  the  ankle  is  more  marked  than  the  flatness 
in  the  sole,  the  tibia  and  fibula  must  be  divided  through  lateral 
incisions,  and  the  deformity  over-corrected.  To  prevent  the  stiffness 
which  may  follow  on  operations  at  or  near  to  the  astragalo-scaphoid 
joint,  Trendelenberg  and  Hahn  prefer  to  divide  the  tibia  and  fibula.  In 
some  cases  valgus  of  the  great  toe  will  also  require  attention. 

CHOPART'S    AMPUTATION     (Figs.   460-463). 

In  this  medio-tarsal  amputation  only  the  astragalus  and  the  os  calcis 
are  retained,  disarticulation  being  effected  through  the  joints  between 
the  above  bones  and  the  scaphoid  and  the  cuboid. 

Value  of  the  Operation. — This  has  been  a  good  deal  disputed. 
The  following  objections  have  been  raised  to  it : 

1.  That  the  tendo  Achillis,  no  longer  counterbalanced  by  the  extensor 
muscles,  which  have  now  lost  their  attachment,  draws  up  the  heel, 
tilting  down  the  scar,  which  now  becomes  tender  and  irritable  (Fig.  463). 
2.  In  the  normal  foot  the  weight  of  the  body  is  transmitted  through 
the  astragalus  to  the  other  bones  of  the  tarsus  and  metatarsus.  NYhen, 
as  in  this  amputation,  these  bones  have  been  removed,  the  weight  of 
the  body  tends  to  thrust  forward  the  astragalus,  no  longer  supported 
by  the   elastic  bones  in  front,  against  the  scar  (Fig.  463),  and  thus 


<  imiwirrs  amputation. 


1053 


renders  this  tender  and  crippling.  The  above  objections  apply  to  the 
operation  performed  for  injury  or  disease,  the  next  to  amputation  for 
the  latter  only.  3.  If  the  operation  be  made  use  of  in  caries,  this 
disease  is  likely  to  recur  in  the  two  bones  left.  In  answer  to  the  first, 
two  of  tlir  above  objections  it  may  be  said  that  this  tendency  to  tilting 
upwards  of  the  heel  and  downwards  of  the  scar  may  be  met :  (a)  By 
stitching  the  anterior  tendons — e.g.,  tibialis  anticus,  extensor  proprius 
hallucis,  and  some  of  the  tendons  of  the  extensor  communis — into  the 


Fig.  460 


Incisions  in  Chopart's  amputation.     (Fergusson)*. 

tissues  of  the  sole-flap  with  stout  carbolised  silk  or  chromic  gut,  so  as 
as  to  give  them  a  fixed  point  by  which  they  may  counterbalance  the 
tendo  Achillis  ;  t  (b)  by  cutting  the  plantar  flap  sufficiently  long,  and 
securing  firm  primary  union  ;  (c)  by  division  of  the  tendo  Achillis. 
This,  however,  is  only  of  fugitive  value  ;  (d)  wearing  a  wedge-shaped 
pad  in  the  boot  to  raise  the  front  of  the  stump;  (e)  preserving  the 
scaphoid,  when  sound,  so  as  to  retain  the  attachment  of  the  tibialis 
posticus.  "  It  has  not  been  shown 
that  this  modification  is  of  special 
value"  (Treves). 

The  third  objection  is  answered 
by  only  performing  this  operation 
for  caries  when  the  disease  is 
limited  to  the  front  of  the  foot,  is 
of  distinctly  traumatic  origin,  and 
occurs  in  a  healthy  patient. 

Operation  (Figs.  460  and  461). 
— -An  Esmarch's  bandage  being 
applied,    and    the    foot    supported 

at  a  right  angle  over  the  edge  of  the  table,  the  surgeon,  standing 
to  the  right  side  of  the  foot,  and  so  that  he  can  easily  face  the 
sole,  places  (e.g.,  on  the  right  side)  his  left  index  and  thumb  imme- 
diately above  the  tubercle  of  the  scaphoid  and  the  corresponding 
point  on  the  outer  side — viz.,  the   calcaneo-cuboid  joint,   which  lies 


*  Too  much  dorsal  nap  is  shown  here  ;  the  next  figure  shows  the  correct  amount. 

f  We  owe  this  ingenious  precaution  to  Mr.  Delegarde,  of  Exeter.  Till  it  is  more 
frequently  made  use  of,  and  a  larger  number  of  cases  are  collected,  the  value  of  this 
amputation  must  remain  somewhat  undecided.  I  have  operated  on  five  occasions — one  a 
severe  crush,  another  for  the  results  of  perforating  ulcer,  and  in  three  for  caries  of  the 
front  of  the  foot  ;  in  all  this  precaution  was  taken,  and  the  stumps  proved  sound  and 
useful.     One  I  watched  for  four  years. 


1054 


OPERATIONS    ON    THE    LOWEB    EXTREMITY. 


midway  between  the  external  malleolus  and  the  base  of  the  fifth 
metatarsal  bone.  He  then  joins  these  points  by  a  slightly  curved 
incision  crossing  the  tarsus,  and  dividing  everything  down  to 
the  bones.  The  foot  being  flexed  upwards,  a  plantar  flap  is  then 
marked  out  by  an  incision  running  from  the  outer  extremity  of  the 
first  up  the  outer  side  of  the  little  toe,  then  across  the  sole  on  a  line 
just  short  of  the  balls  of  the  toes,  and  then  down  the  inner  side  of  the 
great  toe  to  join  the  inner  extremity  of  the  first.*  The  flap  thus 
marked  out  is  raised  with  the  same  precaution-,  given  at  p.  1057.  It  is 
then  held  out  of  the  way,  and  the  anterior  half  of  the  foot  being 
strongly  depressed,  disarticulation  is  effected  by  passing  the  knife 
above  the  tubercle  of  the  scaphoid  between  this  bone  and  the  astra- 
galus, and  then  between  the  concavo-convex  surfaces  of  the  calcaneo- 
cuboid joint.    In  effecting  this  the  position  of  the  joints  and  the  shape 


Fig.  462. 


Fig.  463. 


Stamp  after  Chopart's  amputation. 
(Fergusson. ) 


Stump  stated  by  Farabeuf  to  be 
often  met  with  after  Chopart's  amputa- 
tion, showing  its  shape,  the  position  of 
the  bones,  and  the  influence  of  the 
tendo  Achillis. 


of  the  astragalus  must  be  remembered,  and  Mr.  Skey's  words  borne  in 
mind  :  "  The  joints  should  be  opened  with  tact  and  not  by  force  :  if 
the  knife  be  applied  to  the  right  surface,  it  will  pass  without  effort  into 
the  articulation  ;  if  in  the  wrong  direction,  no  force  will  effect  it/' 

The  anterior  tibial  and  plantar  arteries  are  then  secured,  and,  on 
removal  of  the  Esmarch's  bandage,  any  other  vessels  which  require  it. 
The  flap  is  then  folded  up  over  the  bones,  but  without  any  forcible 
bending,  which  might  interfere  with  the  blood-supply.  While  it  is 
held  in  this  position,  before  any  sutures  are  inserted,  the  extensor 
tendons  (vide  supra)  should  be  carefully  stitched  with  sufficiently  stout 
silk  into  the  fibrous  tissues  which  abound  in  the  plantar  flap,  care 
being  taken,  in  so  doing,  not  to  puncture  the  external  plantar  vessels, 
but  at  the  same  time  to  secure  a  sufficient  hold. 


*  The  flap  should  be  a  full  inch  shorter  than  that  in  Lisfranc's  operation  (p.  1056),  if 
the  tissues  are  sound.  An  unduly  long  and  large  plantar  flap  will  here,  as  after  a 
Lisfranc's  amputation,  form  an  unwieldy  pocket  (Treves). 


TUiriKK'S    AMPUTATION. 


™55 


TRIPIER'S    AMPUTATION*  (Fig.  464). 

This  operation  was  proposed  by  Dr.  L.  Tripier,  of  Lynns,  as  an  improved  modification 
of  Chopart's  amputation, over  which  it  is  thoughl  to  possess  the  following  advantages: 
(1)  The  horizontal  division  of  the  os  calcis  on  a  level  with  the  sustentaculum  tali  gives  a 
large  surface  of  Bupporl  entirely  free  from  the  objections  to  thai  in  <  Ihopart's  amputation 
(p.  1052).  Mr.  Wagstaffe  (  bond.  Med.  Record,  1880.  p.  135)  considered  the  following  to  be 
further  advantages— e.g.,  thai  less  plantar  flap  is  needed,  and  that  the  operator  can  see 
the  state  of  the  os  calcis.  amputating  higher  if  this  bone  be  too  much  diseased.  The 
following  advantages  claimed  for  M.  Tripier's  amputation  over  the  sub-astragaloid 
(P-  I035)  arc  :  ('■)  t1k'  liln,)  is  longer,  (ii.)  the  section  of  the  os  calcis  gives  a  larger  and 
more  solid  basis  of  support.  (2)  By  making  the  section  of  the  os  calcis,  the  tendons, 
especially  the  tendo  Achillis,  are  better  preserved. 

Plantar  and  dorsal  flaps  are  marked  out  on  somewhat  similar  lines  to  the  sub- 
ast  ragaloid  method  (p.  1035)  by  the  following  incisions,  the  dorsal  starting  from  the  outer 
part  of  the  tendo  Achillis  at  its  insertion,  then  passing  about  an  inch  and  a  quarter  below 
the  external  malleolus  forwards  to  a  point  about  the  same  distance  above  the  tuberosity  of 


Fig.  464. 


Tripier's  amputation,     a, 


Section  through  the  skin. 
(T.  Bryant.) 


b,  Through  the  soft  parts. 


the  fifth  metatarsal  bone  ;  the  incision  then  curves  inwards  to  end  at  the  inner  side  of  the 
extensor  proprius  hallucis,  over  the  tarsal  end  of  the  first  metatarsal  bone.  From  this 
point  the  plantar  flap  is  marked  out  by  an  incision  downward  and  forward  over  the  inner 
part  of  the  sole,  about  an  inch  in  front  of  the  base  of  the  first  metatarsal  bone,  and  then 
obliquely  across  the  bases  of  the  metatarsals,  and,  lastly,  backwards,  so  as  to  join  the 
dorsal  incision  over  the  outer  part  of  the  os  calcis.  All  the  dorsal  tendons  are  then 
divided  along  the  line  of  the  incision,  and  the  structures  in  the  plantar  incision  are  cut 
down  to  the  bones.  A  thick  plantar  flap  is  now  raised  until  the  under  surface  of  the  os 
calcis  is  exposed,  and  the  point  of  the  heel  turned.  Disarticulation,  as  for  Chopart's 
amputation,  is  then  performed.  The  periosteum  covering  the  under  aspect  of  the  os  calcis 
is  now  incised  antero-posteriorly,  and  detached  from  the  bone  up  to  the  level  of  the 
sustentaculum  tali.  The  os  calcis  is  next  sawn  through  horizontally  from  within  out- 
wards, on  a  level  with  the  same  process.  The  projecting  angles  are  then  rounded  off,  and 
the  plantar  and  dorsalis  pedis  arteries  tied.  As  in  all  amputations,  the  nerve  that  will 
bear  pressure  in  the  flap — here  the  posterior  tibial — should  be  trimmed  short. 


*  A  case  of  this  amputation  by  Mr.  Hayes,  of  Dublin,  will  be  found  in  the  Brit.  Med. 
Jcnirn.,  1881,  vol.  i.  p.  303. 


1056 


(H'KKATIONS    ON    TIIK    LOWEE    EXTREMITY. 


AMPUTATION    THEOUGH    THE    TARSO-METATARSAL 
JOINTS   (Figs.  465-468). 

This,  though    usually   spoken    of  as    I  lev's   or    Lisfranc's   amputa- 
tion,   includes,    accurately    speaking,    the    following    operations: 

1.  Lisfranc's. — Amputation  by  disarticulation  through  all  the  joints. 

2.  Hey's. — This  is  usually  described  as  amputation   here  by  sawing 
through  the  bases  of  the  metatarsals.     In  reality,  Hey  seems  to  have 

disarticulated  through  the  outer 
four  joints,  and  sawn  off  the 
projecting  internal  cuneiform 
(Observations  in  Surgery,  third 
edition,  p.  552).  3.  Skey's. — 
Disarticulation  through  the  outer 
three  and  the  first  joints,  the 
second  metatarsal  being  sawn 
through  (Oper.  Sun/.,  p.  406). 

Indications. — Few.  (1)  Limi- 
ted crushes  in  which  the  sole  is 
sound.  (2)  Disease  limited  to 
the  front  of  the  foot.  (3)  In- 
veterate bunion,  with  persistent 
sinuses  and  recurrent  attacks  of 
cellulitis.  (4)  Perhaps  perforat- 
ing ulcer.  (5)  Some  cases  of 
frost-bite. 

Owing  to  the  complexity  of 
the  sy  no  vial  membrane  here 
(Fig.  457),  any  disease  which  has 
invaded  the  synovial  membrane 
between  the  second  and  third 
metatarsals  and  the  second  and 
third  cuneiforms,  has  also  spread 
to  that  between  the  scaphoid  and 
three  cuneiforms.  This,  though 
of  small  moment  in  cases  of  in- 
jury, should  put  this  amputation 
aside  in  most  cases  of  disease. 
Lisfranc's  Amputation  (Figs.  465  and  466). — The  preliminaries  are 
the  same  as  in  ( 'hopart's  amputation.  The  surgeon,  standing  to  the 
right  side  of  either  foot,  and  so  as  easily  to  face  the  sole,  places  his 
left  index  and  thumb  on  the  bases  of  the  little  and  great  toe  meta- 
tarsals respectively.  The  first  of  these  can  always  be  found  by 
pressure,  even  if  swelling  is  present;  if  there  be  any  difficulty  with  the 
latter,  it  will  be  found  a  lull  inch  in  front  of  the  readily  detected 
tubercle  of  the  scaphoid.  These  two  points  thus  marked  out  are 
joined  by  a  slightly  curved  dorsal  incision  with  its  convexity  forwards 
As  a  rule,  if  the  tissues  in  the  sole  are  sound,  no  dorsal  flap  should  be 
made,  the  above  incision  being  kept  close  to  the  line  of  the  joints 
through  which  disarticulation  is  to  be  performed. 

The  foot  being  now  flexed  upwards,  the  surgeon,  looking  towards 
the  sole,  marks  out  a  plantar  flap  by  an   incision  running  from  the 


Lisfranc's  amputation.    (Mac  Cormac.) 


AMPUTATION    Til  ROUGH   THE    METATARSAL   .mi  NTS.    1057 

outer  extremity  of  the  first  cut  (for  the  right  foot)  up  the  outer  side 
of  the  foot,  thru  across  the  heads  of  the  metatarsals,  and  down  the 

inner  side,  so  as  to  join  the  inner  extremity  of  the  dorsal  incision. 
Tins  Hap  should  be  made  a  little  longer  on  the  inner  than  on  the 
outer  side  of  the  foot,  so  as  to  cover  the  additionally  projecting  hones 
on  this  side.  Its  cut  edge  being  taken  firmly  hetween  the  finger  and 
thumb,  the  flap  is  then  dissected  up  as  thickly  as  possible — i.e.,  con- 
taining all  the  tissues  possible  in  the  sole.  In  keeping  the  knife 
close  to  the  bones  some  of  the  metatarsophalangeal  joints  will  pro- 
bably be  opened.  Below  these  the  flap,  if  steadily  pulled  upon,  will, 
with  light  touches  of  the  knife,  readily  separate  from  the  metatarsal 
bones.  The  Hap  should  be  raised  evenly,  and  without  scoring  or  any 
button-holes.  'The  prominent  bases  of  the  first  and  fifth  metatarsals 
being  laid  bare,  a  few  strong  touches  of  the  point  of  the  knife  may  be 
required  to  separate  part  of  the  tibialis  anticus  and  peroneus  longus 
from  the  base  of  the  former.     The  anterior  part  of  the  foot  is  now 

Fig.  466. 


Disarticulation  of  the  second  metatarsal  in  Lisfranc's  amputation.   The  knife  is  being 
used,  as  described  below,  to  separate  the  second  from  the  first  metatarsal  bone. 

strongly  depressed  so  as  to  stretch  the  dorsal  ligaments,  and  the  knife, 
having  been  thoroughly  carried  round  the  base  of  the  fifth  metatarsal, 
is  drawn  obliquely  forwards  and  inwards  so  as  to  open  the  joints  of  the 
outer  three  metatarsals  with  the  cuboid  and  the  external  cuneiform. 
The  joint  between  the  first  metatarsal  and  the  internal  cuneiform  is 
next  opened,  and,  lastly,  the  second  metatarsal  is  freed  as  follows : 
The  knife  being  held  firmly  in  the  fist,  its  point  is  inserted  between 
the  first  two  metatarsal  bones,  and  the  knife  carried  backwards 
and  forwards  in  an  antero-posterior  direction  in  the  long  axis  of  the 
foot  (Fig.  466).  The  same  is  then  done  between  the  second  and 
third  metatarsals,  and,  the  lateral  ligaments  being  thus  divided,  the 
joint  between  the  second  metatarsal  and  the  middle  cuneiform  is 
found  and  opened,*  this  being  facilitated  by  strongly  depressing  the 

*  The  position  of  this  joint  must  be  remembered,  and  the  way  in  which  the  base  of  the 
second  metatarsal  bone  is  locked  in  between  its  fellows  and  the  cuneiform  bones.  Its 
base  projects  upwards  between  a  third  and  a  quarter  of  an  inch  above  the  others. 

S. — VOL.  II.  67 


1058 


OPKHATIONS    ON    Till'.    1,'iW  EB    EXTREMITY. 


foot,  care  being  taken  not  to  do  this  so  violently  as  to  Beparate  the 
second  metatarsal  from  its  upper  epiphysis,  or  to  fracture  the  bone.* 

A  few  remaining  touches  of  the  knife,  aided  by  a  twisting  movement, 
will  then  suffice  to  separate  the  foot. 

The  method  by  disarticulation  may  be  a  useful  test  of  a  candidate's 
knowledge  and  skill  at  an  examination.  In  practice,  sawing  through 
the  metatarsals  just  below  their  bases  may  nearly  always  be  substituted, 
as  giving  equally  good  results  with  a  great  saving  of  time  and  trouble. 
The  truth  of  this  I  have  personally  tested. 

This  method  of  cutting  the  plantar  flap  before  any  attempt  is  made  to 
disarticulate  is  strongly  recommended  in  preference  to  disarticulating 
immediately  after  making  the  dorsal    incision  by  passing    the   knife 


Fig.  467. 


Fig.  468. 


Stump  after  Lisfranc's  amputation. 
(Fergusson.) 


c,  Internal  cuneiform.  1,  First  metatar- 
sal. 11,  Second  metatarsal,  e,  Internal 
tarso-metatarsal  interosseous  ligament,  pass- 
ing between  internal  cuneiform  and  ad- 
jacent angle  of  second  metatarsal,  p, 
Peroneus  longus.     (Farabeuf.) 


behind  the  bones  and  cutting  the  flap  from  within  outwards.  In  thus 
disarticulating  before  making  the  plantar  Hap,  it  is  quite  possible  to 
puncture  the  tissues  in  the  sole,  and  perhaps  to  wound  the  external 
plantar  artery.  Again,  passing  the  knife  behind  the  metatarsal  bones 
often  leads  to  a  hitch,  especially  with  the  projecting  fifth. 

The  dorsalis  pedis  and  the  external  plantar  artery  arc  now  secured 
with  any  smaller  vessels  which  need  it.  Tendons  are  cut  square,  nerves 
shortened,  drainage  provided,  and  the  plantar  flap  then  brought  up  and 
secured  in  accurate  position. 

Owing  to  the  thickness  of  the  plantar  flap  and  its  tendency  at  first 
to  unfold  itself  downwards,  numerous  points  of  suture,  of  sufficiently 
stout  wire  or  silkworm -gut,  must  be  made  use  of. 


*  While  the  surgeon  is  disarticulating  the  metatarsal  bones  the  plantar  (lap  must  be 
hell  well  out  of  the  way  to  prevent  its  being  punctured. 


AM  IMITATION    OF   THE   TOES.  1059 


AMPUTATION    OP    THE    TOES. 

Practical  Points. —  (1)  Any  plantar  scar  is  to  be  avoided.  (2)  The 
line  of  the  metatarso-phalangeal  joints  lies  a  full  inch  further  hack  than 
the  inter-digital  folds  of  the  skin  (Holden).     (3)   Partial  amputations 

(save  iii  the  case  of  the  great  toe)  are  very  seldom  advisable,  the  stumps 
left  being  of  little  use,  and  inconvenient  owing  to  their  liability  to 
project  upwards. 

AMPUTATION"    THROUGH    THE    PHALANGES    OR    THE 
INTERPHALANGEAL    JOINTS. 

These  operations  are  not  recommended,  for  the  reasons  just  given. 
If  a  patient  insist  on  having  one  performed,  the  directions  already  given 
for  the  fingers  (p.  4,  Vol.  I.)  will  be  found  sufficient. 

AMPUTATION    OP    ANY    OP    THE    FOUR    SMALLER    TOES 
AT    THE    METATARSO-PHALANGEAL    JOINTS. 

This  amputation  is  performed  much  as  in  the  case  of  the  fingers 
(p.  7,  Vol.  I.),  but  the  following  points  must  be  remembered  : 

(1)  The  line  of  the  joint  lies  a  full  inch  above  the  web.  (2)  The 
head  of  the  metatarsal  bone  is  not  here  removed,  so  as  to  leave  the 
supporting  power  of  the  foot  undiminished.  (3)  It  is  most  important 
to  avoid,  as  far  as  possible,  any  scar  on  the  sole. 

The  scar,  a  simple  antero-posterior  one,  is  well  protected  by  the 
adjacent  toes.  The  incision  should  always  be  begun  on  the  dorsum, 
even  in  the  case  of  the  little  toe,  so  as  to  avoid  friction  of  the  boots. 

AMPUTATION    OP    GREAT    TOE    AT    THE    INTER- 
PHALANGEAL    JOINT. 

This  is  usually  performed  with  a  plantar  flap,  much  as  at 
p.  11,  Vol.  I. 

AMPUTATION    OP    GREAT    TOE    AT    THE    METATARSO- 
PHALANGEAL   JOINT    (Fig.    469). 

This  is  performed  by  the  methods  described  at  p.  7,  Vol.  I.  The 
following  points  must  be  borne  in  mind  : 

(1)  Owing  to  the  large  size  of  the  head  of  the  metatarsal  bone,  the 
flaps  are  often  cut  of  insufficient  length.  The  incision  must  be  begun 
an  inch  and  a  quarter  above  the  joint,  and  carried  well  on  to  the 
phalanx,  one  flap  being  cut  longer  than  the  other  if  needful.  (2)  The 
sesamoid  bones  must  be  left  in  connection  with  the  head  of  the  meta- 
tarsal bone,  as  any  attempt  to  dissect  them  out  is  likely  to  imperil  the 
vascularity  of  the  flaps,  especially  after  middle  life. 

In  all  other  details  the  steps  of  this  amputation  are  very  similar  to 
those  already  given  at  p.  7,  Arol.  I. 

67 — 2 


1060  OPERATIONS   ON   TIIK   LOWEB    EXTREMITY. 

Though  it  is  recommended  by  some  excellent  Burgeons  to  remove 
the  head  of  the  metatarsal  hone  either  transversely  or  obliquely  from 
within  outwards,  this  step,  narrowing  as  it  docs  the  treading  width  of 
the  foot,  is  not  advisable,  unless  the  condition  of  the  skin  is  such  as 

l'i<;.  469. 


Dorsal  and  internal  flaps  for  amputation  of  the  great  toe  and  the  head  of  its 
metatarsal.     (Farabeuf.) 

to   render  it  impossible  to   obtain   sufficient   flaps  to  cover  the  entire 
head. 


AMPUTATION"   OF   THE   GREAT   TOE,    TOGETHER  WITH 
REMOVAL  OF    ITS    METATARSAL  BONE.      (Figs.  472  and  473.) 

This  may  he  performed  by  a  modification  of  the  oval  method  as 
described  for  the  fingers  at  p.  10,  Vol.  I. 

OPERATIONS     ON   THE    TOES    AND   METATARSALS    OTHER 
THAN"  AMPUTATIONS.— HAMMER    TOE,   HALLUX    VALGUS, 

AND   FLEXUS. 

Hammer  Toe. — In  cases  requiring  operation  the  choice  lies  between 
subcutaneous  division  of  the  resisting  structures,  excision  of  the  joint, 
partial  or  complete,  and  amputation.  Forcible  rectification  has  not 
commended  itself  to  me.  The  shortened  skin  will  require  division  by 
a  V-shaped  incision,  and  cases  needing  this  usually  require  more  to  be 
done. 

Rectification  by  Subcutaneous  operation. — The  foot  having  been 
thoroughly  sterilised,  an  assistant  holds  apart  the  adjacent  toes  ;  the 
surgeon,  holding  the  toe  at  first  flexed,  enters  a  sharp-pointed  tenotome 
to  one  side  of  the  middle  line  of  the  plantar  surface.  Turning  the 
edge  towards  the  bone  he  severs  first  one  and  then  the  other  lateral 
ligament  and  then  the  glenoid  and  long  flexor.  The  toe  is  then  brought 
into  good  position.  If  this  cannot  be  effected,  the  skin  may  need 
division.  Tins  failing,  the  head  of  the  first  phalanx  must  be  excised 
either  by  enlarging  the  wound  on  the  plantar  surface  or  by  an  incision 
on  the  dorsum. 

Excision. — I  consider  this  more  certain  than  the  operation  above. 
A  longitudinal  incision  is  made  to  one  side  of  the  extensor  tendon. 
This  is  carefully  freed  and  drawn  aside,  the  joint  is  opened  and  the  head 


OPKKATIONS    ON    THE   TOES. 


1061 


of  the  first  phalanx  removed  with  sharp  bone-forceps  or  a  fine  saw.  If 
complete  rectification  is  impossible  any  contracted  structures  must  be 
divided,  or,  if  needful,  the  base  of  the  second  phalanx  removed. 

After  either  operation  the  corn  often  present  on  the  dorsum  should 
be  removed  and,  if  needful,  any  hallux  valgus  operated  on  at  the  same 
time,  (are  should  be  taken  not  to  apply  the  first  dressing  too  tightly, 
or  sloughing  may  occur. 


Fig.  470. 


Fig.  471. 


Amputation  of  the  little  toe  by  a  single  dorsal  and  external  flap.     (Farabeuf.) 

Amputation. — This  is  often  described  as  needless  and  bad  surgery 
as  conducing  to  hallux  valgus.  I  have  frequently  had  it  performed  in 
hospital  j>ractice,  and  I  only  remember  one  case  in  which  the  patient 
returned  with  hallux  valgus.  Probably,  had  I  seen  to  this  condition 
being  rectified  at  the  time,  this  would  not  have  occurred. 


Fig.  472. 


Fig.  473. 


Amputation  of  great  toe  and  its  metatarsal 
bone  by  internal  flaps.     (Fergusson.) 


The  foot  left  by  the  operation. 
(Fergusson.) 


Hallux  Valgus. — Removal  of  a  sufficient  wedge  from  the  metatarsal 
bone  just  behind  the  joint  with  a  sharp  chisel  is  the  best  operation  here. 
This  form  of  osteotomy  gives  better  results  than  a  linear  one.  Any 
contracted  structures,  e.g.,  the  extensor  proprius  hallucis  should  be 
divided  at  the  same  time.  If  it  be  preferred,  the  base  of  the  first 
phalanx  may  be  removed,  but  the  head  of  the  metatarsal  should  never 
be  excised,  owing  to  its  importance  as  one  of  the  supports  of  the  foot. 
If  much  enlarged  the  bony  projections  may  be  removed. 


1062  OPERATIONS   OH    TIIK   LOWEB    EXTREMITY. 

Ingrowing  toe-nail. — Operation  is  the  best  treatment  of  cases  of 
any  severity  of  this  incorrectly  named  condition.  -Many  methods  have 
hern  described  ;  the  following  is  simple  and  efficient.  It  may  be  per- 
formed under  local  analgesia  (Vol.  I.  p.  652)  and  the  aid  of  an  im- 
provised tourniquet  round  the  base  of  the  toe.  If,  as  is  usually  the 
case,  an  ulcerated  and  infected  condition  of  the  soft  parts  be  present, 
this  must  be  first  dealt  with  by  the  use  of  boracic  acid  or  dilute 
formalin  fomentations,  pure  carbolic  acid,  &c 

From  a  point  at  least  a  quarter  of  an  inch  above  and  a  little  to  the 
outer  side  of  the  inner  angle  of  the  nail-fold,  a  curved  incision  is  carried 
through  sound  skin  to  a  corresponding  point  below  the  nail,  to  reach 
which  the  incision  is  curved  outwards.  From  the  starting  point  a 
straight  incision  is  then  made  between  these  two  points,  directly  for- 
wards, through  the  nail  and  its  bed.  The  included  nail,  skin,  nail-bed 
and  angles  of  the  nail-fold  are  then  completely  excised.  The  edge  of 
the  skin,  carefully  dissected  free  if  needful,  is  then  brought  into  contact 
with  the  vd^-  of  the  nail  and  there  kept  in  position  by  circular  strips 
of  gauze  not  applied  too  tightly.  The  tourniquet  is  then  removed  and 
a  larger  dressing  applied,  if  needful.  The  foot  should  be  kept  well 
elevated.  The  patient  can,  usually,  get  about  in  ten  days,  especially  if 
a  leg-rest  is  used  at  first.  After-attention  to  well-fitting  hoots,  and  to 
cleanliness  of  the  toes  and  the  way  in  which  the  nails  are  regularly 
trimmed,  must  of  course  be  enforced. 


CHAPTER  VIII. 
OSTEOTOMY. 

OSTEOTOMY  OP  THE  FEMUR  FOR  ANKYLOSIS  OF  HIP- 
JOINT. — FOR  GENU  VALGUM.— OSTEOTOMY  OF  THE 
TIBIA. — OSTEOCLASIS    AND    MANUAL    REDUCTION. 

FOR    ANKYLOSIS    OF    HIP-JOINT. 

This  includes  Adams'  operation  of  division  of  the  neck  of  the  femur 
and  Gant's  operation  of  division  of  the  shaft  of  the  femur  just  below 
the  trochanters.  The  latter  being  much  the  simpler,  and  giving 
excellent  results,  will,  I  think,  replace  the  former. 

Indications. — Cases  in  which  the  hip-joint  is  permanently  flexed 
and  stiff,  and  the  patient  accordingly  crippled,  either  from  old  hip 
disease,  or  from  ankylosis  after  rheumatic  fever,  pyaemia,  &c;  cases  in 
which  extension  has  failed,  together  with  trials  of  straightening  the 
limb  with  the  aid  of  anaesthetics. 

Adams'  operation  divides  the  neck  of  the  femur  subcutaneously 
within  the  capsule.  It  is  best  suited  for  those  cases  in  which  the  neck 
remains  unabsorbed,  as  in  ankylosis  after  rheumatic  fever,  and,  much 
more  rarely,  pyaemia.  A  long  tenotome  or  a  straight  narrow  bistoury 
is  entered  about  one  inch  above  the  top  of  the  great  trochanter,  and 
carried  on  the  flat  downwards  and  inwards  over  the  anterior  aspect  of 
the  neck  (p.  898).  The  edge  is  then  turned  towards  the  bone,  and, 
by  cutting  deliberately  and  freely  on  this,  a  passage  is  made  for  the  saw. 
The  knife  being  withdrawn,  the  excellent  saw  which  bears  Mr.  Adams' 
name  is  passed  along  the  wound  made  down  to  the  neck  of  the  bone, 
which  is  then  sawn  through.  After  sawing  for  about  four  or  five 
minutes,  the  limb  should  become  movable.  If  this  is  not  the  case,  the 
section  has  been  made,  not  through  the  neck  itself,  but  through  the 
junction  of  the  neck  and  shaft.  Where  the  surgeon  remains  in  doubt  he 
should  remove  the  saw  and  convert  his  wound  into  an  open  one,  and 
make  sure  of  his  path  by  means  of  a  sterilised  finger. 

In  order  to  bring  down  the  limb  completely,  the  contracted  tendons 
of  the  adductor  longus,  sartorius,  and  perhaps  the  rectus,  will  probably 
require  division.  The  operation  should  be  conducted  with  strict  aseptic 
precautions,  especially  in  adults,  as  it  is  the  skin  on  the  inner  side 
which  is  most  likely  to  give  trouble. 

The  limb  is  usually  straightened  at  once,  and  put  up  with  a  long 
outside  splint — e.g.,  a  Default's — and  a  little  morphia  given  if  needful. 
Where  owing  to  tension  of  the  skin  it  is  unwise  to  complete  the 
rectification  at  once,  this  step  must  be  deferred  for  a  few  days.     The 


1064  OPERATIONS   ON   THE   LOWEB    EXTREMITY. 

hemorrhage  and  ecchymosis  are  generally  trifling  in  amount,  and  the 
wound  heals  quickly. 

This  operation  gives  good  results,  though,  as  stated  below,  I  prefer 
Gant's,  owing  to  its  greater  simplicity.  For  there  is  no  doubt  that  if 
the  bone  is  dense  from  previous  inflammation,  and  if  the  section 
trenches  upon  the  shaft  instead  of  going  through  the  neck  only,  the 
sawing  may  be  very  tedious.  Thus,  I  have  seen  two  cases  in  which 
this  took  over  half  an  hour. 

A  case  is  mentioned  in  a  report  from  a  committee  of  the  Belgian 
Academy  of  Medicine,  in  which  a  patient  who  had  been  submitted  to 
Adams'  operation  insisted  on  getting  up  on  the  twentieth  day. 
Haemorrhage  came  on  from  the  fragments  wounding  the  femoral  vessels 
or  some  large  branch.  The  femoral  was  tied  just  below  Poupart's 
ligament ;  the  haemorrhage  ceased,  but  free  incisions  were  required 
for  suppuration.  The  patient  ultimately  recovered.  The  same  com- 
mittee reported  a  death  from  haemorrhage,  and  one  from  purulent 
infiltration.  No  bad  results  have,  as  far  as  I  am  aware,  followed  in 
England. 

Gant's  operation. — Here  the  shaft  of  the  femur  is  divided  just  below 
the  trochanters. 

Advantages. — The  operation  is  a  simpler  one  than  that  just  given, 
as  the  shaft  is  more  readily  reached  and  divided  than  the  neck. 
Furthermore,  it  is  an  operation  of  wider  applicability,  for  it  is  suited 
to  all  cases,  not  only  those  in  which  a  neck  remains,  but  those  more 
common  cases  of  ankylosis  after  hip-disease,  in  which  repair  has  taken 
place  with  partial  displacement  of  the  head,  or  what  remains  of  it. 
The  fact  that  in  these  cases  there  is  next  to  no  neck  left  to  divide, 
makes  them  unsuited  for  Mr.  Adams'  operation.  For  some  time  after 
this  operation  a  projection  persists  at  the  site  of  operation,  but  this 
deformity  is  of  no  importance  in  this  region,  and  it  diminishes  with 
time. 

A  long  tenotome  or,  better,  a  sharp-pointed,  narrow,  straight 
bistoury,  is  entered  just  below  the  great  trochanter,  and  made  to 
divide  everything  down  to  the  bone  as  it  is  lodged  upon  the  outer  aspect 
of  the  anterior  surface,  and  then  drawn  down  over  the  outer  surface  of 
the  shaft.  As  it  is  withdrawn,  the  wound  is  a  little  enlarged  down- 
wards. The  saw  or  chisel  is  then  introduced  along  the  wound  well 
down  to  the  bone,  and  the  outer  two-thirds  of  this  divided,  the  rest 
being  effected  by  snapping  the  bone  by  lateral  movements.  With  a 
little  practice,  especially  with  the  safer  saw,  it  is  quite  easy  to  divide 
the  bone  completely.  The  tendons  mentioned  above  will  probably 
require  division. 

In  neither  case  is  it  any  practical  good  to  try  and  secure  a  false  joint. 
In  my  experience  the  results  here  are  very  uncertain.  Weight- 
extension  from  the  first  and  the  most  energetic  massage  and  gymnastics 
as  soon  as  the  wound  is  healed  are  required  and,  as  a  rule,  the  patients 
will  not  take  their  share  of  responsibility.  In  cases  of  bilateral  anky- 
losis a  sub-trochanteric  osteotomy  on  one  side,  and  excision  of  the 
head  on  the  other  will  facilitate  the  patient's  sitting.  It  must  be 
remembered  that  after  both  forms  of  osteotomy  relapses  may  follow 
unless  the  after-treatment,  on  the  part  of  surgeon  and  patient,  is 
sufficiently  attended  to. 


OSTEOTOMY    l-'()R    GENU    VALGUM. 


i  </,  5 


OSTEOTOMY  FOR   GENU  VALGUM    (Figs.  474-476). 

Under  this  heading  the  following  operations  will  be  described: — 

I.  Division  of  the  Shaft  of  the  Femur  from  the  Outer  Side 
(Fig.  476). 

II.  Division  of  the  Lower  End  of  the  Femur  from  the 
Inner  Side,  just  above  the  Epiphysial  Line  (Mace wen, 
Fig.  476). 

III.  Division  of  the  Lower  End  of  the  Femur  and  the  Upper 
End  of  the  Tibia  above  and  below  their  respective 
Epiphyses  (Barwell). 

I.  Division     of   the    Shaft    of   the    Femur  from  the  Outer    Side 


Fig.  474.* 


Pig.  475.* 


(Figs.  474-476). — The  limb  being  supported,  with  the  knee  flexed,  on  a 
sand-bag,  an  incision  about  an  inch  and  a  half  long  is  made  at  a  right 
angle  to  and  down  to  the  bone  on  its  outer  side,  about  three  inches 
above  the  external  condyle.  The  knife — a  narrow,  straight  bistoury — 
should  go  down  to  the  bone  deliberately,  and  cut  firmly  and  strongly 
on  it,  enlarging  the  wound  slightly  as  it  emerges,  in  order  that  the 
soft  parts  may  not  be  damaged  if  the  heel  of  the  saw  is  depressed,  and 
that  there  may  be  no  lip  of  tissues  to  hinder  the  escape  of  discharges. 
The  saw  or  chisel  is  then  introduced,  and  the  bone  divided  for  its  outer 
two-thirds.     As  the  thicker  part  of  the  bone  is  on  the  outer  side,  as 

*  Double  genu  valgum  treated  by  division  of  the  shaft  of  the  femur  from  the  outside. 
A  good  average  case,  both  as  to  its  severity  and  the  results  of  operation.  Some  flat  foot 
remains  on  the  left  side. 


io66 


<>I'K  RATIONS   ON   THE    LOWES    EXTREMITY. 


Fig 


soon  as  this  is  divided  the  inner  third  usually  gives  way  readily  on 
carrying  the  knee  and  leg  from  without  inwards.  But  the  operator 
should  continue  the  division  of  the  bone  till  he  can  feel  certain  that 
two-thirds  are  divided,  for  if,  after  dividing  only  half,  he  tries, 
especially  in  the  case  of  a  dense  bone,  to  fracture  the  rest  and  straighten 
the  limb,  either  great  or  prolonged"  force  must  be  made  use  of,  leading 

probably  to  irritation,  cellulitis,  and  sup- 
puration, with,  perhaps,  necrosis;  or  the 
saw  or  chisel  must  be  re-introduced,  a 
point  to  be  always  avoided  if  possible,  as 
the  difficulty  which  is  usually  met  with  in 
hitting  off  the  original  track  will  be  likely 
to  lead  to  the  above  drawbacks. 

The  advantages  of  the  above  method 
are  (i)  that  the  femur  is  divided  at  a 
much  narrower  part  than  in  the  supra- 
condyloid  operation  of  Mace  wen,  and  that 
thus  it  is  more  easily  and  quickly  done. 
(2)  The  bone  section  is  farther  away  from 
the  epiphysis  and  the  line  of  the  synovial 
membrane,  in  case  subsequent  inflam- 
mation takes  place.  (3)  There  are  no 
important  blood-vessels  near. 

I  readily  admit  that  this  operation  has 
the  fault,  as  is  the  case  with  sub-tro- 
chanteric  osteotonry,  of  remedying  one 
deformity  by  adding  another.  Its  safe- 
ness  and  efficiency  lead  me  to  recommend 
it  where  the  operator  is  but  rarely  called 
upon  to  perform  osteotomy. 

II.  Division  of  the  Lower  End  of 
the  Femur  from  the  Inner  Side,  just 
above  the  Epiphysial  Line  (supra-con- 
dyloid  of  Macewen*)  (Fig.  476). — The 
knee  being  flexed  and  supported  firmly 
on  a  sand-pillow  by  the  hands  of  an 
assistant  grasping  the  middle  of  the 
thigh  and  leg,  the  skin  resterilised, 
the  position  of  the  abductor  magnus 
tendon  and  its  tubercle  are  defined,  and 
a  longitudinal  incision  about  an  inch 
long  (a  little  longer  than  the  breadth 
of  the  chisel  to  be  used)  is  made  down 
to  the  bone  at  a  point  where  the  two 
following  lines  meet  —  viz.,  one  drawn 
transversely  a  finger's-breadth  above  the  upper  margin  of  the  external 


The  transverse  line  on  the  shaft 
of  the  femur  shows  the  site  of  divi- 
sion of  the  bone  from  the  outer 
side.  Below  this  are  shown  Mac- 
ewen's  and  Ogston's  operations,  the 
second  operation  being  now  aban- 
doned. The  arrow  indicates  the 
direction  in  which  the  osteotome  is 
worked  in  the  former.f  The  line 
on  the  tibia  shows  the  site  of  divi- 
sion of  the  bone  for  an  ordinary 
ricket}'  curve.  This  curve  in  the 
lower  third  should  have  been  shown 
more  marked.     (After  Barker.) 


*  Osteotomy,  p.  120. 

t  This  is  only  safe  in  a  child's  femur  :  in  an  adult  the  osteotome  is  liable  to  be  broken 
if  pressed  against  the  bone  transversely  to  its  breadth,  ami  nui-t  only  be  worked  in  the 
direction  of  its  breadth.  This  point,  insisted  upon  by  Sir  VV.  Btacewen,  has  been  kindly 
pointed  out  to  me  by  Mr.  Cathcart. 


OSTEOTOMY   FOR   GENU    VALGUM.  1067 

condyle,  and  another  drawn  longitudinally  about  half  an  inch  anterior 
to  the  adductor  tubercle.  The  scalpel  goes  at  once  down  to  the  bone. 
Superficial  veins  may  be  cut,  but  no  artery  normally  distributed,  as 
the  incision  is  below  and  anterior  to  the  anastomotica  magna  and 
above  the  superior  internal  articular.  Before  withdrawing  the  knife, 
the  osteotome  *  is  introduced  by  its  side  down  to  the  bone  in  the  same 
way  as  the  knife — i.e.,  parallel  to  the  long  axis  of  the  limb — is  then 
turned  at  a  right  angle  to  it,  and  the  inner  two-thirds  cut  through. 
The  direction  of  the  bone-incision  is  most  important.  The  surgeon 
must  cut  transversely  across  the  femur  on  a  level  with  a  line  drawn  half 
an  inch  above  the  top  of  the  external  condyle.  This  incision  will 
avoid  the  epiphysis  and  synovial  membrane.  The  line  of  the  former 
may  be  usually  represented  by  one  crossing  the  femur  at  the  level  of  the 
highest  point  of  the  femoral  articulating  surface,  and  running  through 
or  just  below  the  adductor  tubercle,  so  that,  the  incision  being  an  inch 
above  the  tubercle,  the  epiphysis  will  be  cleared.  The  only  part  of  the 
synovial  membrane  which  is  as  high  as  the  bone  incision  is  that  under 
the  quadriceps,  which  may  reach  in  the  adult  as  high  as  two  inches 
above  the  trochlear  surface.  There  is  generally  a  quantity  of  fat  between 
it  and  the  bone.  The  spot  selected  by  Sir  W.  Macewen  for  his  incision 
is  posterior  to  this  point.  As  in  a  valgous  limb  the  whole  internal 
condyle  is  lowered,  a  line  drawn  transversely  from  the  adductor  tubercle 
might  land  the  operator  low  down  in  the  external  condyle.  The 
osteotome,  placed  against  the  inner  edge  of  the  bone,  must  be  driven 
at  first  from  behind  forwards  and  to  the  outer  side  ;  it  is  then  made  to 
move  forwards  along  the  inner  border  until  it  comes  to  the  anterior 
surface,  when  it  is  directed  from  before  backwards  and  towards  the 
outer  posterior  angle  of  the  femur.  By  keeping  on  these  lines  there  is 
no  fear  of  injuring  the  artery.  The  hard  external  surface  usually 
resists  the  osteotome,  especially  in  adults,  but  the  surgeon  will  soon 
recognise  by  touch  or  sound  when  his  osteotome!  meets  this  layer.  It 
is  the  inner  border  and  the  anterior  aspect  of  the  bone  which  it  is 
essential  to  divide  thoroughly  if  the  reintroduction  of  the  instrument 
with  the  difficulties  of  ensuring  its  entering  the  old  groove,  and  the  risks 
of  infection  are  to  be  avoided.  If  it  be  thought  desirable  to  penetrate 
the  outer  dense  part,  it  must  be  done  very  steadily,  so  as  to  check  any 
undue  impetus  on  the  part  of  the  osteotome.  A  sterile  pad  having  been 
secured  over  the  wound,  the  surgeon,  pressing  the  thigh  down  on  the 
table  with  his  left  hand,  and  taking  the  limb  low  down  with  his  right, 
gives  it  a  quick  jerk  outwards,  this  being  repeated  if  needful.  If  it  be 
necessary  to  reinsert  the  osteotome,  care  must  be  taken  to  get  it  into  the 
groove  again,  and  to  use  it  coolly  and  methodically  in  accordance  with 
the  above  given  directions. 

Mr.  Keetley  thus  writes  (Orthopcedic  Surg., -p.  33)  on  "  cases  in  which 
the  surgeon  has  almost  entirely  failed  to  get  the  improvement  possible 

*  In  adults  a  second,  or  even  a  third,  finer  instrument  may  be  used,  being  slipped  in 
over  the  first  as  this  is  withdrawn.     In  children  one  instrument  will  suffice. 

f  The  osteotomes  must  be  bevelled  on  both  sides,  wedge-like,  and  sufficiently  trust- 
worthy for  hardness  and  toughness,  points  only  to  be  secured  by  getting  them  of  first-rate 
and  painstaking  makers.  Sir  W.  Macewen's  test  is  as  follows  :  If  the  instrument  will 
neither  turn  nor  chip  in  penetrating  the  thigh-bone  of  an  ox,  it  is  well  suited  for  cutting 
human  bones.     Its  edge  should  be  sharp  enough  to  pare  easily  the  finger-nail  (Keetley). 


1068  OPERATIONS   ON   THE   LOWER    EXTREMITY. 

from  the  operation.  Such  cases  are  often  supposed  to  be  cases  of 
recurrence,  but  they  are  really  only  examples  of*  bad  management.  The 
points  to  attend  to  are — (i)  Correct  the  deformity  while  the  limb  is  in 
a  position  of  extreme  extension  at  the  knee.  The  slightest  flexion  of 
the  joint  bides  the  deformity  and  deludes  the  surgeon  into  a  false  sense 
of  satisfaction.  (2)  The  exact  amount  of  looseness  of  the  knee-joint, 
if  any,  should  be  noted  before  the  bone  is  divided,  and  allowed  for  in 
putting  up  the  limb.  To  this  end  the  adjustment  will  sometimes  have 
to  be  a  position  of  distinct  varum.  (3)  A  certain  amount  of  spring  in 
the  bones  and  extensibility  in  the  ligaments,  especially  in  the  case  of 
children,  must  be  allowed  for  in  the  same  way." 

Division  of  the  Internal  Condyle  Obliquely  (Ogst  on,  Edin.  Med.  Jburn.,  March,  1877 

(Fig.  476). — This  operation,  though  a  great  improvement  on  the  operations  which  preceded 
it — viz.,  opening  the  joint  and  sawing  off  the  internal  condyle — has  been  entirely  replaced 
by  others — viz.,  Macewen's,  and  division  of  the  shaft  from  the  outer  side.  The  free  opening 
of  the  joint,  with  its  great  risks  if  the  wound  becomes  infected,  and  the  stiffness  in  any  case 
have  led  to  this.     It  will,  therefore,  not  be  described  here. 

III.  Division  of  Tibia  as  well  as  Femur. — The  division  of  the  tibia 
(and  the  fibula  also)  as  well  as  the  femur  has  been  advocated  by  Mr. 
Barwell  and  others.  In  the  majority  of  cases,  though,  at  first  sight, 
there  may  seem  to  be  one  striking  curve  localised  to  one  spot,  a  closer 
examination  shows  that  in  reality  several  curves  are  present,  and  often 
of  different  kinds,  antero-posterior  as  well  as  lateral,  diffused  over  the 
whole  shaft  rather  than  limited  to  one  end.  In  these  cases,  rectifying 
one  curve  often  makes  the  others  more  prominent.  Multiple  osteotomies 
are  required  here,  the  femur  and  the  tibia  each  requiring  division  in 
two  places.  In  one  very  aggravated  case  of  genu  varum,  in  which 
the  limbs  (when  the  ankles  were  placed  together)  formed  a  circle, 
Sir  W.  Macewen  performed  ten  osteotomies  at  one  time  (loc.  supra  cit., 
Figs.  40  and  41).  In  such  severer  cases  most  operators  will  prefer  to 
straighten  one  side  at  a  time. 

Operation. — An  incision  is  made  as  at  p.  1069  over  the  inner  surface 
of  the  tibia  just  below  its  tubercle,  and  the  bone  divided  with  an  osteo- 
tome or  saw  from  within  outwards.  The  tissue  on  the  anterior  part 
just  below  the  tubercle  is  much  the  densest.  The  division  is 
commenced  at  the  posterior  part  of  the  tibia  and  made,  at  first  from 
behind  forwards,  and  then  from  before  backwards.  The  section  of  the 
tibia  should  be  made  on  the  same  occasion  as  that  of  the  femur. 

However  an  osteotomy  wound  is  made,  whether  with  saw  or  chisel, 
no  attempt  should  be  made  to  close  it.  It  is  very  rarely  needful  to 
remove  the  dressings  before  the  tenth  or  fourteenth  day.  If  a  stain 
come  through,  it  should  be  dusted  with  iodoform  and  a  little  fresh  dry 
dressing  applied. 

Sir  W.  Macewen  uses  a  splint  consisting  of  a  long  outside,  and  a 
short  back,  with  a  foot-piece.*  I  have  usually  preferred  plaster  <>l  Paris, 
applied  by  Mr.  Croft's  method,  for  children,  amongst  whom  my  experi- 
ence has  mainly  lain.     It  makes  even,  steady  pressure  upon  the  muscles 

*  Sir  W.  Macewen  advisee  the  use  of  a  mattress  consisting  of  four  parts,  the  t  wo  centre 
pieces  corresponding  to  the  glutreal  region,  and  easily  removed  toadmil  of  the  introduction 

of  the  bed-pan. 


OSTEOTOME    OF   THE   TIBIA.  1069 

around  the  wound,  keeping  them  and  it  at  rest,  and  it  allows  the  patient 
to  be  more  easily  moved,  especially  when  both  limbs  have  been  operated 
on.  The  outer  piece  of  flannel  should  be  brought  high  up,  to  the  level 
oi  the  iliac  crest,  bo  as  to  better  command  the  muscles  which  disturb  the 
upper  fragment  In  all  cases  of  osteotomy,  a  long  outside  splint 
should  be  applied  at  first.  However  the  limb  is  put  up,  the  bandages 
must  be  applied  firmly  and  evenly,  but  without  undue  tightness.  The 
condition  of  the  toes,  as  to  colour  and  movement,  must  he  carefully 
watched.  When  the  dressings  are  removed  at  the  end  of  ten  or  four- 
teen days  I  like  to  have  an  anaesthetic  given,  and  to  rectify  any  slight 
remaining  deformity. 

The  splints  or  plaster  of  Paris  should  he  continued  for  six  weeks, 
when  the  limb  may  he  only  supported  with  sand-bags  if  the  union  is 
firm.  Passive  and  active  movement  may  he  now  allowed.  In  ahout 
three  months  the  patient  may  he  got  up,  with  a  stick,  under  observa- 
tion. From  an  early  date,  care  should  be  taken  that  he  can  bend  his 
knee  well. 

Cuneiform  Division  of  the  Femur. — In  cases  where  the  curve  is 
chiefly  an  antero-posterior  one  affecting  the  middle  of  the  shaft,  the 
deformity  can  only  he  properly  removed  b}r  taking  out  a  wedge.  This 
is  done  on  the  lines  given  above.  An  incision  is  made  through  skin 
and  quadriceps  down  to  the  periosteum,  and  a  second  firm  cut  exposes 
the  hone.  The  divided  muscles  are  then  drawn  aside  with  Spencer 
Wells's  forceps  applied  to  bleeding  points,  and  the  periosteum  separated 
on  each  side  down  to  the  linea  aspera.  A  wedge  is  then  removed  and 
the  bone  straightened.  The  bleeding  is  often  free  from  the  nutrient 
artery,  hut  this  is  arrested  when  the  hone  is  straightened.  The  greatest 
care  must  be  taken  to  keep  within  the  periosteum,  the  soft  parts  being 
thus  uninjured,  and  to  adopt  strict  aseptic  precautions. 

GENU    VARUM. 

As  the  tibia  is  usually  the  bone  which  is  most  at  fault,  the  directions 
for  its  osteotomy  given  below  will  suffice.  When  the  femur  is  also 
much  concerned  it  must  be  divided  by  means  analogous  to  those  given 
for  genu  valgum.  And,  as  in  this  condition  if  the  lower  third  of  the 
tibia  be  also  curved,  osteotomy  of  this  bone  and  the  fibula  (vide  infra) 
will  he  required.     Division  in  two  places  may  be  necessaiy. 

OSTEOTOMY   OP  THE   TIBIA. 

This  may  be  (A)  Simple  Division  or  (B)  Cuneiform — i.e.,  the  taking 
out  of  a  wedge  of  bone.  The  former  of  these,  a  veiy  simple  operation, 
will  suffice  for  the  ordinarily  curved  tibia?,  where  the  bone  is  bent 
laterally,  and  the  bend  is  most  marked  at  the  junction  of  the  middle 
and  lower  thirds.  Cuneiform  osteotomy  will  be  required  when  the 
bending  is  not  only  lateral,  but  antero-posterior  as  well. 

A.  Simple  Osteotomy  of  the  Tibia  (Fig.  476). — The  parts  being 
sterilised,  and  the  limb  resting  on  its  outer  side  on  a  firm  sand-pillow, 
the  surgeon  notes,  at  the  anterior  and  inner  margins  of  the  tibia,  the 
spot  where  the  curve  is  sharpest.  Fixing  his  left  index  over  the  inner 
margin,  he  enters  a  long  tenotome  or  narrow  bistoury  exactly  over  the 


1070  OPERATIONS   ON   THE   LOWER   EXTREMITY. 

cii  si  of  the  tibia,  sends  it  down  under  the  skin  over  the  inner  surface  of 
tin  bone  till  its  point  is  felt  just  beneath  the  finger  ;  it  is  here  pushed 
through  the  skin  to  make  a  counter-puncture  for  drainage.  The  knife, 
hitherto  held  horizontally,  is  now  turned  vertically  and  cuts  firmly  on 
the  bone,  dividing  the  periosteum,  thick  in  these  cases,  in  one  line  right 
across  the  inner  surface  of  the  tibia.  As  the  knife  is  withdrawn  it  is 
made  to  enlarge  the  wound  of  entrance  slightly,  to  make  room  for  the 
saw.  This  (Adams')  is  now  introduced  in  the  same  way  as  the  knife, 
canied  horizontally  down  to,  but  not  through,  the  puncture  through  the 
skin  of  the  inner  border  of  the  tibia.  The  left  index  keeping  guard 
over  the  tibial  artery,  the  saw  is  turned  towards  the  bone  and  cuts 
through  the  inner  two-thirds  of  it.  The  entrance  of  the  saw  into 
cancellous  tissue  can  be  known  by  the  diminution  of  resistance  and  the  ' 
increased  bleeding  which  often  occur,  but  the  best  test  of  the  depth  to 
which  the  operator  has  arrived  is  the  depth  of  the  groove  in  which  the 
saw  has  sunk.  If  it  be  preferred  a  sufficient  wound  is  made,  and  a 
narrow  osteotome  employed.  When  the  bone  is  divided  sufficiently, 
a  sterile  pad  is  placed  on  the  wound,  and  the  surgeon,  firmly  placing 
his  two  hands,  close  together,  immediately  above  and  below  the  wound, 
sharply  carries  the  lower  fragment  outwards.  If  the  saw  has  been 
sufficiently  used,  the  tibia  snaps  distinctly,  while  the  fibula  yields  with 
a  "  greenstick  "  sensation.  But  if  there  be  any  difficulty  here,  this 
bone  must  be  divided  through  a  second  incision.  Great  care  must  be 
taken  to  exert  the  force  just  on  the  sawn  portion,  or  the  ligaments  of 
the  ankle  or  the  superior  tibio-fibular  joint  may  be  strained  and 
damaged.  Attention  has  already  been  drawn  to  the  need  of  using  the 
saw  sufficiently,  otherwise  the  parts  will  be  bruised  and  damaged  in  the 
futile  attempts  at  fracture. 

B.  Cuneiform  Division  of  the  Tibia. — Removal  of  a  Wedge. — 
I  have  not  found  the  plan  of  estimating  the  size  of  the  wedge  to  be 
removed  by  first  making  an  outline  on  paper  of  much  service.  The 
parts  being  duly  sterilised,  an  incision  is  made  along  the  crest  of  the 
tibia  equal  to  the  base  of  the  wedge  which  is  going  to  be  removed.  It 
need  not  be  longer,  as  the  skin  can  be  pulled  up  and  down  if  needful. 
The  periosteum  is  then  divided  cleanly,  and  separated  from  the  tibia 
with  curved  scissors.  This  membrane  being  held  out  of  the  way  with 
retractors,  a  wedge  is  next  removed  with  an  osteotome  or  a  narrow  and 
sharp  chisel  but  little  bevelled.  The  gap  can  then  be  enlarged  by 
removing  from  either  side  further  slices  as  required.  Occasionally 
free  haemorrhage  takes  place  from  the  medullary  artery,  but  this  soon 
stops  with  firm  pressure.  The  limb  is  now  straightened  by  bending 
the  lower  fragment  upwards*  so  as  to  bring  the  surfaces  of  the  gap  in 
contact.  Difficulties  which  may  be  met  with  now  are  usually  due  to 
the  wedge  removed  being  inadequate  in  size  or  in  shape.  A  sharp  pair 
of  bone-forceps  may  now  be  useful.  The  resistance  of  the  periosteum 
at  the  back,  or  of  the  tendo  Achillis  are  also  factors.  The  former  may 
require  the  removal  of  more  bone,  the  latter  division.  The  periosteum 
at  the  upper  and  lower  angles  of  the  wound  may  be  closed  with  sterile 
sutures  cut  short.     The  skin  wound  is  also  closed  above  and  below, 

*  Aided  by  movements  in  the  opposite  direction,  and  from  side  to  side  if  needed.  The 
fibula  should  always  in  these  cases  be  also  divided  to  secure  exactitude. 


OSTEOTOMY    OF   THE   TIBIA.  1071 

bill  lift  open  in  the  centre  for  drainage.  In  this  and  the  preceding 
operation  sufficiently  thick  dressings  should  he  applied  to  meet  any 
oozing  from  the  bone.  Plaster  of  Paris  (p.  1068)  or  back  and  side 
splints  should  be  applied. 

Caiises  of  Death  and  Failure  after  Osteotomy. 

I.  Infective  troubles. — Such  a  case  will  he  found  published  in  the 
Clin.  Soc.  Trans.,  vol.  xii.  p.  27.  It  is  too  probable  that  other 
operators  have  not  been  so  candid.  2.  Carholuria. — A  case  of  rapidly 
fatal  carbolic  intoxication  after  antiseptic  osteotomy  of  the  tibia  will  be 
found  in  the  same  Transactions,  vol.  xiv.  p.  201.  3.  Haemorrhage. — 
At  least  one  case  has  occurred  of  haemorrhage  from  the  femoral  and 
one  from  the  anastomotica  after  division  of  the  femur.  I  have  also 
heard  of  a  case  in  which  the  posterior  tibial  was  injured  in  osteotomy 
of  the  tibia.     4.  Necrosis. 

This  occurred,  twenty  years  ago,  in  one  of  my  cases  of  osteotomy  of  the  femur,  a  lad  of 
16.  It  was  noticed  that  he  took  the  anaesthetic  (ether)  very  badly,  and  when  the  effects 
of  this  had  passed  off  he  was  extremely  restless  and  excited  for  forty  minutes.  To  this  I 
attribute  the  mischief  that  followed.  Suppuration  with  a  very  unhealthy  state  of 
the  wound,  oedema,  and  cellulitis  ensued,  leading  to  necrosis.  Eventually  the  lad 
recovered,  but  required  a  cork  sole  of  two  inches.  The  presence  of  a  pre-systolic  murmur 
perhaps  accounted  for  the  effects  of  the  anaesthetic. 

5.  Division  of  the  tibialis  anticus  tendon. 

This  occurred  in  an  osteotomy  of  the  tibia  performed  by  one  of  my  dressers,  who 
forgot  how  close  the  tendon  lies  to  the  outer  side  of  the  crest.  The  cut  ends  were  joined 
by  chromic  catgut,  and  the  action  of  the  muscle  was,  afterwards,  unimpaired. 

6.  Non-union.  I  have  never  seen  a  case,  but  though  extremely 
rare,  its  occasional  occurrence  (Little,  Trans.  Med.  Chir.  Soc,  1891) 
should  be  a  warning  against  needless  removal  of  bone,  and  any  neglect 
of  strict  asepsis. 

Osteoclasis  and  Manual  rectification. — I  have  never  employed 
osteoclasis,  believing  osteotomy  to  be  more  precise  and  far  simpler. 
Mr.  Keetley's  words  (Orthopedic  Surg.,  p.  49)  are,  as  usual,  weighty 
ones.  "I  have  not  found  the  ultimate  good  in  respect  of  obliteration  of 
deformity  equal,  in  the  average,  to  what  can  be  got  from  osteotom}'." 
Those  interested  in  this  method  should  consult  a  paper  by  Mr.  Grattan, 
of  Cork  (Brit.  Med.  Journ.,Mtiy  3,  1890).  Manual  rectification  is  a 
perfectly  safe  procedure  if  the  bone  be  soft  enough  to  admit  of  a  frac- 
ture, not  mere  bending.  In  such  cases  it  is  a  great  aid  in  the  use  of 
appliances.  But  in  my  experience,  after  the  age  of  four,  so  much 
force  is  required  as  to  render  this  method  inefficient  and  risky  as 
wrell.  In  anterior  or  multiple  curves  it  is  inapplicable  (R.  W. 
Murray  (Brit.  Med.  Journ.,  Aug.  25,  1894).  Treatment  of  severe 
curvatures  of  the  tibia  by  manual  osteoclasis. — Mr.  Openshaw  is  of  a 
different  opinion  ;  his  technique  is  as  follows  (Lancet,  March  4,  1905)  : — 
"  With  the  child  fully  anaesthetised,  the  leg  is  encased  in  cotton-wool 
and  bandaged.  The  child  is  then  turned  over  so  that  the  leg  which  is 
to  be  broken  lies  upon  its  outer  side.  A  wedge-shaped  block,  seven 
inches  by  three  inches  at  the  base  and  six  inches  high,  is  used.  The 
upper  edge  of  this  block  is  about  one  inch  wide  and  four  inches  long  and 
is  covered  with  thick  india-rubber.  The  block  is  put  underneath  the  leg 
transversely  at  the  centre  of  the  curve.     The  operator  with  one  hand 


1072  OPERATIONS    ON    THE    LOWEB    EXTREMITY. 

grasps  firmly  the  foot,  ankle  and  lower  part  of  the  tibia,  and  with  the 
other  hand  the  upper  part  of  the  tibia,  the  hands  of  the  operator 
being  two  to  three  inches  apart.     With  the  block  resting  quite  firmly 

upon  a  firm  table,  and  the  child's  leg  on  the  rubber-covered  edge  of  the 
block,  with  a  steady  and  increasing  pressure,  the  bones  are  snapped 
across  and  the  leg  can  then  immediately  and  easily  be  made  to  assume  a 
straight  position.  In  a  few  instances  the  fibula  can  be  heard  to  crack 
first,  but  in  the  majority  the  fibula  is  simply  bent,  and  the  tibia  alone  is 
broken."  In  some  40  cases  thus  operated  on  Mr.  Openshaw  has  met 
with  no  untoward  result.  The  limb  is  put  up  in  two  Lateral  well-padded 
splints,  and  the  child  sent  home.  It  must  be  brought  lor  inspection  the 
next  day,  when  a  skiagraph  can  be  taken.  The  child  is  able  to  walk  in 
three  or  four  weeks.  It  is  necessary  that  the  tibia  should  be  actually 
fractured.  The  two  legs  are  dealt  with  at  different  times.  In  Mr. 
Openshaw's  opinion  the  leg  of  any  child  under  ten  can  be  dealt  with  in 
this  manner.  I  only  refer  to  osteotomies  performed  in  out-patient  prac- 
tise to  condemn  them.  In  Mr.  Keetley's  words  (loc.  supra  cit.,  p.  1071) 
"  whoever  attempts  to  deal  with  these  cases  in  the  out-patient  depart- 
ments must  not  be  surprised  to  find,  sooner  or  later,  something  very 
foolish  and  unwarranted  done  by  some  patient  out  of  control." 


CHAPTER  IX. 
TENOTOMY. 

TENOTOMY  OF  THE  TENDONS  ABOUT  THE  FOOT. — 
SYNDESMOTOMY. — TENOTOMY  OF  THE  HAMSTRING 
TENDONS. — TENOTOMY    OF    THE    STERNO-MASTOID. 

TENOTOMY    OF    THE    TENDONS    ABOUT    THE    FOOT. 

Division  of  Tibial  Tendons. 

While  I  prefer  to  divide  these  tendons,  e,g.,  in  a  case  of  talipes 
equinovarus  together  with  other  structures  by  a  flap  incision  (p.  1046), 
conditions  may  arise  calling  for  simpler  methods. 

Tibialis  Anticus. — This  is  usually  divided  where  it  is  crossing  the 
ankle-joint  from  without  inwards,  a  little  above  its  insertion  into  the 
internal  cuneiform.  It  has,  here,  the  dorsalis  pedis  vessels  on  its  outer 
side,  but  separated  from  it  by  the  extensor  proprius  hallucis. 

The  surgeon  usually  stands  on  the  opposite  side  of  the  leg  to  that  of 
the  tendon,  either  facing  the  trunk  or  with  his  back  towards  it,  as  is 
most  convenient.  The  assistant  stands  opposite  to  him,  grasping  the 
foot  with  one  hand  and  the  leg  with  the  other.  The  position  of  the 
tendon  is  made  out  by  making  it  tense  by  abducting  and  flexing  the 
foot.  The  surgeon  then  notes  the  position  of  the  anterior  tibial  vessels, 
defines  exactly  the  width  of  the  tendon,  and  places  the  tip  of  his  index 
finger  exactly  on  the  side  of  the  tendon  farthest  from  him.  He  then 
inserts  the  tenotomy  knife  vertically  close  to  the  tendon  on  the  side 
nearest  to  him  ;  sinks  it  lightly  till  he  feels  sure  it  is  on  a  level  lower 
than  that  of  the  tendon ;  then  sends  it  horizontally  across  till  he  feels 
its  point  just  under  his  index  finger,  and,  having  turned  its  edge 
upwards,  finally,  by  a  series  of  light  levering  or  sawing  movements,  cuts 
through  the  tendon.  The  assistant  relaxes  the  foot — i.e.,  adducts  and 
bends  it  upwards — when  the  knife  is  first  introduced,  but  places  it  on 
the  stretch  at  a  signal  from  the  surgeon.  Finally,  as  soon  as  the  com- 
pletion of  the  creaking  sound  and  the  sudden  snap  denote  the  division 
of  the  tendon,  the  foot  is  again  relaxed.  A  small  pad  of  sterile  gauze 
being  at  once  applied,  the  foot  is  put  up  in  the  everted  position.  For 
this  purpose  nothing  is,  to  my  mind,  so  simple  and  efficient  as  a  well- 
padded  splint  of  the  proper  width,  with  two  notches  at  its  lower  end, 
the  upper  end  being  just  below  the  knee  in  infants,  and  the  lower  pro- 
jecting two  inches  and  a  half  below  the  foot.  The  splint  is  applied  to 
the  outer  side,  the  leg  being  first  rolled  in  a  flannel  bandage  to  prevent 
pressure-sores. 

Tibialis  Posticus. — It  is  usually  recommended  to  divide  this  an  inch 

s. — vol.  11.  68 


1074  OPERATIONS   ON   THE   LOWER   EXTREMITY. 

and  a  half  or  two  inches  above  the  internal  malleolus.*  The  tendon  is 
here,  separated  from  the  posterior  tibial  vessels  by  the  flexor  longus 
digitorum. 

The  surgeon  and  his  assistant  occupying  positions  as  above,  the 
exact  site  of  the  tendon  is  defined,  if  possible,  by  abducting  and 
bending  down  the  foot.  In  fat  infants  it  is  often  quite  impossible  to 
feel  the  tendon,  and  in  these  cases  a  spot  midway  between  the  anterior 
and  internal  borders  of  the  leg  will  be  the  best  guide,  as  denoting  the 
inner  margin  of  the  tibia.  The  surgeon  then  introduces  a  sharp 
tenotome  so  as  just  to  touch,  if  possible,  the  inner  margin  of  the  tibia, 
taking  care  to  sink  the  blade  sufficiently  to  open  the  sheath  freely. 
This  being  done,  a  blunt  tenotome  is  introduced  through  the  same 
opening,  and  pushed  under  the  tendon  ;  the  edge  being  then  turned 
towards  it,  and  the  tibia  used  as  a  fulcrum,  the  tendon  is  severed, 
together  with  that  of  the  flexor  longus  digitorum.  The  assistant  first 
relaxes  and  then  extends  the  tendon,  as  advised  above. 

If  the  artery  be  cut,  as  shown  by  the  jetting  haemorrhage  and  the 
blanching  of  the  foot,  firm  pressure  must  be  applied,  the  foot  being 
first  bandaged.  No  eversion  must  be  practised,  but  the  foot  put  up  in 
the  faulty  position  for  about  a  week. 

Plantar  Fascia,  f — This  may  be  divided  just  below  its  origin  from 
the  os  calcis,  or  in  advanced  cases  of  talipes  close  to  the  transverse 
crease,  which  is  here  found  in  the  sole.  With  regard  to  this  fascia,  the 
surgeon  should  not  tie  himself  down  to  any  fixed  spot,  but  divide 
resisting  bands  whenever  they  are  felt. 

Syndesmotomy. — This  term  was  introduced  by  Mi.  l;.  W.  Parker  [Congenital 
foot,  p.  62  et passim),  who  believes  that  in  many  cases — e.g.,  severe  ones,  cases  not  treated 
in  early  life,  and  in  some  relapsed  cases — the  foot  cannot  be  rectified  even  by  multiple 
tenotomy.  He  attributes  this,  not  to  adhesions,  but  to  the  faulty  shortness,  and  unyielding 
nature  of  the  ligaments.  Chief  amongst  these,  in  equinovarns,  are  the  ligaments  about 
the  astragalo-scaphoid  joint.  "In  these  cases  there  is  a  capsule  made  up  above  and 
internally  by  a  blending  together  of  the  superior  astragalo-scaphoid  ligament  with  fibres 
from  the  anterior  ligament,  and  the  anterior  portion  of  the  deltoid  ligament  below  with 
fibres  from  the  inferior  calcaneo-scaphoid  ligament.  To  these  are  united  fibrous  expansions 
of  the  tendons  of  the  anterior  and  posterior  tibial  muscles  ;  together  they  form  an 
unyielding  capsule  of  great  strength,  which  is  attached  to  the  several  bones,  not  in  the 
usual  manner,  but  in  adaptation  to  their  altered  relative  positions.  This  1  would  name 
the  'astragalo-scaphoid  capsule.'  "  Mr.  Parker  gives  directions  for  dividing  this  structure 
which  can  be  made  to  combine  division  of  the  tibial  tendons.  While  I  consider  this 
method  superior  to  that  just  given,  I  much  prefer  that  by  a  Bap  (p.  1046),  by  which  the 
needful  tendons,  fascia  and  ligaments  can,  all,  be  divided  together.  In  syndesmotomy  it 
is  more  difficult  to  make  sure  of  dividing  the  tibialis  posticus. 

The  site  chosen  for  this  combined  division  of  tendons  and  ligaments  is  a  little  below 
and  anterior  to  the  tip  of  the  internal  malleolus. J  Other  guides  are  the  site  of  the 
astragalo-scaphoid  joint,  and  in  older  cases  the  transverse  crease  which,  running  down  on 
to  the  sole,  denotes  the  continued  inversion  of  the  foot.  Two  tenotomes  are  required,  one 
of  ordinary  pattern,  and  one  curved,  somewhat  sickle-shaped,  and  with  a  cutting  blade 
about  half  an  inch  in  length. 

*  The  tendon  is  here  rather  farther  from  the  artery,  and  the  surgeon  will  be  above 
the  commencement  of  its  synovial  sheath,  in  which  it  traverses  the  internal  annular 
ligament. 

t  Division  of  the  palmar  fascia  is  fully  described  at  p.  28,  Vol.  I. 

\  Mr.  Parker  (loc.  supra  rit.,  p.  78)  shows  that  Velpeau  and  Syme  pointed  out  the 
possibility  of  dividing  the  tendon  of  the  tibialis  posticus  here. 


TKXOTO.MV    ()K    TIIK    TENDONS    A.BOUT   THE    FOOT.     1075 

The  surge tOtM  the  position  of  the  arteries,  and   the   lines  along  which   the   tibial 

tendons  are  earring  towards  the  internal  cuneiform.  Saving  marked,  al  the  spot  above 
given,  the  position  of  these  tendons,  he  enters  a  Bharp-pointed  tenotome,  the  parts  being 
relaxed,  just  above  the  posterior  tibial  artery,  and  pushes  it  outwards  on  to  the  dorsum 
tn  a  -put  just  short  of  the  dorsalis  pedis  artery,  the  knife  travelling  jusl  beneath  the  skin 
to  make  a  path  E01  the  next  instrument,  which  does  the  work.    The  curved  tenotome  is 

then  inserted  under  the  skin,  and  pushed  on,  Hat-wise,  till  its  tip  can  be  felt  over  the 
tibialis  anticus ;  it  is  then  turned  blade  downwards,  the  tibialis  anticus  is  felt  to  give  way, 
and,  as  the  knife  cuts  on  the  subjacent  bones  and  cartilages,  the  b'gaments  are  felt  to 

yield  to  it,  while,  as  it  is  withdrawn,  its  edge  divides  the  tibialis  posticus. 

Tendo  Achillis. — This  should  he  divided  half  an  inch  above  its 
insertion  in  an  infant,  and  an  inch  and  a  half  in  an  adult. 

The  foot  and  ley;  being  turned  well  over  on  to  the  outer  side,  and  the 
tendon  being  relaxed  by  the  assistant  bending  the  foot  downwards,  the 
margins  of  the  tendon  are  accurately  defined.  The  knife  is  then  intro- 
duced vertically  close*  to  the  inner  side  of  the  tendon  till  it  reaches 
a  sufficient  depth  to  ensure  being  beneath  it;t  it  is  then  pushed 
horizontally  across  under  the  tendon  till  it  is  felt  under  the  skin  by  the 
left  index  finger,  which  accurately  marks  out  the  outer  limit  of  the 
tendon ;  the  blade  is  then  turned  towards  the  tendon,  which  being  at 
the  same  time  put  on  the  stretch  by  bending  up  the  foot,  is  divided  by 
a  series  of  levering  movements  of  the  handle.  Creaking  movements, 
followed  by  a  sudden  snap  or  thud,  denote  complete  division,  when 
the  tendon  is  to  be  at  once  relaxed  and  the  knife  brought  out 
horizontally. 

The  Peronei. — The  peroneus  longus  and  brevis  occasionally  require 
division.  They  may  be  divided  simultaneously  by  entering  a  tenotome 
between  them  and  the  bone  about  two  inches  above  the  external  mal- 
leolus. Immediately  above  this  process  they  are  more  under  cover  of 
the  bone.  If  divided  below  it,  their  synovial  sheath  would  be  opened ; 
this  is  to  be  avoided  in  case  of  infection. 

Date  of  rectification.  In  the  case  of  the  smaller  tendons,  and  in  the 
more  common  cases  of  tenotomy,  e.g.,  for  congenital  equinovarus, 
this  should  be  immediate.  Where  the  tendo  Achillis  has  been  divided, 
and  in  many  cases  of  tenotomy  for  infantile  paralysis,  correction  must 
be  made  more  gradually.  Whatever  operation  is  performed,  over-correc- 
tion must  be  ensured  during  the  first  fortnight,  owing  to  the  certain 
tendency  to  relapse.  For  retaining  appliances  I  prefer  felt  or  poro- 
plastic  in  children,  or  a  notched  splint,  like  a  Dupuytren's  (p.  1073).  If 
plaster  of  Paris  is  employed  it  should  be  in  a  form  that  is  removable 
as  soon  as  possible,  to  allow  of  the  needful  daily  movements  of  the 
joints,  and  rubbing.  Thus,  after  about  ten  or  fourteen  days,  the  foot 
should  be  daily  manipulated  by  the  surgeon  for  a  while  ;  and,  later  on, 
several  times  daily  by  the  mother  or  nurse,  the  surgeon  seeing  the 
case  every  few  days.  If  such  manipulations  are  daily  persevered  with, 
and  the  case  kept  under  the  surgeon's  eye,  expensive  boots  and  other 
apparatus  will  not  be  needed  in  children.  To  allow  of  these  manipula- 
tions being  begun  early  over-correction  is  essential.     Finally,  if  only 

*  So  as  to  avoid  the  posterior  tibial  artery. 

t  Young  operators  often  do  not  insert  the  knife  sufficiently  deep  ;  they  thus,  when  it  is 
pushed  across,  get  into  the  tendon  instead  of  beneath  it,  and  so  divide  it  incompletely. 

68—2 


1076  OPERATIONS   ON   THE   LOWEB    EXTREMITY. 

justice  were  done  to  the  methods  of  tenotomy  and  division  of  ligaments 
and  to  ensuring  early  over-correction,  we  should  hear  little  of  severer 
methods. 

TENOTOMY   OF    THE   HAMSTRINGS. 

The  patient  being  rolled  two-thirds  on  to  his  face,  the  surgeon  stands 
on  the  same  side  as  that  on  which  lies  the  tendon  to  be  divided,  facing 
or  turned  from  the  trunk  as  is  most  convenient.  An  assistant  stands 
opposite  to  him  to  relax  and  tighten  the  tendon. 

Biceps. — The  exact  limits  of  the  tendon  being  defined,  the  surgeon 
introduces  a  sharp  knife  close  to  the  inner  side  of  the  biceps,  so  as  to 
get  between  it  and  the  external  popliteal  nerve,  and  having  sunk  it 
sufficiently  to  get  beneath  the  tendon,  pushes  the  knife  outwards,  hori- 
zontally, till  it  is  felt  beneath  the  skin  under  the  left  index,  which  marks 
the  outer  limit  of  the  tendon.  The  edge  being  turned  towards  this,  the 
tendon  is  extended  by  the  assistant,  and  divided  in  the  usual  way. 
AYhen  this  is  done,  the  limb  is  flexed  and  the  knife  withdrawn 
horizontally. 

When  the  tendon  is  cut,  a  cord  often  rises  up  close  to  it.  This  may 
be  the  nerve,  and  the  knife  must  on  no  account  be  re-introduced. 

On  account  of  the  close  vicinity  of  this  structure,  and  because,  in 
cases  of  any  duration,  contracted  bonds  of  fascia  are  also  present,  I 
much  prefer  the  open  method  by  a  small  flap  made  with  every  precau- 
tion. The  wound  is  united  afterwards  with  one  or  two  horsehair 
sutures. 

Semi-tendinosus  and  Semi-membranosus. — These  tendons  can  be 
divided  in  the  same  way  as  the  biceps.  A  contracted  knee  can  generalhr 
be  straightened  after  division  of  the  biceps  and  semi-tendinosus.  If  it 
is  needful  to  insert  the  knife  more  deeply  so  as  to  divide  the  semi- 
membranosus, it  would  be  well  to  use  a  blunt-pointed  tenotome,  or  to 
operate  through  an  open  incision. 

In  one  case  of  a  girl  of  16,  after  I  had  divided  the  biceps  and  semi-tendinosus,  I  had 
dipped  the  point  of  the  knife  a  little  more  to  ensure  division  of  the  deeper  and  larger  semi- 
membranosus. Most  profuse  haemorrhage  followed  from  the  superior  internal  articular 
vessels.  Firm  padding  and  bandaging  were  applied,  and  the  limb  put  up  in  the  faulty 
position  for  four  days.     No  recurrence  of  the  bleeding  took  place. 


TENOTOMY   OF  THE   STERNO-MASTOID. 

The  open  method,  in  which  the  muscle  is  divided  by  means  of  an 
angular  incision  along  the  anterior  border  of  the  sterno-mastoid  and 
inner  third  of  the  clavicle  is  the  best  here  as  it  allows  of  every  step 
being  seen,  of  avoiding  abnormal  vessels,  and  securing,  not  only  com- 
plete division  of  the  muscle,  but  also  of  any  fascial  bands. 

If  punctures  are  employed  the  two  heads  are  best  divided  separately 
just  above  the  clavicle.  The  muscle  being  made  prominent,  by  one 
assistant  manipulating  the  head  and  another  depressing  the  shoulder, 
the  surgeon,  standing  facing  the  patient  on  the  side  to  be  operated 
upon,  defines  the  limits  of  the  inner  border  of  the  sternal  tendon, 
opens  the  fasciae  sufficiently  freely  here,  and  then,  taking  a  blunt-pointed 


TENOTOMY    OF    THK    STKI!\<>  MASTOID.  1077 

tenotome,  insinuates  it  horizontally  behind  and  close  to  the  tendon 
till  it  is  felt  just  beneath  his  left  index  finger,  which  is  placed  ;it  the 
outer  margin  ;  the  edge  is  then  turned  towards  the  tendon,  and  divides 
it.  It  is  withdrawn  with  the  usual  precautions.  The  clavicular  tendon 
is  divided  in  a  similar  way  through  another  puncture. 

Care  must  be  taken  to  avoid  the  anterior  jugular,  which  runs  out- 
wards under  the  muscle  a  little  above  the  clavicle,  and  the  external 
jugular,  which  lies  at  a  varying  level  close  to  the  outer  border  of  the 
clavicular  head.  If  a  sharp  tenotome  were  dipped  too  deeply,  the 
internal  jugular  might  also  be  wounded. 

If  any  smart  venous  haemorrhage  occur,  a  pad  of  dry  gauze  should 
be  firmly  bandaged  on. 

Causes  of  Failure  after  Tenotomy. 

1.  Infective  troubles.  These  usually  arise  from  the  use  of  dirty 
instruments  which  clean  themselves  at  the  patient's  expense,  or 
carelessness  in  operating  through  an  open  wound.  2.  Incomplete 
division  of  the  tendon.  3.  Division  of  important  structures — e.g.,  the 
tibial  arteries,  the  external  popliteal  nerve,  the  anterior  or  internal 
jugular  veins.  4.  Non-union  of  the  tendon.  5.  Mal-union  of  the 
tendon — i.e.,  adhesions  formed  by  it  to  adjacent  structures,  e.g.,  its 
sheath  or  a  bone.  These  are  both  extremely  rare.  6.  Breaking  off 
the  point  of  the  tenotome,  usually  against  a  bone. 


CHAPTER    X. 
OPERATIONS  ON  NERVES. 

NERVE  SUTURE. — NERVE  STRETCHING. 
NERVE  SUTURE. 

This  may  be  required  as  a  primary  or  secondary  operation.  The 
latter  is  accompanied  with  much  more  difficulty,  owing  to  the  greater 
retraction  of  the  nerve  ends,  their  bulbous  or  filiform  extremities,  their 
being  often  buried  in  scar  tissue  or  matted  by  it  to  neighbouring  parts 
— e.g.,  tendons  and  fasciae  ;  to  which  must  be  added  other  unfavourable 
points — e.g.,  the  atrophy  and  fatty  change  in  the  muscles  and  the  stiff- 
ness of  the  joints. 

Primary  Suture.* — As  the  mode  of  uniting  nerves  will  be  fully 
described  under  the  head  of  secondary  nerve  suture,  the  more  difficult 
proceeding,  it  need  not  be  repeated  here.  It  only  remains  to  emphasise 
the  importance  of  always  resorting  to  it,  and  not  trusting  to  spon- 
taneous cure.  Howell  and  Huber  (Journ.  of  Physiol.,  vol.  xiii.)  have 
collected  84  cases  of  primary  nerve  suture ;  42  per  cent,  of  these 
were  successful,  40  per  cent,  were  improved,  and  in  the  remaining  18  per 
cent,  the  operation  failed.  The  results  of  secondary  suture  can  never 
be  so  good  as  these. 

The  chief  cause  of  failure  here  is  infection  of  the  wound.  As  in  all 
cases  operated  on  at  short  notice  sterilisation  may  be  incomplete. 
Irrigation  with  some  dilute  antiseptic  should  be  employed  ;  the  wound 
should  not  be  closely  sutured  at  first,  sufficient  drainage  should  be 
employed,  and  a  boracic  acid  fomentation  frequently  applied  for  the 
first  few  days,  when  the  remaining  sutures  can  be  drawn  together,  and 
the  usual  dressings  employed. 

Secondary  Suture. — The  operation  on  the  median  or  ulnar  will 
be  considered,  as  these  are  so  commonly  injured.  The  following  steps 
must  be  remembered  :  (1)  Finding  the  nerve  ends.  (2)  Freeing  and 
resecting  them.  (3)  Passing  the  sutures,  and  bringing  the  ends  into 
apposition.     (4)   Dressing  the  wound,  and  the  after-treatment. 

1.  Finding  the  Nerve  Ends. — With  accurate  anatomical  knowledge 
this  is  easy.  An  Esmarch's  bandage  does  not  appear  to  be  necessary, 
as  the  incision  is  made  parallel  with  the  vessels,  and  the  use  of  one 
leads  to  oozing  afterwards.  Mr.  Bowlby  {!<><■.  infra  eit.,  and  Hunt. 
Lect.,  Lancet,  July  16,  1887)  thinks  that  the  parts  should  be  rendered 

*  Much  information  on  the  subject  of  primary  and  secondary  suture  will  be  found  in 
the  section  on  Suture  of  Tendons  (p.  40,  Vol.  I.). 


NERVE   SUTURE.  1079 

bloodless.  If  this  course  is  adopted  care  must  be  taken  to  provide 
any  needful  drainage,  and  the  bandage  must,  if  possible,  be  applied 
sufficiently  far  from  the  wound  not  to  interfere  with  pressing  down  the 
parts  when  the  nerve  ends  are  approximated.  If  this  bandage  is  em- 
ployed, the  parts  should  be  made  absolutely  evascular  ;  careless  applica- 
tion will  only  cause  most  annoying  oozing.  An  incision,  two  to  three 
inches  long,  being  made  over  and  parallel  to  the  nerve  ends,  the  deep 
fascia  and  any  sear  tissue  are  carefully  divided  and  the  ends  found,  the 
upper  bulbous  and  the  lower  filamentous  usually,  and  not  always  in  a 
line  with  each  other.  If  the  distal  end  be  very  difficult  to  find  owing 
to  its  filiform  shape  and  its  being  embedded  in  scar  tissue,  the  wound 
should  be  prolonged,  the  nerve  found  lower  down,  and  traced  up  to  the 
distal  end.  The  ends  are  next  freed  from  the  adjacent  parts,  and 
cleared  of  cicatricial  tissue. 

2.  Resection  of  the  Nerve  Ends. — This  is  best  effected  by  sharp 
scissors,  with  one  stroke,  and  without  any  bruising.  If  the  nerve  is 
held  with  forceps,  these  must  hold  the  sheath  only.  In  case  of  primary 
suture,  jagged  or  frayed  ends  need  only  be  pared  sufficiently.  In  later 
cases  there  is  much  more  difficulty.  Supposing  the  upper  bulbous  end 
to  be  taken  first,  before  this  is  pared  the  nerve  should  be  carefully 
stretched,*  so  that  dissecting-forceps  or  any  other  means  of  holding 
the  nerve  may  inflict  any  necessary  damage  on  parts  that  will  be  cut 
away.  It  is  not  necessary  to  cut  away  the  whole  of  a  bulb ;  remov- 
ing the  greater  part  will  expose  healthy  nerve  fibres.  Mr.  Bowlby 
(Inj.  and  Dis.  of  Nerves,  p.  165)  advises  that  the  section  of  the  upper 
end  should  be  carried  through  the  uppermost  part  of  the  bulb,  close  to 
the  normal  trunk.  Not  only  will  numerous  young  fibres  be  found  here, 
but,  as  he  points  out,  the  tougher  tissue  of  the  bulb  affords  an  excellent 
hold  for  the  sutures.  With  regard  to  the  lower  end,  Mr.  Bowlby  thinks 
that  all  that  is  needed  is  "  to  cut  away  the  extreme  end,  which,  being 
matted  with  fibrous  tissue  and  compressed  by  the  surrounding  scar,  is 
very  likely  to  contain  no  nerve  tubules.  It  is  seldom  necessary  to 
remove  as  much  as  a  quarter  of  an  inch,  and,  however  unhealthy 
the  section  may  look,  no  good  is  ever  to  be  gained  by  a  further 
sacrifice."! 

3.  Passing  the  Sutures  and  bringing  the  Nerve  Ends  into  Apposition. — 
The  suture  should  be  of  properly  prepared  sterilised  silk  or  chromic 
gut.  There  has  been  much  dispute  as  to  whether  they  should  be  passed 
through  the  substance  of  the  nerve  itself  or  only  through  the  sheath. 
Experience  has  shown  that  the  former  practice  is  not  only  harmless  to 
the  nerve,  but  is  the  method  most  generally  applicable.  Two  at  least 
should  be  then  passed  at  a  sufficient  distance  from  the  ends — viz.,  at 
least  a  quarter  of  an  inch — otherwise,  they  will  cut  out  when  they  are 
tightened.  Additional  ones  in  the  sheath  will  remove  some  of  the 
tension.     Where  there  is  much  separation,  several  sutures  should  be 


*  An  Esmarch's  bandage,  if  applied,  will  be  found  in  the  way  now,  interfering,  as  it 
usually  must,  with  the  stretching  of  the  nerve. 

f  As  the  whole  length  of  the  lower  end  is  in  the  same  condition  of  degeneration 
throughout,  manifestly  no  good  can  be  done  by  cutting  off  successive  sections  in  the  hope 
that  the  cut  surface  may  look  more  healthy  than  that  which  is  seen  in  the  first  section 
(Bowlby). 


1080  OPERATIONS    <>\    THE   LOWEB    EXTREMITY. 

passed  through  part  of  the  depth  of  the  nerve,  one  suture  thus 
taking  off' some  of  the  tension  from  its  fellows.  Another  method  is  to 
pass  one  suture  completely  through  the  nerve  trunk  at  least  a  quarter 
of  an  inch  from  each  cut  end.  When  the  sutures  in  the  nerve  itself 
have  been  tied,  two  or  three  more  very  fine  ones  may  be  placed  in  the 
sheath,  where  the  nerve  is  large  enough. 

In  cases  of  much  separation,  before  any  sutures  are  passed,  and  again 
before  they  are  tied,  the  parts  should  be  as  much  relaxed  as  possible, 
and  the  upper  end  brought  down  by  pressing  down  the  soft  parts. 
Stretching  the  nerve  has  been  already  advised. 

All  hemorrhage  being  scrupulously  arrested,  and  drainage  provided 
according  to  the  amount  of  the  disturbance  of  the  parts,  &c,  the  usual 
dressings  are  applied,  and  the  limb  placed  on  a  well-padded  splint  in  a 
position  which  will  best  retain  the  nerve  ends  in  apposition  with  the 
least  discomfort  to  the  patient. 

Amount  of  Nerve  Tissue  which  may  be  Successfully  Removed. — From 
half  an  inch  to  three-quarters  of  an  inch  is  probably  an  average 
amount. 

Causes  of  Failure. — i.  Infection  of  the  wound. .  2.  "Wide  separation 
of  ends  and  subsequent  tension.  3.  Atrophy,  bulbous  enlargement  and 
sclerosis  of  nerve  ends,  so  marked  as  to  require  much  trimming,  and 
thus  tending  to  wide  separation.  4.  Unnecessarily  rough  handling 
of  the  nerve  ends. 

Aids  in  Difficult  Cases. — 1.  Previous  stretching  of  the  ends.  2.  Ap- 
proximation of  the  ends  by  position  of  the  limb.  3.  Using  several 
sutures,  which  distribute  the  tension  evenly.  4.  The  use  of  "  stitches 
of  support"  (p.  48,  Vol.  I.).  5.  Autoplastic  operation  with  nerve-flaps. 
M.  Letievant  advises  to  make  a  slit  through  the  nerve  with  a  narrow 
bistoury  about  one-fifth  of  an  inch  from  the  end  ;  the  knife  being  then 
carried  upwards  for  an  inch  or  an  inch  and  a  half,  is  made  to  cut  to 
one  side  so  as  to  make  a  flap.  The  same  is  then  done  with  the  lower 
end,  and  the  two  flaps,  being  turned  towards  each  other,  are  united  by 
their  raw  surfaces  (Fig.  31,  Vol.  I.).  Dr.  C.  A.  Powers,  of  Denver 
{Ann.  of  Surg.,  Nov.  1904,  p.  641),  from  a  collection  of  cases  in  which 
this  method  was  used,  concludes  that  of  six  (all  doubtful  ones  being 
excluded)  two  were  failures,  and  four  partial  or  complete  successes. 
6.  Gluck  and  Vanlair  advise  that  the  nerve  ends,  whether  united  or 
only  placed  as  closely  as  possible  in  apposition,  should  be  passed 
through  and  left  in  a  decalcified  bone-tube,  so  as  to  keep  the  uniting 
material  and  granulations  in  a  straight  line.  7.  The  substitution  of 
threads  of  silk  and  catgut  may  be  tried  (p.  50,  Vol.  1.)  ;  and  this  may 
be  combined  with  the  last  mentioned  plan.  8.  Scar  tissue  may  be 
used  as  a  bridge  between  the  ends. 

Thus,  Mr.  Pick  (Lancet,  1892,  vol.  i.  p.  693)  in  a  case  of  secondary  suture  of  the  median 
nerve  more  than  two  years  after  the  injury,  found  lying  beside  the  upper  cut  end  some 
organising  inflammatory  material.  Dissecting  this  from  the  side  of  the  nerve,  and  leaving 
it  still  attached  to  the  lower  end  of  the  upper  piece,  he  turned  it  down,  and  sutured  it  to 
the  lower  end  of  the  nerve.  When  the  patient  was  last  seen  the  function  of  the  nerve  was 
in  process  of  restoration. 

9.  Implanting  one  nerve  trunk  upon  another.  Dr.  Powers  (loc.  supra 
cit.)  gives  abstracts  of  ten  cases  in  which  implantation  or  anastomosis 


m:i;vk   SUTURE.  1081 

was  employed;  in  five  or  six  the  results  are  encouraging.  This  method 
is  indicated  where  nerve  trunks  run  parallel,  £.<?.,  in  the  forearm  ;  in  the 
case  of  the  popliteals  it  lias  been  much  less  satisfactory.  Two  noteworthy 
cases  are  quoted  from  Dumstrey  (Deut. Zeitsch.f.  Chir.,  Bd.  Ixii.  1901- 
1902,  s.  376). 

In  one  of  extensive  destruction  of  the  ulnar.  Dumstrey  implanted  the  peripheral 
portion  of  this  nerve  into  a  button-hole  in  the  median  and  placed  substitution  threads  of 
catgul  between  the  same  point  in  the  median  and  the  proximal  portion  of  the  ulnar.  In 
Unci'  months  there  was  a  marked  return  of  sensation,  to  a  less  degree  of  motion,  and 
a  diminution  of  the  contraction.  In  a  ease  quoted  by  Dumstrey,  Sick  and  Senger  thus 
deal!  with  a  ease  of  extensive  destruction  of  the  radial.  The  peripheral  portion  of  the 
radial  ami  the  median  nerves  having  \>rvn  exposed  by  one  incision,  a  flap  was  split  from 
the  median  and  carried  under  the  muscles  to  the  peripheral  portion  of  the  radial.  For 
several  months  there  was  no  improvement,  but,  in  a  year  and  a  half,  the  paralysis  had 
almost  entirely  disappeared.  In  other  cases  the  central  end  of  the  injured  nerve  has  been 
sutured  into  a  parallel  one,  at  one  point,  and,  a  little  lower  down,  the  peripheral  end  is 
implanted  in  like  manner. 

10.  Perhaps  the  use  of  zigzag  incisions  made  in  the  upper  end 
(Fig.  32,  Vol.  I.).  11.  Making  use  of  nerve-grafts.  Gluck  has 
resected  an  inch  and  a  half  of  the  great  sciatic  in  chickens,  and 
replaced  it  by  a  bit  of  a  rabbit's  sciatic  sutured  in.  The  birds  walked 
afterwards  as  well  as  those  treated  by  direct  suture.  In  man  the 
results  have,  on  the  whole,  been  unsatisfactory. 

Mr.  Mayo  Robson  (Clin.  Sue.  Trans.,  vol.  xxii.  p.  120)  after  the  removal  of  a  growth 
from  the  median  nerve,  leaving  a  gap  of  two  inches  and  a  half  between  the  ends,  success- 
fully made  use  of  a  corresponding  bit  of  the  posterior  tibial  nerve  from  a  limb  which  was 
amputated  in  the  adjoining  theatre.*  The  following  conditions  are  rightly  given  as 
essential :  First,  the  entire  absence  of  tension  ;  two  inches  and  a  half  of  nerve  being 
employed  to  fill  an  interval  of  two  inches  and  a  quarter.  Secondly,  great  care  was 
observed  in  handling  the  nerve  to  be  transplanted.  Thirdly,  the  transplanted  posterior 
tibial  nerve  was  transferred  immediately  as  living  tissue  into  its  new  bed.  Fourthly,  only 
one  fine  catgut  suture  was  employed  at  each  end  to  fix  the  nerve.  The  same  surgeon 
successfully  used  the  spinal  cord  of  a  rabbit  as  a  graft  in  the  median  nerve  of  a  man 
{Brit.  Med.  ./num.,  Oct.  31,  1S96,  p.  1312). 

Mr.  Damer  Harrison,  of  Liverpool  {Clin.  Soc.  Traits.,  vol.  xxv.  p.  166),  gives  nine  other 
cases  of  nerve-grafting.  The  nerves  used  were  the  sciatic  of  recently  killed  rabbits  or 
kittens,  and  the  median  from  a  human  arm.  Of  the  ten  cases,  three  are  stated  to  have 
been  perfectly  successful,  six  partially  successful,  and  only  one  a  failure. 

Mr.  C.  Heath  made  use  of  nerve-grafting,  replacing  a  gap  in  the  ulnar,  due  to  removal 
of  a  sarcoma,  by  two  and  a  half  inches  of  the  posterior  tibial  nerve  from  a  limb  just 
amputated  {Lancet,  1893,  vol.  i.  p.  1195).  A  fibro-sarcoma  had  been  removed  from  the 
ulnar  nerve.  The  graft  was  retained  in  position  by  two  fine  silk  sutures  at  either  end. 
About  twenty  minutes  elapsed  from  the  time  at  which  the  limb  from  which  the  nerve 
was  taken  was  severed  from  the  body  and  the  time  when  the  junction  of  the  piece  of 
nerve  with  the  ulnar  nerve  was  completed.  The  wound  healed  by  first  intention,  but 
fourteen  months  later  there  was  no  restoration  of  function  in  the  nerve. 

Larger  statistics  are  less  favourable  (Powers,  loc.  supra  cit.  ,■ 
Peterson,  Amer.  Jonm.  Med.  ScL,  1889).  Thus  of  23  cases,  according 
to  Powers,  the  results  were  "good"  in  three,  and  "fair"  in  three. 
He  concludes  that  this  method  should  be  discarded.  In  a  case  of 
extensive  destruction  of  the  external  popliteal  nerve  he  implanted,  about 

*  In  its  brief  transit  the  nerve  was  placed  in  a  solution  of  carbolic  acid  (1  in  40). 


ioS2  <>PKi;.\Tln\S   ON    THE    LOWEB    EXTREMITY. 

two  weeks  later,  the  injury  having  healed,  four  inches  of  the  great 
sciatic  of  a  dog.  The  result  seven  years  later  was  "  ;i  complete  failure 
as  regards  motion,  and  this  in  the  face  of  conditions  which  seemed  to 
promise  a  good  result.  The  ends  of  the  implanted  fragment  were 
carefully  approximated,  the  sutures  suitable,  wound  healing  was 
perfect,  and  the  fragment  stayed  in." 

The  graft  does  not  remain  as  nerve  tissue,  but  merely  acts  as  a 
conducting  material  for  the  growth  of  the  new  nerve  fibrils,  in  the 
same  way  as  strands  of  catgut  may  do. 

12.  In  cases  of  injury  to  the  musculo-spiral  nerve,  where  the  ends 
are  too  far  apart  to  admit  of  their  junction  by  suture,  they  have  been 
successfully  approximated  by  resecting  sufficient  of  the  humerus — 
Wheeler  (Lancet,  1894,  vol.  i.  p.  939),  Mann  (ibid.,  1893,  vol.  ii.  p.  59). 
This  procedure  is  always  attended  with  the  risk  of  non-union.  The 
only  cases  in  which  it  is  clearly  indicated  are  those  in  which  the  nerve 
injury  is  accompanied  by  such  a  condition  of  the  hone  or  hones  as  a 
false  joint,  e.g.,  in  a  case  of  Prof.  Keen  (Chipault's  ':  Ktat  actuel  de  la 
chirnrgie  nerveuse,"  1901-1903). 

Period  required  for  Repair. — The  following  appears  to  he  a  fact  not 
sufficiently  recognised.  The  period  required  for  union  after  secondary 
nerve  suture  is  very  much  longer  than  is  usually  supposed  to  be  neces- 
saiw,  owing  to  the  peripheral  end  being  degenerated,  the  muscles 
atrophied,  and  the  joints  fixed.  Complete  restoration  of  function  will 
often  require  from  one  to  two  }'ears.  A  patient  who  leaves  his  surgeon 
apparently  but  little  better  for  the  operation  may  return  at  the  end  of 
the  above  time  with  great  improvement  in  the  function  of  the  limb. 
But  it  is  seldom  or  never  possible  to  restore  the  function  of  the  part 
absolutely  (Bowlby,  Lancet,  July  26,  1902). 

It  is  the  condition  of  the  muscles  and  joints  which  alone  puts  any- 
thing like  a  limit  on  the  period  at  which  secondary  suture  can  be 
successfully  practised. 

The  longer  the  interval*  between  the  injury  and  the  suture,  the  more 
perseveringly  must  friction,  electricity,  passive  and  active  movement, 
and  massage  be  made  use  of,  and  the  more  will  patience  be  required  by 
both  patient  and  surgeon. 

Modern  Gunshot  Injuries  <>/'  Nerves. — Mr.  G.  H.  Makins,  C.B. 
{Surgical  Experiences  in  Smith  Africa,  1899-1900,  p.  yjz)  gives  the 
following  advice  as  to  operative  treatment.  "  Early  interference  was 
only  warranted  by  positive  knowledge  that  some  source  of  irritation  or 
pressure  could  be  removed  ;  thus  a  bone  splinter,  or  a  bullet,  or  part 
of  one,  particularly  portions  of  mantles. 

"  In  case  of  contusion,  the  expiration  of  three  months  is  the  earliest 
date  at  which  operation  should  be  taken  into  consideration.  The 
two  strongest  indications  for  operations  are  (1)  signs  pointing  to  the 
secondary  implication  of  the  nerve  in  a  cicatrix,  especially  when  these 
are  of  such  a  nature  as  to  indicate  Local  tension,  fixation  or  pressure  ;' 
(2)  the  possibility  of  the  irritation  being  the  result  of  the  presence 
of  some  foreign  body;  in  such  cases  the  X-rays  will  often  give  useful 
help. 

*  The  longest  of  these  with  which  I  am  acquainted  is  a  case  of  M.  Tillaux's  in  which 
fourteen  yeai>  had  elapsed  between  the  injury  to  the  median  and  its  suture. 


NERVE    STRETCHING.  1083 

"  With  regard  to  the  early  exploration  of  cases  of  traumatic  neuralgia, 
it  may  be  pointed  out  that  when  this  was  undertaken  the  results  were, 
as  a  rule,  very  temporary.  In  11111113''  cases,  either  no  macroscopic 
evidence  of  injury  to  the  nerve  was  discovered,  or  a  bulbous  thickening 
was  met  with  of  such  extent  as  to  make  excision  inadvisable. 

"  Even  when  complete  section  of  the  nerve  was  assured  by  the  absence 
oi'  any  power  of  reaction  to  stimulation  by  electricity  from  above  on 
the  part  of  the  muscles,  operation  was  better  not  undertaken  until 
cicatrisation  had  reached  a  certain  stage.  If  done  earlier  than  the 
end  of  three  weeks,  the  sutured  spot  became  implicated  in  a  hard 
cicatrix,  and  any  advantage  to  be  obtained  by  early  interference  was 
lost.  When  partial  division  of  a  trunk  was  determined,  the  same 
date  was  the  most  favourable  one  for  exploration,  the  gap  in  the 
nerve  being  freshened  and  closed  by  suture.  There  is  little  doubt, 
however,  that  in  some  cases  such  injuries  were  recovered  from 
spontaneously." 

The  same  authority  thus  advises  in  cases  where  the  lesion  to  the 
nerve  was  of  doubtful  nature  (ibid.  p.  370).  "  As  favourable  prognostic 
elements  we  may  bear  in  mind  low  velocity  on  the  part  of  the  bullet, 
and  with  this  a  lesser  degree  of  contiguity  of  the  track  to  the  nerve. 
The  early  return  of  sensation  is  a  favourable  sign,  and  in  this  relation 
the  development  of  hypersesthesia,  whether  preceded  by  anaesthesia  or 
no,  points  to  the  maintenance  of  continuity  of,  and  a  moderate  degree 
of  damage  to  the  nerve.  The  early  return  of  sensation,  even  if 
modified  in  acuteness,  was  always  a  very  hopeful  sign  ;  also  the  pro- 
duction of  formication  in  the  area  of  distribution  of  the  nerve  on 
manipulation  of  the  injured  spot." 


NERVE    STRETCHING. 

This  operation,  introduced  into  England  in  1880,  and  much  used  in 
the  immediately  succeeding  }^ears,  has  fallen  into  abeyance,  the  clinical 
results  having  failed  to  come  up  to  the  expectations  raised  by  the 
operation. 

Indications. — Of  the  following  list  it  is  only  in  the  first  six  that  the 
operation  can  be  considered  justifiable.  It  is  certainly  so  in  cases  of 
sciatica  due  to  exposure  to  cold  and  wet,  from  the  results  in  two  cases 
in  which  I  operated. 

I.  Neuralgia?. — In  all  cases  where  previous  treatment  has  failed, 
nerve  stretching  may  be  practised  before  division  of,  or  removal  of, 
part  of  a  nerve.  The  conditions  justifying  this  in  facial  neuralgia  have 
been  already  given  (p.  416,  Vol.  I.).  2.  Sciatica. — Nerve  stretching  is 
especially  indicated  here  in  cases  due  to  rheumatic  inflammation  of  the 
nerve  from  exposure  to  cold  and  wet.  Dr.  J.  P.  Bramwell  has  pub- 
lished (Brit.  Med.  Journ.,  June  19,  1880)  five  cases  of  this  kind,  in 
which  much  benefit  followed  stretching  the  great  sciatic.  The  most 
suitable  cases  are  those  where  the  pain  is  limited  to  the  distribution  of 
the  nerve.  In  patients  no  longer  young,  organic  disease,  e.g.,  in  the 
pelvis,  and  like  causes  must  be  carefully  excluded.  If  the  pain,  after 
being  distinctly  benefited,  reappears,  it  would  be  justifiable  to  stretch 
the  nerve  again  by  an  incision  lower  down.     The  more  definite  is  the 


1084  OPERATIONS   ON   THE   LOWEB    EXTREMITY. 

sensation  of  adhesions  broken  down  at  the  time  of  the  operation,  the 
better  is  the  prognosis.  3.  Locomotor  ataxy. — One  or  both  great 
sciatics  have  been  stretched  with  a  view  of  improving  the  lightning 
pains,  the  involuntary  joking*  of  the  lower  limbs,  and  the  gait.* 
While  improvement,  for  a  varying  period  may  be  expected  as  far  as  the 
first  two  are  concerned,  the  prospect  of  improving  the  ataxy  is  very 
doubtful.  Furthermore,  the  slow  healing  of  the  wound  in  these  cases 
must  be  borne  in  mind.  4.  Spasmodic  contractions  of  voluntary 
muscles. — Here  the  operation  seems  to  have  been  followed  by  success, 
temporary  at  least,  in  a  very  large  number  of  cases.  Where  the 
spasmodic  affection  is  of  traumatic  origin — e.g.,  where  a  limb,  after  a 
contusion,  is  at  the  same  time  contracted  and  the  seat  of  spasmodic 
movements — stretching  of  the  nerves  concerned  may  be  absolutely 
curative.  Quite  another  class  of  case — viz.,  stretching  the  facial 
for  tic  convulsif — has  been  considered  at  p.  416,  Vol.  I.  5.  Reflex 
epilepsy. — Sir  Y.  Horsley  (Diet,  of  Surg.,  vol.  ii.  p.  61)  states  that, 
in  those  cases  of  epilepsy  where  the  attack  is  preceded  by  violent 
pains  localised  distinctly  to  different  nerves,  very  marked  relief 
(amounting  to  cure  in  several  instances)  has  been  obtained  by  stretch- 
ing the  nerve  trunks  thus  indicated.  6.  Anaesthesia  of  leprosy. — 
Lawrie,  of  Lahore,  seems  to  have  met  with  striking  success,  the 
50  cases  published  being  all  successful.  The  late  Dr.  B.  Rake  (Brit. 
Med.  Joiirn.,  1890,  vol.  ii.  p.  953)  advised  repeated  stretching  of  the 
great  sciatic  as  preferable  to  amputation  for  the  painful  perforating 
ulcer  of  leprosy.  7.  Infantile  paralysis. — Sir  V.  Horsley  (loc.  supra 
cit.)  states  that  in  1861  Dr.  Bastian  had  the  great  sciatic  nerve 
stretched  to  improve  the  nutrition  in  a  limb  the  seat  of  the  above 
disease.  The  effect  was  to  markedly  increase  the  temperature  and 
colour  of  the  part,  and  apparently  improve  the  state  of  the  tissues. 
The  result,  however,  does  not  seem  to  have  been  such  as  to  find 
imitators. 

Operation. — The  following  remarks  refer  to  the  great  sciatic  only, 
the  nerve  which  has  been  most  frequently  stretched. 

The  parts  being  sterilised,  an  incision  about  four  inches  long  is  made 
over  the  nerve  in  the  centre  of  the  back  of  the  thigh,  commencing 
about  an  inch  and  a  half  below  the  lower  border  of  the  glutseus 
maximus.  The  interval  between  the  hamstrings  being  hit  off,  retractors 
are  inserted,  and  the  nerve  found  a  little  to  the  inner  side  of  the 
biceps.  The  fatty  tissue  around  it  is  then  carefully  incised  till  the 
white  epineurium  itself  of  the  nerve  is  exposed.  Unless  there  be  evidence 
of  effusion  within,  it  is  better  not  to  open  the  sheath.  The  nerve,  being 
most  entirely  separated  from  adjacent  parts,  is  now  stretched.  The 
force  with  which  this  is  accomplished  must  vary  somewhat  with 
different  cases.  Thus,  in  sciatica,  the  index  linger, |  sterilised,  being 
hooked  under  the  nerve,  this  should  be  raised  well  out  of  its  bed  in  the 

*  In  a  case  of  Dr.  Bastian's  {Jirit.  Med.  Journ.,  July  2,  1881),  the  patient,  in  an 
advancc'l  stage  of  ataxy,  experienced  so  much  relief  from  the  stretching  of  one  great 
sciatic,  that  he  asked  for  an  operation  on  the  other  side.  An  interesting  paper  by  Dr. 
Cavafy,  with  19  cases  collected  from  different  sources,  will  be  found  in  the  Brit,  Med, 
Jowrn.,  1881,  pp.  928,  973. 

f  In  the  case  of  smaller  nerves  a  blunt  hook  would  be  employed. 


NERVE   STHKTCHING.  1085 

hope  of  adhesions  being  felt  to  give  wajr  both  at  the  part  stretched  and 
at  a  distance  also. 

Mr.  Marshall  (Bradshawe  Lecture,  p.  28)  thought  that  in  neuralgia 
the  stretching  should  be  performed  both  ways.  In  ataxy  it  is  essential 
to  stretch  down  from  the  body. 

The  nerve,  being  found  to  be  loose  and  elongated,  is  replaced  in  its 
bed,  any  bleeding  is  attended  to,  drainage,  if  needful,  provided,  and  the 
wound  carefully  closed.  Aseptic  precautions  must  be  made  use  of 
throughout,  and  the  limb  kept  quiet  with  a  splint  or  sand-bags. 

In  cases  of  stretching  for  sciatica,  gentle  movements  of  the  limb 
should  be  begun  as  soon  as  possible  to  prevent  the  re-formation  of 
adhesions. 


PAET  VI. 
OPERATIONS    ON    THE    VERTEBRAL   COLUMN. 


SPINA  BIFIDA.— LAMINECTOMY  OR  PARTIAL  RESECTION 
OF  THE  VERTEBRA. — TAPPING  THE  SPINAL  THECA. 
—SPINAL     ANESTHESIA. 

SPINA   BIFIDA. 

Indications. — All  operative  treatment  should,  if  possible,  be  post- 
poned until  the  child  is  two  years  of  age  or  older.  The  operation  is  tin  in 
borne  far  better,  as  is  shown  by  published  results.  Where,  in  younger 
children,  rapid  increase  in  the  size  of  the  swelling  is,  however,  taking 
place,  and  leakage  is  threatening  or  has  actually  occurred,  the  methods 
of  injection  or  tapping  may  be  resorted  to  as  palliative  measures, 
although  the  results,  with  few  exceptions,  will  be  disappointing. 
Briefly,  the  smaller  the  swelling,  the  less  the  evidence  of  involvement 
of  the  spinal  cord  or  nerves  ;*  the  more  the  overlying  skin  approaches 
to  normal,  the  less  the  swelling  shows  signs  of  increase  in  size  ;  and 
the  older  the  child — the  greater  are  the  chances  of  cure.  The  greatest 
possible  importance,  therefore,  attaches  to  the  question  of  careful 
selection  of  cases  to  be  submitted  to  operative  interference. 

Operations. — Simple  tapping  being  merely  palliative  and  any  form 
of  drainage,  e.g.,  with  sterilised  horsehair,  being  very  liable  to  be 
followed  by  infective  meningitis,  especially  if  the  coverings  of  the  sac 
are  thin  and  unhealthy,  the  only  two  methods  before  us  are :  I.  Injection 
with  Morton's  Fluid.     2.  Excision. 

I.  Injection  with  Morton's  Fluid. — The  Clinical  Society's  Com- 
mittee (Trans.,  vol.  xviii.)  collected  71  cases  treated  by  this  method. 
Of  these,  35  recovered,  27  died,  4  were  relieved,  and  5  unrelieved. 
In  a  letter  to  the  Committee  (dated  May  n,  1885),  Dr.  Morton  was 
able  to  refer  to  50  cases  thus  treated.  Of  these,  41  appear  to  have  been 
successful,  and  9  unsuccessful.  But  it  is  obvious  that  these  statistics 
are  largely  unreliable.  It  is  not  unfair  to  say  thai  nearly  every  suc- 
cessful case  has  been  at  once  reported,  while  scores  of  unsuccessful  ones 
have  never  been  heard  of.     Owing  to  the  large  number  of  successes 

*  Points  which  make  it  probable  that  nerve  trunks  or  the  cord,  or  both,  are  present  in 
the  sac,  are  paralysis  of  the  sphincters  or  lower  extremities,  a  large  sessile  tumour  with  a 
broad  base,  and  the  appearance  of  cord-like  bands  when  the  sac  is  thin  enough  to  transmit 
light. 


SPINA    BIFIDA.  1087 

which  attended  the  use  of  this  method,  it  is  the  only  one  which  was 
recommended  by  the  Committee  of  the  Clinical  Society.  In  four  of 
the  cases  in  which  I  have  employed  this  method  while  complete 
shrinking  of  the  sac  was  secured  in  each,  hydrocephalus  eventually 
supervened.  And  where  this  is  not  the  case,  the  later  effects  of 
pressure  of  the  cicatricial  tissue  upon  any  nerves  present  must  be 
remembered. 

The  parts  having  been  sterilised,  a  syringe  which  will  hold  about  two 
drachms  of  the  iodo-glycerine  solution*  is  chosen,  and  a  fine  trocar. 
The  calibre  of  this  must  not  be  too  fine  for  the  thick  fluid  which  has  to 
pass  through  it.  The  puncture  into  the  swelling  should  be  made  well 
at  one  side,  obliquely  through  healthy  skin,  and  not  through  the 
membranous  sac-wall,  the  objects  being  to  avoid  wounding  the  cord  or 
nerves,  and  also  to  diminish  the  risk  of  leakage  of  cerebro-spinal  fluid. 
Unless  the  sac  is  very  large  it  is  probably  better  not  to  draw  off  much, 
if  any,  of  the  fluid  from  the  sac  on  the  first  occasion.  The  position  of 
the  child  during  the  injection  has  been  a  good  deal  dwelt  upon,  most 
recommending  that  it  should  be  upon  its  back.  The  Clinical  Society's 
Committee  advise  that  the  child  should  be  upon  its  side.  About  a 
drachm  of  the  fluid  should  be  injected.  Every  care  must  be  taken  to 
prevent  any  continued  escape  of  the  cerebro-spinal  fluid,  now  and  later, 
it  being  clearly  understood  that  any  such  leakage,  which  is  most  difficult 
to  prevent,  will  lead  to  infective  meningitis  and  death.  When  the 
needle  is  withdrawn  the  puncture  should  be  pressed  around  it,  and 
immediately  painted  with  collodion  and  iodoform,  a  dressing  of  dry 
gauze  being  also  secured  with  collodion.  I  prefer  to  give  a  little 
chloroform  to  prevent  any  crying  and  straining  at  the  time.  The  child 
should  be  kept  as  quiet  as  possible  afterwards,  on  its  side,  and  an 
assistant  should  make  sure,  for  the  first  hour  at  least,  that  no  leaking 
is  going  on.  Shrinking  of  the  cyst,  continuing  steadily,  shows  that 
all  is  well.  If  the  injection  fail  altogether,  or  only  cause  partial 
obliteration  of  the  sac,  it  should  be  repeated  at  intervals  of  a  week  or 
ten  days. 

2.  Excision  of  the  Sac.f — This  is  the  method  which,  in  spite  of 
certain  grave  dangers,  promotes,  on  the  whole,  the  best  results  in 
carefully  selected  cases.  The  dangers  are,  of  course,  the  suddenness 
with  which  the  fluid  may  escape,  with  grave  resulting  changes  in  the 
hydrostatic  pressure  and  circulation  in  the  cerebro-spinal  system,  shock 
from  interference  with  important  nerve  filaments,  and  meningitis  set  up 
at  the  time  or  as  the  result  of  subsequent  leakage. 

A  wise  selection  of  cases  is  most  difficult.  It  is  only  possible  to 
advise  in  general  terms.  A  condition  of  the  overlying  parts  which 
renders  it  doubtful  if  asepsis  can  be  secured  to  begin  with,  should  forbid 
operation.  Weak  antiseptics  are  likely  to  be  useless,  and  strong  ones 
harmful ;  they  may  even  inflict  further  damage  on  the  closely  adjacent 
nerve  tissues.  An  advanced  degree  of  jmralysis  present  should  contra- 
indicate  interference ;  it  will,  probably,  be  impossible  to  separate  and 

*  The  fluid  is  iodiiie,  gr.  x  ;  iodide  of  potassium,  53  ;  glycerine,  3J. 

t  The  Clinical  Society's  Committee  collected  23  cases  treated  by  excision  of  the  sac. 
Of  these  16  recovered,  seven  died.  They  point  out  that  no  mention  of  the  contents  of  the 
sac  is  made  in  six  cases  ;  that  nerves  were  certainly  absent  in  16  cases  ;  and  that  in  one, 
which  was  fatal,  they  were  certainly  present  (Trans.,  vol.  xviii.  p.  380). 


1088  OPERATIONS   ON    THE    VERTEBRAL   COLUMN'. 

return  the  nerves  present  in  the  walls  of  the  sac,  and  what  is  the  real 
value  of  the  life  which  it  is  attempted  to  preserve  ?  It  will  he  remem- 
bered that  this  condition  and  the  preceding  one  often  coexist.  Other 
severe  malformations  are  also  contra-indications.  As  I  stated  ahove, 
any  operation  should,  when  possihle,  he  deferred  till  ahout  the  age  of 
two  years.  The  effects  of  the  interference  are  hetter  met,  the  parts  are 
metre  eas}r  to  handle,  and  one  source  of  infection,  that  from  the  usually 
closely  adjacent  anus  is  diminished.  In  the  rare  variety  of  meningocele 
such  delay  is  especially  indicated. 

Operation. — It'  needful,  the  too  rapid  escape  of  fluid  can  he  prevented 
by  a  preliminary  tapping  and  attention  to  the  position  of  the  patient. 
Every  precaution  against  shock  must  be  taken  before,  during  and  after 
the  operation,  and  this  must  be  completed  as  quickly  as  is  consistent 
with  safety.  The  parts  having  been  sterilised  and  arrangements  made 
for  keeping  the  head  low  prior  to  and  during  the  opening  of  the  sac, 
elliptical  incisions  are  made  through  the  skin  on  either  side  of  and 
sufficiently  far  from  the  base  to  ensure  if  possible  (a)  sound  skin  and 
(J3)  sufficient  skin  to  meet  in  the  middle  line  after  partial  excision  of 
the  sac  and  removal  of  the  fluid.  Such  incisions  are  always  to  be 
employed  when  the  central  skin  is  unsound  and  undermining  will  be 
required.  In  other  cases  a  flap  may  be  preferable.  The  skin  is  then 
dissected  back  on  each  side  with  great  care  so  as  to  avoid,  if  possible, 
punctures  of  the  membranes,  until  the  laminae  are  reached.  It  may 
now  be  found  that  the  tumour  is  clearly  a  meningocele  being  attached 
by  a  pedicle,  which  may  be  quite  slender.  In  such  a  case  the  interior 
of  the  pedicle  is  inspected,  and  if  it  contain  no  structures  of  importance, 
it  should  be  surrounded  with  a  purse-string  ligature  of  fine  kangaroo- 
tendon,  and  the  sac  beyond  cut  away. 

If  there  is  no  pedicle  the  sac  is  now  carefully  opened,  at  first  with  a 
trocar  so  that  the  fluid  is  slowly  withdrawn,  and  the  effects  on  the 
cerebral  centres  noted.  The  opening  is  then  enlarged,  and  the  interior 
carefully  examined.  If  no  nerve  structures  are  present,  the  redundant 
sac  is  then  cut  away  with  blunt-pointed  scissors,  and  the  edges  brought 
together  with  a  continuous  sterilised  suture.  So  far  the  operation  has 
been  simple  and  straightforward.  We  must  now  consider  more  difficult 
cases.  Where  the  coverings  are  in  great  part  thin  and  translucent, 
even  when  this  condition  extends  to  the  margin  of  the  swelling,  if  the 
coverings  can  be  rendered  aseptic  they  may  be  partly  utilised  to  form 
the  meningeal  flaps,  the  adjoining  skin  being  undermined  and  made  to 
slide  over  the  new  meninges. 

When  on  opening  the  sac  nerve  structures  are  seen  within,  that  part 
of  their  course  which  lies  in  the  sac  must  be  carefully  detached  with 
blunt-pointed  instruments,  until  they  can  be  gently  pushed  through  the 
opening  that  communicates  with  the  spinal  canal.  In  more  difficult 
cases,  incisions  must  be  made  with  blunt-pointed  scissors  between 
portions  of  nervous  structures,  in  order  to  set  them  free,  or  they  must 
be  returned  with  a  part  of  the  sac  en  nuixxc.  In  cases  where  the 
presence  of  nerve  structures  difficult  to  detach  is  marked,  the  safest 
plan  will  be  the  last.  Having  opened  and  examined  the  sac,  the 
surgeon  cuts  away  any  superfluous  part  that  is  safe,  then  detaches  the 
remainder  and  returns  it  with  the  nerves  which  run  in  it,  through  the 
opening,   into  the  canal.     It  is  greatly  to  be  desired  that  surgeons 


SPINA    BIFIDA.  r68g 

should  specify  what  nervous  structures  wire  present,  and  how  they 
were  dealt  with.  As  a  rule  this  h;is  been  most  imperfectly  done. 
When-  it  is  plain  that  the  sac  and  its  contained  nerves  cannot  be 
returned  without  sacrificing  some  of  the  latter,  thesurgeon  should  hold 
his  hand  and  close  the  wound.  However  small  the  nerves  may  be,  it 
is  impossible  to  determine  their  importance.  Their  removal  runs  a 
decided  risk  of  causing  permanent  paralysis,  or  of  increasing  that 
already  present. 

The  nerve  structures  having  been  returned,  the  flaps  of  meninges  and 
skin  are  sutured  separately  and  not  in  one  line.  A  precaution  of  Mr. 
Hobson's  (Clin.  Soc.  Trans.,  vol.  xviii.  p.  211)  should  be  followed  here. 
The  skin  and  meningeal  flaps  should  be  so  cut  that  their  lines  of 
union,  when  sutures  are  applied,  are  not  opposite.  Thus,  the  flaps 
should  be  cut  of  unequal  width,  so  as  to  bring,  e.g.,  the  wider  skin  flap 
on  the  left  side,  and  the  wider  meningeal  one  on  the  right.  Another 
means  of  obtaining  the  same  end  is  to  suture  the  membranes  trans- 
versely, and  the  skin  longitudinally.  In  some  cases  periosteal  grafts  * 
or  bones  from  freshly  killed  animals  have  been  introduced  with  varying 
success,  and  are  to  be  preferred  to  attempts  to  close  the  gap  by  frag- 
ments chiselled  off  from  the  laminae  or  sacrum.  Considering  the  tender 
age  and  feeble  powers  of  these  patients — infants,  as  a  rule — it  is  cer- 
tainty not  worth  while  to  prolong  an  operation,  anaesthetic,  &c,  for 
this  purpose.  If,  however,  the  patient  is  not  an  infant  and  the  condition 
is  good,  and  moreover  if  the  gap  in  the  spine  is  a  large  one,  an  attempt 
should  be  made  to  protect  this  by  means  of  flaps  of  aponeurosis  and 
muscle  derived  from  the  erector  spinas.  Either  one  large  flap  may  be 
raised  and  swung  across  so  that  the  line  of  sutures  is  at  the  side,  or 
two  flaps  may  be  used  and  united  in  such  a  manner  that  the  line  of 
sutures  is  not  immediately  beneath  the  skin  sutures.  The  very  lowest 
part  of  the  meningeal  and  skin  flaps  ma}'  be  left  unsutured,  but  no 
drainage  will  be  needed,  and  leakage  is  greatly  to  be  deprecated. 
Sterilised  pads  having  been  placed  on  the  wound,  a  sufficient  thickness 
of  salicylic  wool  is  then  applied,  and  bandaged  with  firm  and  even 
pressure.  For  the  first  few  days  the  head  should  be  kept  low  and  the 
spine  raised  so  as  to  prevent  the  tendenc}'  to  leakage  of  cerebro-spinal 
fluid,  and  to  take  the  tension  off'  the  sutures.  Prof.  A.  Henle 
(v.  Bergmann's  Syst.  of  Pract.  Surg.  (Amer.  Trans.),  vol.  ii.  p.  662) 
advises  strapping  the  child  to  a  plaster  of  Paris  cast  of  the  anterior 
surface  of  the  body,  reaching  from  the  neck  to  the  feet.  The  hips  and 
knees  are  partially  flexed  and  the  legs  somewhat  separated.  Soiling 
of  the  dressings  is  thus  prevented.  The  patient  is  raised  for  the 
purpose  of  feeding.  A  shield  of  silver,  vulcanite,  or  thin  sheet-lead 
should  be  worn  later  until  the  parts  have  thoroughly  consolidated. 

Causes  of  Failure  after  the  Radical  Cure  of  Spina  Bifida. — 
1.  Leakage  and  infective  meningitis.  2.  Convulsions  and  rapid  death. 
Mr.  Clutton,  who  brought  a  successful  case  of  Dr.  Morton's  treatment 

*  Dr.  R.  T.  Hayes,  of  Rochester  (N.  Y.)  introduced  twenty  grafts  of  periosteum  from 
a  freshly  killed  rabbit.  Three  months  later  the  case  was  reported  to  be  satisfactory,  with 
a  firm,  hard,  resistant  covering.  {Mid.  Record,  June  16,  1883.)  Messrs.  Watson  Cheyne, 
C.B.  and  Burghard  (Man.  of  Surg.  Treat.,  Part  iv.  p.  301)  advise  the  use  of  the  scapula  or 
skull  bones  of  rabbits.  "  The  scapula,  divested  of  its  muscles,  forms  a  very  satisfactory 
plate,  and  has  succeeded  in  more  than  one  instance." 

S. — VOL.  II.  69 


iu(,o  OPERATIONS   ON    THE    VERTEBRAL   COLUMN. 

before  the  Clinical  Society  {Trans.,  vol.  xvi.  p.  34),  mentioned  another 
in  which  this  treatment  was  immediately  followed  by  fatal  convulsions. 
The  same  proved  fatal  in  about  ten  hours  in  a  case  under  my  care.  Sir 
W.  Bennett,  during  the  same  discussion,  mentioned  a  case  in  which, 
owing  to  the  child  being  indisposed  at  the  time,  he  declined  to  operate. 
On  its  way  home  the  child  died  of  convulsions,  lie  remarked  that  if 
he  had  used  the  injection,  this  would  have  been  credited  with  the 
convulsions.  3.  Paraplegia.  This  setting  in  after  injection  may  be 
temporary  or  permanent.  4.  Hydrocephalus.  This  also  may  make 
its  appearance  after  the  injection  with  iodo-glycerine  or  excision,  as 
happened  in  a  case  of  my  own  three  weeks  after  the  latter  operation. 
The  nerves  here  were  few  and  small  and  easily  detached  with  the 
adjacent  sac  into  the  canal.  5.  After  tapping  or  injection  the  swelling 
may  progress  unaltered. 

LAMINECTOMY,  OR  PARTIAL  RESECTION  OF  THE 
VERTEBRA.* 

This  rare  operation  may  be  referred  to  here  under  the  following 
indications:  A.  Cases  of  injury,  i.e.,  Fracture*  and  Dislocation.  B. 
Penetrating  wound  of  the  canal.  C.  Gunshot  Injuries.  D.  Cases  of 
inflammatory  disease — e.g.,  Pott's  curvature.     E.  Cases  of  new  growth. 

A.  Cases  of  Injury. — Here  the  operation  has  been  suggested  by  the 
analogous  one  performed  on  the  skull,  and  the  large  amount  of  success 
which  has  followed  it.  But  the  analogy  is,  for  several  reasons,  a  decep- 
tive one.  Thus,  owing  to  the  small  size  of  the  cord,  an  injury  which 
would  only  damage  the  brain  slightly,  almost  inevitably  destroys  the 
structure  of  the  cord  throughout  its  thickness.  Again,  it  must  be 
remembered  that  a  fragment  of  bone  often  inflicts  injury  upon  the  cord 
instantaneously,  and  that,  in  a  moment,  irremediable  damage  may  be 
done,  though  all  deformity  may  be  absent.  Further,  the  cord  may  be 
most  severely  damaged,  though  its  theca  shows  no  sign  of  injury. 

Again,  when  the  surgeon  trephines  the  skull,  he  not  only  hopes 
that  the  damage  is  slight  and  of  a  removable  nature,  but  he  also 
believes  that  the  only  damage  to  the  bones  is  that  which  lies  (lose  to 
his  trephine  and  finger.  But  in  the  ease  of  the  spine  we  are  faced  by 
this  dilemma  :  If  the  fracture  has  been  from  direct  violence,  and  the 
spinous  processes  and  laminae  have  been  driven  in,  it  is  only  too  probable 
that  when  these  are  elevated  the  spinal  cord,  so  limited  in  size,  will  be 
found  too  much  damaged  to  profit  by  the  operation.  On  the  other 
hand,  if  the  fracture  has  been  caused  by  indirect  violence,  it  is  almost 
certain  that  the  bodies  of  one  or  more  vertebrae  will  have  been  crushed 
down,  and  a  portion  shot  back  into  the  canal. !  In  this  ease  the  frag- 
ment which  has  inflicted  the  injury,  and  which  is  keeping  up  the  mis- 
chief, will  be  in  front  of  the  cord  and  out  of  reach,  even  if  the  cord  were 
in    a    condition    to    be    much    benefited    by    its   removal.     A   surgeon 

*  Laminectomy,  like  appendicectomy,  is  objectionable  from  its  hybrid  derivation,  but 
••is,  like  the  above  term,  ii    is  explicit,  convenient,  and  already  in  general  use,  it  will  be 
used  here.     Partial  resection  of  the  vertebra:  is  the  only  term  which  is  correct  and  suffi- 
cient.    It  is,  however,  too  long  and  cumbrous  Eor  general  use  in  these  days  of  hurry. 
-  is  a  very  common  condition,  judging  from  museum  specimens. 


LAMINECTOMY.  ,,,()r 

trephining  the  Bpine  under  these  conditions  would  be   Like  one  who 

trephined  the  skull  in  order  to  remove  depressed  fragments  of  the 
vertex,  when  all  the  time  a  portion  of  the  base  of  the  skull  was  tying 
jammed  into  the  under  surface  of  the  brain. 

But  it  is  not  only  in  the  damage,  but  in  the  violence  of  the  fracture 

also  that  no  analogy  lies  between  the  two  cases.  Fracture  of  the  spine 
is  usually  due  to  indirect  violence,  as  when  the  neck  is  broken  by  a  fall 
on  the  head,  or  when  the  lower  dorsal  spine  is  fractured  by  a  fall  of  a 
sack  upon  the  shoulders.  Even  when  the  fracture  is  due  to  direct 
violence,  it  is  of  an  entirely  different  nature  to  that  for  which  the 
surgeon  hopes  to  trephine  successfully  in  the  skull,  and  one  far  more 
likely  to  produce  extensive  and  crushing  damage — e.g.,  the  fall  of  coal 
or  earth,  or  a  fall  from  a  height  upon  a  projecting  body. 

kinally,  permanent  compression  of  the  cord — compression  that  can  be 
removed,  as  can  fragments  of  the  skull — is  a  very  rare  event.*  Even 
where  permanent  compression  is  present  laminectomy  will  do  but 
little.  The  surgeon  may  find  it  possible  to  restore  the  lumen  of  the 
vertebral  canal,  but  the  cord  has  usually  been  crushed  as  well  as  com- 
pressed. Mischief,  usually  hopeless  mischief,  has  been  done,  for  it  has 
been  proved  by  experiments  and  otherwise  that  a  crushed  cord  is 
incapable  of  regeneration. 

It  remains  to  be  shown  that  trephining  the  spine  is  not  only  likely 
to  be  void  of  any  good  results,  but  that  it  also  involves  serious  risks  and 
entails  additional  dangers  of  its  own.  Thus,  the  conversion  of  a  simple 
into  a  compound  fracture,  the  formation  of  a  large,  deep,  and  more  or 
less  ragged  wound,  the  risk  of  subsequent  suppuration  with  free  access 
to  the  sheath  of  the  cord,  the  opening  up  of  cancellous  tissue  with 
its  various  channels  and  exposure  of  these  to  possible  suppuration 
— all  these  have,  I  admit,  been  lessened  by  the  use  of  modern  pre- 
cautions. But  the  risk,  though  diminished,  remains  ;  the  large  amount 
of  venous  oozing  tending  to  soak  qnickly  through  in  this  region  can 
only  be  met  by  frequent  dressing.  And  though  it  has  been  shown  that 
in  some  of  these  cases  the  wound  has  healed  quickly,  and  though  no 
improvement  has  followed,  the  spinal  column  has  not  been  fatally 
weakened  by  the  removal  of  the  laminae  and  spines,  yet  the  weakening 
for  a  time  must  be  considerable  ;  and  it  must  be  remembered  that  by 
the  removal  of  these  structures  the  mobility  of  the  fractured  parts  will 
be  much  inci-eased,  and  when  any  attempt  is  made  to  vary  the  position 
of  the  patient  in  bed,  there  will  be,  for  some  time,  a  risk  of  disturbing 
the  fragments  and,  thus,  of  inflicting  further  injury  on  the  cord. 

It  will  be  seen  from  the  above  that  my  own  opinion  is  averse  to  any 
surgical  interference  in  cases  of  fractured  spine,  owing  to  the  amount 
of  damage  to  the  cord  being  usually,  from  the  first,  irreparable.  To 
quote  other  writers :  Mr.  Thorburn  {Surgery  of  the  Spinal  Cord,  1889, 
p.  160;  Brit.  Med.  Journ.,  1894,  vol.  i.  p.  1348)  comes  to  the  same 
conclusion,  but  draws  an  important  distinction  between  the  cord  and 
its  nerves.  This  writer  thus  sums  up  the  question  of  operative  inter- 
ference in  fractures  and  dislocations  of  the  spinal  column  (loe.  supra 


*  J.  Hutchinson,  Land.  Hosp.  Bep.  ;  Thorburn,  loc.  infra  tit.  It  will  be  noticed  that 
permanent  compression  is  a  very  different  thing  from  irreparable  injury.  The  latter  is 
present,  only  too  frequently. 

69 — 2 


[092  OPERATIONS   ON    THE    VERTEBRAL   COLUMN. 

ait.) :  "  In  compound  fractures,  operate.  In  fractures  of  the  spinous 
processes  and  lamina;,  with  injury   to  the  cord,  we  also  operate.     In 

simple  fractures  and  dislocations  of  the  bodies  of  the  vertebra,  if  there 
is  a  reasonable  probability  that  the  injury  is  due  to  haemorrhage,* 
operation  is  advisable,  but  in  all  other  cases  of  this  nature  we  cannot 
hope  to  do  good  save  where  the  injury  is  below  the  level  of  the  first 
lumbar  vertebrae.  In  such  cases  laminectomy  is  an  eminently  valuable 
Burgical  procedure."  Mr.  Thorburn  advocates  surgical  interference 
here  on  the  following  grounds:  (l)  "  We  may  here  expect  a  regenera- 
tion of  the  nerve  roots,  the  physiological  evidence  being  strongly  in 
favour  of  such  regeneration,  and  not  against  it,  as  in  the  case  of  the 
cord.  (2)  The  absence  of  spontaneous  recovery  in  such  cases  in  itself 
indicates  the  presence  of  a  mechanical  obstacle,  such  as  permanent 
compression  by  bone,  blood-clot,  or  cicatrix,  otherwise  we  should  expect 
the  roots  of  the  cauda  equina  to  recover,  as  other  peripheral  nerves 
alter  severe  injuries."  For  my  own  part  I  should  only  be  inclined 
to  interfere  where  the  following  conditions  are  present:  A  history 
of  a  direct  injury ;  mobility  and  displacement,  laterally  or  down- 
wards, of  the  spinous  process;  great  local  tenderness;  the  usual 
symptoms  of  swelling,  &c.  ;  and  paraplegia  less  marked  than 
usual. 

Those,  on  the  other  hand,  who  advocate  surgical  interference  do 
so  on  the  following  ground  :  Dr.  J.  W.  White  (Ann.  of  Surg.,  July  1889) 
believes  that  fracture  of  the  laminae  and  spinous  processes,  and  there- 
fore relievable  pressure  on  the  spinal  cord,  will  not  be  found  so  rare 
as  has  been  usually  believed.  I  fear  that  the  weight  of  pathological 
evidence  is  all  the  other  way.  Dr.  Weeks  (Trans.  Amer.  Surg.  Assoc, 
1901,  p.  319)  considers  that  "  the  surgeon  should  perform  laminectomy 
in  every  case,  if  the  condition  of  the  patient  is  such  as  to  justify  any 
operation,  regarding  the  operation  in  the  first  instance  as  an 
exploratory  one.  The  hope  of  restoration  of  function  in  those  cases 
in  which  the  cord  is  not  irretrievably  injured  depends  on  the  prompti- 
tude with  which  the  cause  of  compression  is  removed  ;  and,  however 
small  the  number  of  cases  in  which  benefit  is  to  be  looked  for,  I 
hold  that  even  those  few  justify  one  in  immediate  operation.  Laminec- 
tomy is  not  a  difficult  operation,  since  the  soft  parts  are  always  found 
torn  and  quite  detached  from  the  bone,  and  the  introduction  of  cutting 
instruments  under  the  lamina  is  very  easy  from  the  displacement 
present." 

One  case  only  is  given,  a  very  interesting  one,  as  Ear  as  it  goes,  as  it  occurred  in  a 
patient  of  70,  and  the  laminectomy  exposed  a  fracture  of  the  lamina'  of  the  third 
and  fourth  cervical  vertebrae.  Very  few  details  arc  given  of  the  patient's  condition— the 
left  upper  and  lower  extremities  appeal'  to  have  been  chiefly  affected — or  of  the  operation. 
Two  and  a  half  months  later  there  was  sonic  improvement  in  the  motion  of  the  left  arm 
and  hand,  the  patient  could  walk  short  distances  by  being  supported  on  cither  side,  and 
the  action  of  the  bladder  had  become  normal. 


*  Mr.  Thorburn  thinks  thai  the  following  would  be  the  most  advisable  steps  in  these 

very  ran-  cases:  A  laminectomy  at  the  seat  of  injury,  and  an  endeavour  to  arrest  the 
haemorrhage  and  to  give  exil  to  the  blood  :  this  procedure  being  combined  in  the  first 
instance  with  paracentesis  of  the  meninges  in  the  lumbar  region  after  Quincke's  method 
(vide  iitfra),  and  this  failing,  a  secondary  laminectomy  at  the  lower  part  of  the  spine. 


LWIIXKCTOMY.  IO93 

Dr.  J.  C.  M uniit,  ibid.,  in  the  discussion  on  the  above  paper,  stated 
that  lie  had  had  21  cases  oi 'laminectomy,  but,  gave  no  further  informa- 
tion whatever.     Dr.  Mister  and  Dr.  Chase,  <>t'  Boston  {Ann.  of  Surg., 

11)04),  also  advocate  operative  interference.  Two  cases  are  given  sug- 
gesting  a  total  transverse  lesion  of  the  lower  cervical  cord.  <  hie  patient 
died  in  about  twelve  months  from  cystitis  and  pyelo-nephrit is.  The 
other  recovered  sufficiently  to  again  engage  in  business.  The  authors 
follow  Dr.  Walton  (Journ.  ofMent.  and  New.  Dm.,  vol.  xxix.,  1902) 
in  advocating  laminectomy  because  there  are  no  typical  infallible 
symptoms  from  which  it  can  be  asserted  that  the  cord  is  crushed 
beyond  a  certain  degree  of  repair.  While  evidence  of  degeneration 
may  persist  after  a  laminectomy,  the  improvement  which  followed  in 
the  second  case  suggests  that  an  "  increased  transmission  of  impulses 
takes  place  along  the  remaining  scattered  fibres ;  the  analogue  of 
which  is  found  in  the  increase  of  functions  occurring  in  the  kidney 
after  unilateral  nephrectomy,  showing  the  power  of  nature  to  accom- 
modate herself  to  adverse  conditions." 

I  remain  of  opinion  that  where  alarge  number  of  cases  of  laminectomy, 
carefully  reported,  are  placed  before  the  profession,  the  balance  of 
pathological  evidence  will  be  against  operation.  A  few  isolated  cases 
in  which  a  varying  degree  of  recovery  has  followed  may  show  that 
where  the  condition  of  the  patient  and  the  surroundings  are  favourable, 
interference  in  skilled  hands  with  the  object  of  exploration  is  justifi- 
able. Beyond  this  we  cannot  go.  Few  will  accept  the  statement  of 
Dr.  Weeks  that  in  these  cases  "laminectomy  is  not  a  difficult  opera- 
tion." Even  if  the  tearing  of  the  soft  parts  facilitates,  as  he  claims  is 
always  the  case,  the  preliminary  steps  of  the  operation,  such  injury 
facilitates  the  introduction  of  infection,  and,  a  little  later,  the  diffi- 
culties in  restoring  irregularities  of  the  vertebras — I  refer  especially 
to  their  bodies — ma}r  be  enormous.  If  operation  be  undertaken,  it  is 
clear  that  this  should  be  as  soon  as  the  patient  has  recovered  from  the 
primary  shock :  if  possible  within  the  second  twenty-four  hours. 
While  the  Rontgen-rays,  if  available,  should  always  be  employed, 
their  use  is,  often,  unsatisfactory. 

B.  Penetrating  Wounds  of  the  Spinal  Cord. — Mr.  Thorburn  (loc. 
supra  cit.)  shows  that  while  the  percentage  of  recovery  is  good  as  to 
life,  complete  recovery  of  function  is  uncommon,  owing  to  the  little 
power  of  recovery  of  function  after  a  destructive  lesion  of  the  spinal 
cord  in  man,  especially  in  adults.  He  would  also  regard  as  useless  the 
operation  of  suture  of  the  pia  mater  as  proposed  by  Chipault,  and 
points  out  that  it  may  be  harmful  not  only  by  necessitating  manipula- 
tion of  the  injured  cord,  but  also  by  confining  effused  blood  and  serum, 
and  thus  increasing  the  pressure  upon  those  parts  which  have  escaped 
section.  With  the  nerve  roots,  on  the  other  hand,  which  are  capable 
of  repair,  operation  and  suture  would  be  quite  justifiable. 

C.  Operative  Interference  in  Injuries  of  the  Column  and  Cord  from 
Gunshot  Injuries. — G.  H.  Makins,  C.B.,  our  most  recent  authority 
(Surgical  Experiences  in  South  Africa,  1899 — 1900,  p.  340),  is  very 
emphatic  here.  "  In  no  form  of  spinal  injury  is  this  less  often  indicated, 
or  less  likely  to  be  useful.  It  is  useless  in  the  cases  of  severe  concussion, 
contusion,  or  medullary  haemorrhage  which  form  such  a  very  large 
proportion    of  those    exhibiting    total  transverse  lesion,   and    equally 


ioQ4         «>n:i:  \Tin\>  n\   tiik  yi:kti;i;i;.\l  COLtJMN. 

unsuited  to  casee  oi  partial  Lesion  of  the  same  character.  Extra- 
medullary  haemorrhage  can  rarely  be  extensive  enough  to  produce  signs 
calling  for  the  mechanical  relief  of  pressure;  the  section  of  the  cord 
cannot  be  remedied.  In  one  case  with  signs  of  total  transverse  lesion, 
in  which  a  laminectomy  was  performed,  no  apparent  lesion  was 
discovered,  and  this  would  1'rcqnently  be  the  case,  since  the  damage  is 
parenchymatous." 

Only  three  indications  for  operation  exist.  "  (i)  Excessive  pain 
in  the  area  above  the  paralysed  Begment;  operation  is  here  of  doubtful 
practical  use,  except  in  so  far  as  it  relieves  the  immediate  suffering  of 
the  patient.  (2)  An  incomplete  or  recovering  lesion,  when  such  is 
mpanied  by  evidence  furnished  by  the  position  of  the  wounds, 
pain  and  signs  of  irritation,  of  pressure  from  without,  or  possibly 
palpable  displacement  of  parts  of  the  vertebrae,  that  the  spinal  cord  is 
encroached  upon  by  fragments  of  bone.  (3)  Retention  of  the  bullet, 
accompanied  by  similar  signs  to  those  detailed  under  (2). 

"  In  both  the  latter  cases  the  aid  of  the  X-rays  should  be  invoked 
sorting  to  exploration. 

'•  Operation,  if  decided  upon,  in  either  of  the  two  latter  circumstances, 
may  be  performed  at  any  date  up  to  six  weeks;  but  if  pressure  be  the 
actual  source  of  trouble,  it  is  obvious  that  the  more  promptly  the 
operation  is  undertaken  the  better." 

I ».  ( 'a8(  8  of  Inflammatory  Disease — e.g.  Pott's  Curvature.* — Interfer- 
ence here  will  be  but  very  rarely  called  for,  as  we  have  abundant  evidence 
that  paralysis,  even  when  of  long  duration,  has  a  marked  tendency 
to  recovery,  if  the  treatment  by  absolute  rest  in  the  recumbent  position 
is  vigorously  enforced. +  Where  a  sufficient  trial  of  this  has  really  failed, 
operative  interference  is  justifiable  if  there  be  no  evidence  of  tuber- 
culous disease  elsewhere  or  infected  sinuses.  Dr.  De  Forest  Willard 
("  Tubercular  Conditions  of  the  Spine  requiring  Surgical  and  Mechanical 

renee  should  be  made,  in  addition  to  the  writings  quoted  above,  to  the  follow- 
ing :  (ij  In  cases  of  injury.  Mace  wen,  Brit.  Med.  Journ.,  1888,  vol.  ii.  p.  308  ;  Keetley, 
ibid.,  p.  421  :  Duncan,  Edin.  Med.  Journ.,  1889,  p.  830  ;  E.  Hart,  a  case  of  M.  P< 
Brit.  Med.  .four,,..  1889,  vol.  i.  p.  672  ;  H.  W.  Allingham,  ibid.,  p.  838  ;  Chipault,  (in:,  de* 
H6p.  ;  Arch.  Gen.  de  Med.,  1890;  J.  r.,  1890,  1891,  and  1892  ;  these  papers  are 

now  in  (Jhipault's  work  on   the  Surgery  of  the  Nervous  System  ;    Schede  of 

Hamburg,  Ann.  of  Surg.,  1S92,  vol.  ii.  p.  230  ;  Wyeth,  ibid.,  August,  1S94  ;  Biddell,  Med. 
mid  Surg.  March  30,  1895  :  Lejare,  Gaz.  des.  //»/>..  June  2,  1SS4  ;  Arnison,  ihid., 

May,  1895.     (2)  In  cases  of  Pott's  curvatures,  liacewen  and  Duncan  (loc.  supra  tit.'); 
■.  July  14,  1888  :  W.  A.  Lane,  Brit,  Med.  Journ.,  April  20,  1889;  Lancet, 
July  5.  1S90  ;  .'.  York  Med.  Journ.,  Nov.  24,  1888  ;  Kraske,  Centr.f.  Chir.,  1890, 

3.   Lloyd,  of  New  Yeik,  Ann.  of  Surg.,  18^2.  vol.  ii.  p.  289;  Bullard  and 
Burrell,  Trans.  Med.  Orthop.  Assoc,  vol.  ii.  p.  241.     Several  of  the  above  cases  have  been 
rted  so  soon  after  the  operation  that  their  value  would  be  much  increased  i>y  the 
ami.  later  details.     (3)  Incasesof  new  growths.  Dr.  (Power's  and  Sir  V.  Hoi- 

papei  (loc.  supra  cit.~)  and  the  appended  table.  See  also  Dr.  J.  W.  White's  paper  (loc. 
supra  rit.').  and  hi~  table  of  the  most  obvious  diagnostic  points,  p.  32  :  Starr,  "  Tumour  of 
the  Spin;  Journ.  Med.  Soc.,  June,  1S95  ;  and  Patnam  and  Collins  Warren 

n.  of  M>  ii .  S  "i.  1S99). 

M   st  "t  the  suits  of  laminectomy  are  merely  examples  at  post 

hoc,  ergo  propter  he  _.     1  have  read  the  reports  of  many,  and  have  little  doubt 

rl  it.     J'li'  -  include  the  cases  in  which  laminectomy  has  led  to  the  liberation 

of  pus  and  the  exposure  and  erasiou  of  pre- vertebral  fo  ■;  "  <  K<  etley,  Orthop.  Stir*/.,  p.  4 76). 


LAMINECTOMY.  1095 

Relief "  (Ann.  of  Surg.,  <  October,  1905,  p.  5 14))  thus  sums  up  on  tbis  point : 
■•  Laminectomy  for  paraplegia  is  advisable  only  after  Long  continued  and 
patient  treatment  from  oneto  two  years,  since  the  prognosis,  especially 
in  children,  is  favourable  ami  good  powers  <>i'  locomotion  may  be 
confidently  expected.  Tin'  operation  is  justifiable  in  selected  cases  where 
loss  of  motion  and  sensation  are  progressively  worse  and  the  Bymptoms 
threaten  lite"  The  anatomical  difficulties  and  risks  of  laminectomy 
are  well  given  in  this  candid  and  practical  paper. 

Mr.  Thorburn  (loc.  supra  fit.)  gives  the  following  indications  and 
contra-indications  for  operation.  Indications:  (i)  "Assuming  the 
prognosis  t<>  be  thus  favourable,  we  are  never  called  upon  to  perform 
Laminectomy  save  under  certain  special  conditions.  It  will  not  be 
argued  that  the  recovery  alter  laminectomy  is  more  complete  than  that 
produced  by  Nature,  and  experience  shows  that  relapses  also  are  only 
too  common  after  operation.  The  indications  which  appear  to  me  to 
point  to  the  necessity  for  operations  are  then  as  follows  :  A  steady 
increase  in  symptoms  in  spite  of  favourable  conditions  and  treatment. 
The  presence  of  symptoms  which  directly  threaten  life.  Thus,  in  my 
second  case,  the  secondary  chest  troubles  were  very  grave.*  Intract- 
able cystitis  would  fall  into  this  category,  but  it  is  by  no  means 
common,  and  we  can  hardly  agree  with  those  who  hold  that  the  condition 
is  in  itself  incapable  of  spontaneous  recovery. 

"  The  persistence  of  symptoms,  in  spite  of  complete  rest,!  is  the 
indication  which  has  been  most  commonly  adopted,  but,  as  we  have 
already  seen,  such  symptoms  may  persist  for  very  long  periods  and 
then  yield  to  absolute  rest.  It  is,  however,  not  improbable  that,  in  a 
few  cases,  cicatricial  pachymeningitis,  or  rather  peripachymeningitis, 
may  remain  after  the  original  pressure-lesion  has  ceased  to  act,  and 
may  thus  keep  up  paraplegia  until  the  constricting  tissue  is  removed. 

"  4.  In  posterior  caries  (that  is,  in  caries  of  the  arches  of  the  verte- 
bras) operation  is  clearly  indicated,  as  here  we  can  readily  both  treat 
the  paraplegia  and  remove  the  whole  of  the  tuberculous  tissue.  Two 
cases  of  this  nature  are  recorded  by  Abbe  and  by  Chipault  respectively, 
and  both  proved  highly  successful. 

"  5.  In  my  fifth  case,' the  existence  of  severe  pain,  which  was  rapidly 
exhausting  the  patient,  was  regarded  as  an  indication  for  surgical 
interference. 


*  Dr.  Parkin,  of  Hull,  in  a  valuable  paper  (Brit.  Med.  Jouni.,  1894,  VOi-  "■  P-  700)> 
illustrated  by  cases  of  laminectomy  for  spinal  caries,  mentions  a  case  aged  9,  admitted  for 
cervical  caries,  cyanosis  and  bronchitis.  As  the  condition  became  more  critical,  the  sixth 
cervical  spine  was  removed.  The  cord  was  found  compressed  and  bent  by  a  mass  of  bone 
and  fibrous  tissue,  the  remains  of  the  fourth  and  fifth  vertebra?.  When  the  cord  was 
freed,  pulsation  returned.  Very  great  benefit  followed  on  the  operation,  but  the  child 
died  nearly  three  months  after  of  tubercular  meningitis,  thought  to  be  due  to  a  caseating 
gland  found  at  the  necropsy.  Xo  evidence  of  caseation  or  recent  caries  was  found  in  the 
vertebra;. 

f  Readers  with  careful  and  well-balanced  minds  will  not  fail  to  note  on  reading  the 
accounts  of  many  of  these-  cases,  published  as  successful  cases  of  laminectomy  for  spinal 
caries,  that  many  of  them  before  being  submitted  to  operation,  had  only  been  treated  by 
re>r  for  a  few  days  or  weeks,  "  the  mother  having  full  directions  to  keep  the  child  in  the 
same  horizontal  posture.''  In  other  cases,  after  a  brief  period  of  in-patient  treatment,  the 
children  have  been  sent  out  in  Sayre's  jackets  to  attend  as  out-patients. 


1096  OPERATIONS   ON   THE    VERTEBRAL   COLUMN. 

"  6.  Lastly,  children  as  a  rule  yield  better  results  than  do  adults,  so 
that,  other  things  being  equal,  childhood  may  also  be  regarded  as  an 
indication  for  operation. 

"  Contra-indications. — The  presence  of  active  tuberculous  changes 
in  other  organs.  Macewen  holds  that  we  should  not  operate  when 
there  is  pyrexia,  which  is  almost  tantamount  to  saying  that  we  should 
not  operate  in  presence  of  active  tuberculosis.  If,  however,  the  pyrexia 
were  clearly  due  to  cystitis,  then  Ave  might  regard  it  as  an  indication 
for,  rather  than  against,  interference.  Again,  general  meningitis 
(although  fortunately  very  rare)  will  at  times  obviously  be  present  and 
will  probably  prove  fatal  whether  we  operate  or  not." 

E.  Cases  of  New  Growth. — It  is  in  the  intra-dural  variety  of  these, 
when  the  level  of  the  growth  can  be  correctly  estimated,  that  laminec- 
tomy is  most  decisively  indicated.  Sir  V.  Horsley  has  here,  as  in  so 
many  other  instances  connected  with  the  surgery  of  the  central 
nervous  system,  operated  with  brilliant  success  (Med.-Chir.  Soc, 
vol.  lxxi.  p.  383). 

The  patient  was  one  of  Dr.  Gowers',  aged  42,  and  his  chief  symptoms  were  complete 
paralysis  of  the  lower  limbs  and  abdomen,  the  former  being  frequently  flexed  in  clonic 
spasms,  the  pain  accompanying  these  being  extremely  severe.  There  was  loss  of  tactile 
sensibility  as  high  as,  and  involving  the  distribution  of,  the  fifth  dorsal  nerve.  The 
bladder  and  rectum  were  completely  paralysed.  The  growth  proved  to  be  an  almond- 
shaped  fibro-myxoma  resting  on  the  left  lateral  column,  in  which  it  had  formed  a  deep 
bed,  and  adherent  to  the  fourth  dorsal  nerve.  The  patient  recovered  perfectly,  the  report 
being  continued  up  to  a  year  after  the  operation. 

A  great  deal  of  useful  information  may  be  obtained  from  a  paper  on 
this  subject  by  Messrs.  Putnam  and  Warren  (Amer.  Journ.  of  Med.  Sci., 
October,  1899).  The  authors  give  a  resume  of  33  cases  of  spinal 
tumour  treated  by  operation.  Of  these  operations  "  seven  led  to 
recovery  and  10  to  more  or  less  improvement,  although  only  in  five 
of  these  latter,  amongst  which  our  first  case  was  included,  was  the 
improvement  considerable  or  lasting." 

On  the  other  hand,  15  of  the  operations  were  fatal,  so  that  the 
mortality  was  nearly  50  per  cent.,  a  fact  not  to  be  lost  sight  of  when 
this  operation  is  contemplated. 

Dr.  J.  Collins  (Med.  llec,  Dec.  6,  1902)  gives  abstracts  of  70 
cases  of  growths  of  the  spinal  cord  collected  from  the  literature  of  the 
preceding  six  years.  Thirty  of  these  were  operated  upon.  The 
results  were  as  follows:  12  were  successful,  8  partially  so,  and  10 
wholly  unsuccessful.  The  operation  was  considered  successful  when 
followed  by  cessation  of  pain  and  recovery  of  motor  power  ;  partially 
successful  when  pain  was  relieved,  motor  power  slightly  restored, 
and  the  case  ceased  to  progress;  unsuccessful  when  followed  by 
death.  A  report  of  32  cases  of  growths  of  the  spinal  cord,  which 
were  operated  upon,  to  which  one  is  added,  by  F.  Krause,  is  given 
in  v.  Bergmann's  Syst.  of  Pract.  Surg.  (Amer.  Trans.),  vol.  ii. 
p.  646.  In  31  the  growth  was  found ;  18  or  54*5  per  cent, 
recovered,  or  improved  sufficiently  to  walk;  15  or  45*5  per  cent. 
died.  In  one  case  the  growth  was  not  found  because  it  was  looked 
for  too  low  down,  in  another  case  it  was  not  recognised.  One  of 
the  best  recent  papers  is  that  by  Dr.  H.  Gushing  {Ann.  of  Surg., 
•I  une  1904),  on  a  case  of  "  intra-dural  growth  of  the  cervical  meninges." 


LAMINECTOMY.  1097 

The  history  before  and  after  the  operation  is  most  folly  detailed. 
Summaries    of    10    other   cases    of  intra-dural    growth    successfully 

operated  upon  are  also  given.  Dr.  Ilarte,  of  Philadelphia,  gives 
(Ann.  of  Surg,,  October,  1905,  p.  514)  a  full  list  of  cases  in  which 
laminectomy  was  performed  for  intraspinal  "tumours."  These  are 
briefly  but  instructively  analysed  as  to  the  nature  of  the  condition 
found  and  the  mortality.  This  he  finds  to  be  nearly  47  per  cent. 
He  holds  that  it  should  be  capable  of  reduction  to  30  per  cent., 
but  in  neither  of  these  estimates  is  allowance  made  for  cases  which 
have  not  been  published. 

Operation  of  Laminectomy. — The  thick  skin  of  this  region  must  be 
sterilised  as  carefully  as  possible,  especially  in  the  cases  of  injury  in 
which  operation  is  undertaken  at  comparatively  short  notice.  To  meet 
this  difficulty  a  step  taken  at  the  Breslau  Hospital  (v.  Bergmann, 
loc.  supra  cit.)  may  be  useful.  After  the  incision  in  the  skin  is  made 
the  adjacent  area  is  covered  with  boiled  oil-silk,  containing  a  slit  the 
length  of  the  wound,  the  margins  of  the  oil-silk  being  stitched  to  the 
subcutaneous  edges  of  the  wound,  and  covered  with  towels  changed 
from  time  to  time.  When  this  guard  is  securely  in  situ,  the  gloves 
and  instruments  are  resterilised.  Every  precaution  must  be  taken 
against  shock  before,  during,  and  after  the  operation.  As  the  patient 
must  be  placed,  as  far  as  is  safe,  in  the  prone  position,  pressure  must 
be  taken  off  the  chest  by  the  use  of  small  pillows,  and  the  operator 
must  be  prepared  for  the  need  of  rolling  over  the  patient  from  time 
to  time,  especially  in  those  cases  where  the  abdominal  muscles  are 
paralysed.  A  longitudinal*  incision  is  made  down  to  the  spinous 
processes,  with  its  centre  opposite  to  the  site  of  the  supposed 
displacement  or  disease.  The  deep  fascia  having  been  divided 
a  little  to  either  side  of  the  spines  and  also  transversely  at  the 
upper  and  lower  angles  of  the  wound,  the  tendinous  attachments 
of  the  muscles  are  cut  from  the  spine,  and  the  muscles  completely 
detached  from  these  processes,  the  laminae,  and  from  the  transverse 
processes  as  far  as  is  necessary,  by  the  edge  of  a  short,  stout 
scalpel  or  a  chisel,  the  spinous  processes  being  used  as  a  fulcrum.  The 
use  of  a  blunt  instrument  is  more  likely  to  lead  to  some  sloughing, 
especially  where  the  structures  separated  are  largely  tendinous.  To 
prevent  haemorrhage,  Spencer  Wells's  forceps  are  quickly  applied  to  the 
chief  points,  and  sterilised  pads  out  of  sterile  saline  solution  at  a  tempera- 
ture of  no0  are  tightly  packed  by  retractors  into  the  incision  on  one 
side  of  the  spine,  while  the  operation  is  proceeded  with  on  the  other. 
This  will  best  meet  the  chief  bleeding,  which  is  very  free  for  a 
time.  Sterilised  adrenalin  (1 — 1000)  should  be  at  hand.  Efficient 
compression  will  usually  suffice.  Any  vessels  that  require  it  being 
tied,  and  the  muscles  held  back  with  retractors,  any  remaining 
muscular  tissue  is  scraped  away  and  the  periosteum  reflected  with  a 
suitably  curved  elevator.  In  cases  of  tuberculous  disease,  where  access 
is  desired  to  the  bodies  of  the  vertebrae  rather  than  to  their  posterior 
processes  and  the  spinal  canal,  the  operator  may  desire  to  make  his 

*  A  flap,  with  its  base  ia  the  middle  line  or  to  one  side,  is  recommended  by  some,  but, 
not  admitting  of  ready  enlargement,  can  only  be  suitable  to  those  cases  where  the  nature 
and  site  of  the  lesion  are  exactly  known. 


1098    OPERATIONS  ON  THE  VERTEBRAL  COLUMN. 

att.uk   postero-laterally  through  the  transverse  pr<  and  pedicles 

rather  than  through  the  spines  and  laminae.  In  these  cas<  5  especially 
it  will  be  well  for  the  operator  to  refresh  his  memory  by  having  the 
corresponding  part  of  the  column  in  a  dry  state,  kept  at  hand  by  an 
assistant  (Keetley).  In  the  one  case  the  spinal  canal  is  skirted,  in 
the  other  it  is  entered.  But  to  obtain  free  access,  it  is  often  advisable 
to  combine  the  two  routes  in  tuberculous  cases.  Twoorthree  spinous 
processes,  if  unfractured,  are  then  cut  off  close  to  their  bases  with 
powerful  bone-forceps  with  jaws  at  different  angles.  The  laminae  may 
be  next  removed  by  spinal  saws,  aided  by  a  trephine,  or  the  opening 
made  by  this  instrument  may  he  enlarged,  as  in  the  skull,  by  bone- 
forceps.  Sir  V.  Horsley  has  devised  hone-forceps  well  adapted  to 
working  at  the  hottom  of  a  deep,  steep  wound-cavity.*  Dr.  \Y.  S. 
Bickham,  in  a  very  instructive  article  on  the  technique  of  operations 
on  the  vertebral  column  (Ann.  of  Surg.,  March  1905),  recommends 
strongly  Doyen's  saw  for  removal  of  the  lamina?  and  spinous  processes. 
This  is  a  strong  Hey's  saw  with  an  adjustable  guard,  and  is  illustrated 
in  Vol.  I.  p.  377.  The  guard  of  the  saw  is  set  at  10  mm.,  which  will 
give  a  sufficient  cutting  edge  to  pass  completely  through  the  laminae 
at  any  portion  of  the  spine,  provided  the  section  he  made  well  within 
the  laminae  proper,  and  at  a  right  angle  to  their  surface.  It  is  usually 
impossible  to  complete  the  section  of  one  side  with  the  saw  in  one 
position,  as  the  proximal  end  of  the  saw  will  not  travel  the  full  length 
of  the  wound  satisfactorily.  The  surgeon  must  divide  the  upper  part 
of  the  lamina;  on  both  sides,  sawing  from  below  upwards,  and  then 
walk  round  the  table  and  complete  the  sections  by  sawing  in  the 
reverse  direction.  The  usual  flat  probe  tests  the  depth  of  the  section. 
Partial  division  of  the  lamina'  above  and  below  those  to  be  removed 
is  unavoidable,  and  harmless  (Bickham).  A  chisel  and  mallet  may  be 
used  along  an  already  made  saw-line,  to  complete  the  section ;  but 
even  here  the  vibrations  may  be  hurtful.  Further,  unless  a  groove  is 
first  made  with  a  saw,  the  line  of  the  chisel  is  liable  to  be  irregular. 
A\  hen  the  lumen  of  the  canal  is  narrowed,  this  instrument  becomes  a 
dangerous  one.  Where  the  arches  and  the  dura  may  be  adherent,  the 
bone  must  be  removed  with  great  caution;  "picked  away  piecemeal," 
Tubby  (Orthop.  Surg.,  p.  74).  In  the  case  of  fracture,  any  loose  bone 
will  of  course  be  tested  and  removed  by  sequestrum-forceps,  The 
supra-  and  intra-  spinous  ligaments  and  the  ligaments  subflava  are  next 
divided  with  blunt-pointed  scissors  at  the  two  ends  of  the  wound  and 
the  isolated  segment  of  bone  and  ligaments  is  then  partly  prised,  partly 
dragged  out.  In  cases  of  fracture-dislocation,  attempts  may  be  made 
by  manipulation  of  the  parts  now  exposed  by  the  wound,  combined 
with  extension  and  rotation,  to  rectify  the  position.  The  dura  mater, 
covered  with  peculiar  vascular  fat,  is  next  exposed.  At  this  stage,  if 
the  opening  be  too  narrow,  it  must  be  enlarged  with  rongeur-forceps 

_  '>n  should  take  the  trouble  to  be  provided  with  the  necessary  instruments. 

The  ordinary  saws  and  forceps  are  quite  unfitted  tor  removing  the  laminae,  and,  in  the 
of  the  cervical  spine,  may,  by  prolonging  the  operation  and  pressing  on  the  cord 
-  about  a  fatal   result,   ae  occurred  in  one  case   which  came   to   my  knowledge. 

Haemorrhage  from  the  bones  should  be  arrested  by  packing  applied  as  above,  or  (II 

loe.  supra  cit.")  by  Horsley's  wax. 


LAMINECTOMY.  1099 

ami  gouge,  [f  the  operation  is  to  be  completed  in  one  Bitting  (p.  1 101), 
the  next  step  is  usually  to  expose  the  cord  and  membranes.  The 
latter  are  generally  found  covered  by  a  varying  amount  of  fatty  tissue  con- 
taining veins.  This  layer  should  he  quickly  divided,  exactly  in  the  middle 
line  with  sharp  scissors,  and  the  two  halves  packed  to  one  side  with 
pledgets  of  sterilised  gauze  to  meet  haemorrhage.  Irrigation  with  hot, 
sterile  saline  solution  may  also  he  tried.  The  dura  mater  is  then 
examined.  If  no  pulsation  be  present,  compression  or  increased 
tension  suggest  themselves.  Where  it  is  needful  to  open  the  membranes 
in  the  case  of  a  growth,  or  the  presence  of  blood,  or  to  inspect  a 
damaged  cord,  this  step  is  best  effected  by  picking  up  the  dura  mater 
with  two  pairs  of  forceps  (one  of  these  is  held  by  an  assistant),  and 
then  dividing  the  dura-arachnoid  between  these  with  scissors. 
Opening  the  suh-dural  and  still  more  the  sub-arachnoid  space 
will  of  course  increase  the  risk  of  infection  from  the  escape  of 
fluid,  and  is  therefore  not  a  step  to  be  undertaken  lightly.  Thus 
the  dura  should  only  be  opened  when  fluid  such  as  blood  is 
present  within,  when  the  condition  of  the  cord  requires  investigation, 
when  sufficient  mischief  is  not  found  outside,  or  when  an  intra- dural 
growth  exists.  This  step  is  especially  to  be  avoided  in  tuberculous 
cases,  from  the  risk  of  meningitis  (Chipault).  Cerebro-spinal  fluid  is 
carefully  mopped  away,  and  if  the  spine  is  horizontal  and  the  head 
is  lowered,  the  flow  usually  soon  ceases.  If  needful,  the  flow  must 
be  arrested  by  a  small  pledget  of  gauze.  Where  the  anterior  sur- 
face of  the  cord  or  the  posterior  aspect  of  the  body  of  the  vertelme 
needs  investigation,  it  is  possible  by  means  of  an  aneurysm -needle 
to  partially  displace  the  cord.  If  during  this  step  it  is  really  need- 
ful to  divide  one  or  two  nerve-roots,  these  should  be  subsequently 
united  b}r  suture.* 

In  a  few  cases  the  cord  itself  has  been  sutured  like  a  divided  nerve, 
the  stitches  taking  up  the  membranes  and  the  cord  itself.  Such  cases 
are  recorded  by  Dr.  Harte  and  Dr.  Stewart,  and  Dr.  Estes  (Trans. 
Amer,  Surg.  Assoc,  1902,  pp.  28,  44),  and  by  Dr.  Fowler  (Ann.  of 
Surg:,  October,  1905,  p.  507).  In  this  case  the  careful  report  is 
continued  up  to  two  years  after  the  injury.  The  results  are  encouraging, 
especially  in  two  of  the  cases. 

In  cases  of  caries,  dense  scar  tissue,  granulation  tissue,  pus,  or  a 
tuberculous  mass  may  present  themselves  when  the  dura  mater  is 
exposed.  In  some  it  will  be  sufficient  to  take  away  the  diseased 
material,  till  pulsation  of  the  cord  reappears  ;  in  others  the  tougher 
leathery  substance  must  be  snipped  away  with  scissors  till  the  cord  is 
exposed  with  a  surface  made  as  smooth  as  possible,  and  it  is  clear 
that,  if  not  pulsating,  it  is  not  constricted.  Any  carious  bone  that  is 
within  reach  will  of  course  be  removed  by  the  sharp  spoon.  If,  as  is 
not  unlikely,  the  mischief — e.g.,  tuberculous  caries,  abscess  and 
granulation  tissue — lie  in  front,  this  must  be  got  at,  if  possible,  by 
drawing  the  cord  from  side  to  side  with  an  aneurysm-needle,  and  cautious 
removal  of  part  of  the  transverse  processes  and  adjacent  bones  (p.  1098). 

*  Dr.  Fowler  stated  (/or.  infra  cif.)  that  :  "  Spiller  and  Frazier  found  that  after  division 
of  a  posterior  root  in  the  dog,  followed  by  immediate  suture,  regeneration  occurs,  and  that 
regeneration  into  the  cord  does  not  occur."" 


iioo         OPERATIONS  ON  THE   VERTEBRAL  COLUMN. 

When  all  diseased  bone,  granulation  tissue,  &c,  lias  been  removed 
with  the  sharp  spoon,  a  small  Hushing  gouge,  or  gauze  mops,  iodoform 
emulsion  may  be  applied,  and  the  greater  part  of  the  wound  closed ; 
drainage,  preferably  by  means  of  gauze,  should,  however,  be  provided 
for  twenty-four  or  forty-eight  hours,  as  oozing  may  be  considerable. 

In  the  case  of  growths  the  intra-dural  ones  hitherto  operated  upon 
have  been  usually  met  with  on  the  postero-lateral  aspect  of  the  cord. 
A  capsule,  more  or  less  complete,  is  generally  present.  It  is  to  be 
noted  that  even  when  the  correct  level  has  been  exposed,  growths  of 
the  cord  are  sometimes  difficult  of  recognition.*  Such  a  case  has  been 
alluded  to  at  p.  1096.  This  fact  is  well  illustrated  by  the  case  which 
forms  the  basis  of  Dr.  H.  Gushing' s  paper  {he.  supra  cit.).  "Fluid 
escaped  in  considerable  amount  from  the  sub-dural  space.  The  dura 
was  then  incised  the  full  length  allowed  by  the  exposure,  and  on 
holding  apart  the  edges  of  the  membrane  the  thin  transparent 
arachnoid  bulged  into  the  opening  like  a  distended  bubble.!  This  was 
pricked,  and  the  fluid  spurted  from  the  opening  in  jets  corresponding 
with  the  cardiac  and  respiratory  rhythm.  Not  until  the  contents  of  the 
sub-arachnoid  space  were  thus  evacuated,  and  the  transparent  membrane 
had  settled  closely  over  the  cord,  was  it  apparent  that  there  was  some 
underlying  abnormality.  The  arachnoid  was  then  incised,  and  lying 
on  the  left  side  of  the  cord  was  seen  an  oval  growth  of  dusky  purplish 
colour."  This,  removed  by  "  gentle  manipulations"  and  "shelling 
out,"  proved  to  be  a  fibro-sarcoma.  The  patient  made  an  excellent 
recovery,  and,  three  months  later,  was  able  to  return  to  his  work.  In 
this  case  to  facilitate  removal  of  the  growth  one  posterior  nerve- 
root  was  divided.^  Where  such  a  root  is  infiltrated  it  must  be 
sacrificed. 

Treatment  of  the  "Wound. — To  wash  away  clots  and  check  oozing, 
flushing  with  hot  sterilised  saline  solution  may  be  employed,  or  a 
solution  of  adrenalin  made  use  of.  From  the  extent  and  depth  of  the 
wound  and  the  condition  of  the  muscles,  drainage  by  at  least  a  strip  of 
sterilised  gauze  is  indicated.  When  the  theca  has  been  opened,  the 
lowest  portion  of  the  incision  should  be  left  open,  the  rest  being 
closed  by  a  continuous  suture  of  fine  silk.  The  muscles  are  brought 
together  with  buried  sutures  of  silk  or  catgut.  In  a  tew  cases  the 
haemorrhage  has  been  so  severe  as  to  necessitate  parking  the  wound. 
Where  there  is  much  oozing  the  first  dressings  will  require  changing  at 
the  end  of  twelve  hours,  and  subsequently,  perhaps,  once  in  two  days. 
The  skin  should  on  these  occasions  be  carefully  resterilised.     Efficient 

*  If  no  growth  can  be  found  in  the  region  exposed,  the  Burgeon  should  not  hesitate  to 
remove  the  spines  of  three,  four  or  five  of  the  vertebra'  higher  up.  The  chances  of  an 
error  in  diagnosis  are  much  less  than  those  of  failing  to  find  the  tumour  through  timidity 
in  exploration.     Of  course  the  extent  of  the  operation  must   l»  I   largely  by  the 

condition  of  the  patient  ;  and.  in  ease  of  collapse,  the  operation  should  be  concluded  after 
a  day  or  two,  if  possible,  when  reaction  has  occurred  (llarte.  Ann.  of  Surg.,  October,  1905). 

f  Dr.  H.  Cashing  observes  that  it  has  several  times  been  noticed  in  these  cases  that 
the  meninges  below  the  growth  are  greatly  distended  with  fluid  (chiefly  sub-arachnoid) 
under  an  increased  tension,  the  growth,  as  it  were,  acting  as  a  cork  to  thf  spinal  llask  in 
which  the  fluid  continuously  accumulates. 

X  This  was  believed  to  be  the  seventh  cervical.  The  loss  of  sensation  which  followed 
is  described  with  the  full  detail  which  abound>  in  this  excellent  paper. 


TAPPING    THE   SPINAL   THECA.  iioi 

support  should  be  supplied  by  sand-bags.  A  plaster  of  Paris  jacket 
should  be  applied  as  soon  as  possible.  The  application  of  this  at  the 
first  considerably  prolongs  the  time  of  the  patient  being  on  the  table, 
and  where  much  oozing  takes  place,  may  interfere  with  this  being 
efficiently  dealt  with.  The  necessity  remains  of  after-attention  to 
such  conditions  as  cystitis,  or  the  most  successful  operation  will  be 
brought  to  nought. 

Causes  of  Failure  and  Death  after  Laminectomy. — Many  of  these 
will  have  been  made  clear  by  the  above  given  details  :  (i)  Shock. 
Here,  as  in  the  case  of  the  brain,  the  question  of  completing  the  operation 
in  a  second  stage  will  sometimes  arise.  As  I  have  already  stated 
(p.  1098),  the  failure  of  the  surgeon  to  supply  himself  with  proper  instru- 
ments may  lead  to  needless  prolongation  of  the  operation  and  pressure 
on  the  theca,  which,  especially  in  operations  on  the  cervical  region, 
may  help  to  bring  about  a  fatal  result.  (2)  Haemorrhage.  This  has 
been  fully  alluded  to  ;  the  extra-dural  plexus  appears  to  be  usually 
obliterated  in  cases  of  Pott's  curvature.  According  to  Chipault 
haemorrhage  is  much  most  serious  in  the  neck,  since  death  has 
resulted  three  times  from  a  lesion  of  the  vertebral  artery.  (3)  Respi- 
ratory trouble,  partly  due  to  the  prolonged  anaesthetic.  In  one 
case  (Deaver,  Inter.  Journ.  Med.  Sci.,  December,  1888)  the  respiration 
became  much  embarrassed  towards  the  end  of  the  operation ;  this, 
continuing  till  the  patient's  death  three  days  later,  was  attributed  to 
injury  to  the  phrenic  nerve  with  an  exploring  needle.  The  dura  mater, 
thickened  and  adherent  to  the  bones,  had  been  thus  explored  after 
removal  of  the  third  and  fourth  cervical  arches  which  wrere  carious. 
(4)  Infective  complications.  (5)  Tuberculous  or  other  secondary 
deposits  elsewhere.  (6)  Temporary  improvement  followed  by  a 
relapse. 

TAPPING    THE    SPINAL    THECA. 

The  following  are  the  chief  indications  for  its  employment, 
i.  Pressure  of  the  cerebro-spinal  fluid  on  the  nerve  centres  in  hydro- 
cephalus (Quincke),  growths,  and  effused  blood.  In  the  case  of  growths 
of  the  brain  temporary  relief  of  headache  has  followed,  but  death  has 
taken  place  suddenly  in  several  cases,  owing  to  the  withdrawal  of  the  fluid 
having  allowed  the  growth  to  make  pressure  upon  the  medulla.  In  tuber- 
culous meningitis  it  has  been  used  as  a  means  of  diagnosis  (Quincke). 
It  has  also  lessened  the  headache  ;  in  the  epidemic  cerebro-spinal  form 
puncture  has  occasionally  withdrawn  pus.  ii.  As  a  means  of  diagnosis 
in  different  forms  of  meningitis,  serous,  purulent  and  tuberculous* 
(Quincke),  iii.  In  the  treatment  of  tetanus.  In  my  own  mind  this, 
together  with  intra-neural  injections,  is  the  most  scientific  and  pro- 
mising method  of  dealing  with  this  terrible  disease.  American  surgeons 
from   their   enormous  experiencet  have   shown  the  way  here.      The 

*  Fiirbringer  found  tubercle  bacilli  in  27  out  of  37  cases  of  tubercular  meningitis,  one 
of  which  is  stated  to  have  ended  in  recovery  (Berlin  Clin.  Woeh.,  Nov.  13,  1893). 

f  Thus  a  leading  article  (Jowm.  Amer.  Med.  Assoc.,  Aug.  29,  1903)  shows  that  out  of 
the  casualties  of  the  Fourth  of  July  celebration  of  that  year  alone,  466  ended  fatally. 
Four  hundred  and  tifteen  cases  of  tetanus  occurred,  and  it  is  believed  that  this  list  is 
incomplete. 


ii02  OPERATIONS   ON    THE    VERTEBRAL   COLUMN, 

treatment  must,  be  early,  and,  in  many  cases,  prophylactic.     "  It  lms 

been  well  said   that   a   patient    wlio   is    having   tetanic   symptoms   is  imt 

beginning  to  have  tetanus — he  is  beginning  to  die  from  it."  The  intra- 
spinal injection  has  been  successful  when  accompanied  by  intra-neuraJ 

ones  into  each  of  the  trunks  of  the  brachial  plexus,  each  being  repeated, 
the  intra-neural  one  by  reopening  the  incision  made.  It  is  well  to  try 
and  scratch  some  of  the  nerves  in  the  cauda  equina  (Rogers,  Journ. 
Amer.  Med.  Assoc,  May  14,  1903).  Any  wound  present  should  he 
thoroughly  disinfected  and  drained.  The  experimental  work  of  Marie, 
Meyer  and  others  and  the  results  prove  this  method  to  be  more  Logical 
than  intra-cerebral  injection,  simpler,  and  less  dangerous. 

Operation. — The  interval  between  the  third  and  fourth  lumbar 
vertebra1  may  be  found  in  thin  patients  by  counting  downwards  from 
the  twelfth  dorsal  vertebras.  In  stout  or  muscular  patients  a  line 
drawn  between  the  highest  points  of  the  iliac  crest  usually  traverses 
the  upper  edge  of  the  fourth  lumbar  spine  when  the  column  is  flexed. 
It  is  better,  even  in  children,  in  order  to  secure  the  needful  rigidity, 
to  have  a  special  needle  4  to  5  cm.  long.  In  adults  the  length  should 
be  8  to  g  cm.  The  above  space  having  been  marked  with  iodine  and  the 
sterilised  skin  steadied  by  the  left  index  finger,  the  needle  is  introduced 
just  outside  the  upper  margin  of  the  fourth  lumbar  spine,  if  the  above 
space  be  selected.  It  should  be  directed  a  little  upwards  and  towards 
the  middle  line.  Slight  resistance  is  felt  as  the  point  traverses  the 
ligamentum  subflavum.  If  it  should  be  stopped  by  bone  the  point 
is,  of  course,  withdrawn  a  little,  and  directed  differently.  Fluid  is 
usually  reached  in  children  at  a  depth  of  2  to  3  cm.,  in  adults  at 
about  4  to  7  cm. 

When  the  fluid  is  being  withdrawn  to  relieve  tension,  the  operator 
must  be  guided  by  the  pulse,  any  tendency  to  syncope,*  or  pain  in 
the  head. 

Albertin  {Lyon.  Mai.,  Oct.  8,  1899)  reported  a  most  interesting 
case,  which  serves  to  illustrate  the  usefulness  of  this  measure  in 
relieving  intra-spinal  pressure  in  certain  cases: — 

A  mriii  fell  from  a  window,  striking  his  knees  and  then  his  back.  Paraplegia  was  the 
immediate  result,  the  reflexes  were  absent,  ami  there  were  large  areas  of  cutaneous 
anaesthesia.  The  sphincters  were,  however,  unaffected.  Fourteen  days  later  Albertin 
inserted  a  trocar  into  the  spinal  canal  in  the  lumbar  region,  ami  drew  oil'  one  ounce  of 
blood-stained  fluid.  Forty-eight  hours  later  the  reflexes  had  returned,  and  from  this  time 
slow  improvement  took   place,  so    that  two  weeks  later  the  patienl  could  walk    with 

Cb.es.      The  final  result  is   not  given. 

Spinal  Anaesthesia.— This  method,  introduced  by  Dr.  L.  Corning, 
of  New  York,  has  had  an  extended  trial  in  America,  .and  is  largely 
employed  by  Trench  surgeons.  It  has  never  found  favour  in  this 
country.  While  it  is  possible  by  its  adoption  to  diminish  shock  (vide 
infra),  it  is  clear  that  the  method  is  not  without  difficulties  and 
dangers,  and  is  only  likely  to  be  used  where  the  surroundings  are 
especially  favourable,  as  in  :l  large  hospital.     The  drug  chiefly  used  has 


Showingthal  the  puncture  of  the  spinal  membranes,  not  to  mention  the  injection  of 
encaineand  Btovaine,  which  is  considered  below,  is  not  without  risk,  Gumprecht 

!/'•</.    Her//.,    :goo,   Bd.   xxvi.   S.   3S6)  reported   17  cases   of  sudden   death    following 

simple  lumbar  puncture  for  diagnostic  purpo 


TAPPING    THE   SPINAL   THECA.  n<>; 

been,  till  recently,  cocaine.  Those  interested  in  the  subject  will  find 
much  information  in  papersbyDr.  W.  White  and  Dr.  Patterson  (Amcr. 
Journ.  Mr, I.  Sri..  [901,  p.  227)  ;  Turner  {Prease  Mid.,  Nov.  7, 
1900),  a  report  of  210  successful  cases,  112  of  which  were  intra- 
peritoneal operations.  Dr.  W.  M.  Perkins  collected  (Netv  Orleahs 
Med.  and  Sun/.  Journ.,  September,  1902)  2,345  cases  of  spinal 
analgesia;  of  these  16  or  1  in  146  appear  to  have  died  from  the  use 
of  this  method.  The  most  frequently  used  injection  was  10  to  15  m. 
of  a  2  per  cent,  solution  of  cocaine  muriate,  containing  one-fifth  to 
three-tenths  of  a  grain  of  the  drug.  Analgesia  usually  begins  in 
about  ten  minutes  or  less,  and  is  complete  up  to  the  umbilicus  in 
about  twenty.  Disagreeahle  nausea  was  present  in  about  one-third 
of  the  cases  and  severe  headache  in  a  few.  Temporary  retention  of 
urine  and  paraplegia  have  occurred.  The  most  serious  risks  are 
infection,  the  dangers  of  cocaine  itself,  and  the  possibility  of  permanent 
injury  to  the  cord.  Like  other  modes  of  analgesia  it  is  not  suited  to 
children  or  nervous  patients,  as  a  rule.  The  cases  which  chiefly  call 
for  the  use  of  this  method  are  abdominal  ones,  especially  where 
peritonitis  is  present  (vide  infra),  and  some  of  amputation,*  though 
in  the  latter  the  method  of  Crile  (Vol.  I.  p.  226)  by  intra-neural  injection, 
e.g.,  in  the  lower  extremity  of  the  great  sciatic  and  anterior  crural,  in 
order  to  diminish  shock  when  a  general  anaesthetic  is  employed,  or 
local  analgesia  (Vol.  I.  p.  652),  in  cases  such  as  amputation  for  diabetic 
gangrene,  will  be  preferred  by  most. 

<v>uite  recently  {Brit.  Med.  Journ.,  May  12,  1906)  Mr.  Dean  has 
drawn  attention  to  the  value  of  intra-spinal  analgesia  with  stovainet 
in  cases  of  acute  general  peritonitis.  Three  cases  of  operation  in 
acute  appendicitis,  one  for  volvulus  of  the  sigmoid,  and  two  of  castration 
are  given.  In  five  of  the  cases  analgesia  was  most  satisfactory.  In 
the  case  of  the  volvulus  grave  failure  of  respiration  set  in  while 
the  volvulus  was  being  reduced,  and  though  the  patient  rallied  from 
this,  cardiac  collapse  followed  from  which  the  patient  died  nine  hours 
after  the  operation.  In  such  a  case  the  result  may  well  have  been 
due  to  the  effect  of  the  volvulus  and  not  to  the  drug.  Mr.  Dean 
considers  that  by  intra-spinal  analgesia  with  stovaine  surgical  shock 
is  avoided,  "  patients  having  extensive  wounds  inflicted  upon  the 
abdominal  wall  with  manipulation  of  inflamed  viscera,  and  flushing  of 
the  peritonaeal  cavity  seem  little  if  at  all  affected." 

Method. — The  space  between  the  third  and  fourth  lumbar  vertebra  is 
usually  chosen  (p.  1102).  As  there  is  a  risk  of  producing  an  amount  of 
intercostal  paralysis  sufficient  to  seriously  hinder  respiration,  Mr.  Dean 
advises  that  the  drug  be  given  by  graduated  dosage.  "  In  these  acute 
cases  it  is  very  difficult  to  estimate  the  amount  that  will  be  required  to 

*  Dr.  Gibbon  (Philad.  Med.  Journ.,  May  2,  1903)  reports  a  case  of  painless  amputation 
of  the  leg  after  the  intra-spinal  injection  of  cocaine.  The  patient  suffered  from  tuber- 
culous diseasr  of  the  ankle,  and  a  general  ana-sthetic  was  considered  to  be  contra-indicated. 
The  great  sciatic  and  anterior  crural  were  first  exposed  and  injected  by  the  infiltration 
method  with  a  i  per  cent,  solution.  The  amputation  was  painless  and  the  patient  made 
a  good  recovery. 

f  Stovaine  is  the  chlor-hydrate  of  one  of  the  amino-alcohols.  I;  Its  chief  physiological 
difference  from  cocaine  is  that  it  is  a  vaso-dilator,  not  a  vaso-constrictor,  and,  further,  it 
seems  to  have  a  tonic  effect  on  the  heart "  (Dean). 


1 104 


OPERATIONS    ON    THE    VERTEBRAL   COLUMN. 


produce  complete  anesthesia,  and,  owing  to  the  danger-zone  of  inter- 
costal paralysis  being  near  the  limit  of  the  anaesthesia  required, 
it  is  necessary  to  feel  one's  way.  I  consider  that  it  is  of  paramount 
importance  in  cases  in  which  the  anaesthesia  has  to  reach  the  level  of 
the  upper  abdomen  to  commence  with  a  minimal  dose,  and  to  gradually 
increase  it  if  necessary.  This  means  that  it  is  necessary  to  keep 
the  cannula  in  until  the  maximum  effect  has  been  produced.  I  com- 
mence with  a  dose  of  06  ccm.  as  a  minimum  ;  and  if  at  the  end  of 
seven  minutes  it  is  obvious  that  one  dose  is  too  small,  an  extra  0*3  ccm. 
should  be  given  until  the  extent  of  the  anaesthesia  required  is  obtained. 
This  is  the  only  way  at  present  to  avoid  the  danger-zone  of  inter- 
costal paralysis."*  To  allow  of  the  cannula  being  retained,  and  to 
prevent  its  being  pressed  upon,  or  disturbed  during  any  movements, 
Mr.  Dean  has  devised  a  flexible  cannula  which  he  considers  possible 
to  leave  in  position.  Whatever  syringe  is  used  must  meet  the 
requirements  of  being  easily  sterilised,  and  of  holding  3  to  4  ccm.  of 
the  solution. 

*  In  the  same  periodica]  Dr.  D.  Mackenzie  gives  the  following  caution  as  to  intra- 
spinal analgesia,  the  result  of  his  experience  of  stovaine  on  mucous  membranes  such  as 
those  of  the  nose  and  throat.  Having  found  that  in  one  case  a  10  per  cent,  solution  left 
too  long  hi  .situ  caused  superficial  sloughing,  he  points  out  the  need  of  observation  as  to 
any  irritant  effects  arising  after  the  operations  under  intni-spinal  analgesia.  "  In  the  case 
of  the  spinal  cord  in  particular  care  should  be  exercised,  for,  if  the  drug  effects  a  destruc- 
tive or  irritant  effect  mi  mucous  membranes,  it  stands  to  reason  that  a  delicate  nervous 
tissue  may  also  suffer  from  an  intimate  contact  with  stovaine,  even  when  it  is  used  in  very 
weak  solution." 


INDEX  OF  NAMES. 


VOLUME     II. 

ABBE  I  I!.),  nephrectomy  for  renal  sarcoma  in  children,  198,  201,  205  ;  Murphy's  button, 

371,  372  ;  intestinal  anastomosis,  403  ;  modification  of  Kader"s  method  of  gastrostomy, 

454  ;  -string''  method  of  treating  oesophageal  stricture.  457  ;  drainage  after  choledo- 

chotomy.  555  :  suppuration  after  injection  of  carbolic  acid  into  a  hydrocele  sac.  740  : 

laminectomy.  1094 
Abbe-Kader.  method  of  gastrostomy,  454 
Abbott,  case  of  enteroplasty,  420 
Aberxethy.  incision  for  ligature  of  external  iliac.  7 
Adams,  osteotomy  of  femur,  1063 

Albarrax,  papilloma  of  ureter,  197,  202  ;  growths  of  the  bladder,  595,  598 
Albert  (Vienna),  method  of  gastrostomy,  450,  452  ;  arthrodesis,  963 
Albert,  malignant  disease  of  spleen,  530 
Albertix,  tapping  spinal  theca,  1102 

ALEXANDER,  intraperitonaeal  rupture  of  bladder,  653  ;  prostatic  abscess,  686 
Alexaxdrow.  litholapaxy  in  male  children,  647 
Allex  (L.  \Y.),  removal  of  pancreatic  calculus,  580 
Allixgham  (H.  W.),  lumbar  colotomy,  122  ;  inguinal  colotomy,  133  ;  enteroplasty.  421  ; 

perforating  typhoid  ulcer,  333  ;    bone  bobbin,  376 ;  ligature  for  haemorrhoids,  761  ; 

haemorrhage  after  operation  for  haemorrhoids,  767  ;    complications  after  operations 

for  haemorrhoids.  770  ;  vulcanite  tube  for  use  after  excision  of  the  rectum,  780  ; 

partial  excision  of  the  rectum,  783  ;  excision  of  the  rectum  by  the  abdoniino-perinaaal 

route,  805  ;  laminectomy,  1094 
Allixgham  (W.),  surface-marking  of  the  colon,  120 
AXLIS,  forceps  for  enterorraphy,  360 
Alsberg,  stricture  of  the  ureter.  253 
AmusSAT,  colotomy.  no 

Amyx.  successful  operation  for  extensive  abdominal  injury,  426 
ANDERSON  (of  Nottingham),  excision  of  gastric  ulcer,  317;  suture  of  the  bladder  after 

su.pra-pu.bic  lithotomy,  627 
ANDERSON  (W.),  forceps  for  gall-stones,  549  ;    case  of  papilloma  of  the  bladder,  588  ; 

ectopia  vesicae,  706 
ANDREWS,  gastrotomy  for  haemorrhage,  463,  464 
ANGUS,  successful  operation  for  perforated  duodenal  ulcer,  329 
Axxaxdale,  case  of  gunshot  wound  of  the  abdomen,  438;   internal  derangements  of 

the  knee,  974 
Axxaed  and  Bowex,  pneumococcal  peritonitis,  343 
Axschultz,  removal  of  new  growths  of  liver,  540 
Axsox.  perforated  gastric  ulcer,  315 
Axtyllus.  method  of  treatment  of  popliteal  aneurysm  contrasted  with  Matas's  operation, 

988,  991 
ARMSTRONG,  perforated  typhoid  ulcer,  331 
Arnisox.  laminectomy.  1094 

ARNOLD  (W.  E.).  amputation  at  the  hip-joint,  882 
Ashe,  inflammation  of  Meckel's  diverticulum.  313 
ASHUBST,  mortality  of  rapture  of  bladder,  653  ;  mortality  of  amputations  at  the  hip-joint 

by  Wyeth's  method.  878 
Ashurst  and  Harte,  perforated  typhoid  ulcer,  329.  330.  332 
Aylex,  irrigation  in  dysentery,  144 

S. — VOL.  II.  70 


iio6  INDEX   OF   NAMES. 

Baeb  (l">.    P.),   conservative  Burgery   of   the  uterine  appendages,  839;  Bupra-vaginal 

hysterectomy,  847,  850 
Bailed  (I;.),  bone  bobbin  Eor  enterorraphy,  377 
Baker,  renal  decapsulation,  240 
Bakes  (Mobbant),  ligature  of  common  iliac  fur  haemorrhage,  [4  ;  method  of  fixing  the 

bones  after  knee  excision.  9G0 
BALDT, ovariotomy,  821,823  ;  removal  of  uterine  appendages,  838  ;  relations  of  cervix  uteri, 

843  ;  vaginal  hysterectomy,  857,  859,  861,  864 
BALL  (Sir  C),  the  sentinel  pile,   771  ;    results  of  excision  of  the  rectum.  779;    BUtures 
after  excision  of  the  rectum.  789 ;  question  of  colotomy  before  excision  of  t  he  reel  um, 
7S1  :  abdomino-anal  method,  806 
Ballance,  enterorraphy,  382,  383  ;  splenectomy  for  injury,  528 
B  \  i.tii  asard,  results  of  experimental  renal  decapsulation,  239 
BANGS  (L.  1>.),  treatment  of  tuberculous  disease  of  the  bladder,  611 

Banks  (Sir  W.  M.),  ligature  of  external  iliac  by  abdominal  section,  24  ;  ligature  of  the 
abdominal  aorta,  31  ;   strangulated  hernia,  49  ;    radical  cure  of  enormous  hernias, 
72  ;  treatment  of  artificial  anus,  415  ;  use  of  adhesions  in  operations  on  bile  ducts.  556 
Barbour,  foreign  body  in  the  female  bladder,  649 
I'. AiiDENHEUER,  complete  extirpation  of  the  bladder,  607 
BaRETTE,  partial  intestinal  resection,  394 

Barker,  local  analgesia  in  operation  for  strangulated  hernia,  42  ;  cause  of  death  after 
operations  for  strangulated  hernia,  48  ;  question  of  formation  of  artificial  anus  or 
resection  of  damaged  intestine,  50  ;  wound  of  obturator  artery,  51  ;  radical  cure  of 
umbilical  hernia,  59,  107  ;  method  of  radical  cure  of  femoral  hernia,  93  ;  ruptured 
kidney,  201  ;  nephrectomy,  207  ;  abdominal  nephrectomy,  209  ;  rupture  of  ureter, 
255  !  intussusception,  274,  279  ;  appendicitis,  300  ;  perforated  gastric  ulcer  and 
infected  peritonaeum,  320  ;  resection  of  intestine,  393,  396,  398,  400,  434  ;  gunshot 
wounds  of  abdomen,  439  ;  pylorectomy  in  two  stages,  476  ;  excision  of  the  hip,  89G  ; 
flushing-gouge,  899  ;  semilunar  incision  for  excision  of  the  knee,  954  ;  excision  of  the 
knee,  956,  959  ;  treatment  of  fractured  patella,  968 
BARLING  (CI.),  appendicitis,  294  ;  exploration  of  tubercular  kidney,  196  ;  nephrectomy 

in  hydro- or  pyo-nephrosis,  196  ;  supra-pubic  cystotomy  in  the  young,  630 
Barnard  (Dr.),  gunshot  wounds  of  duodenum  and  transverse  colon,  431 
Barnard,  successful  removal  of  gall-stone  causing  intestinal  obstruction,  284  ;  mortality 
of  operative  interference  in  these  cases,  286  ;  drainage  of  appendicular  pelvic  abscess, 
301  ;  treatment,  of  coxa  vara,  911 
Barrs,  criticism  of  operative  treatment  of  chronic  constipation,  410 
Barth,  partial  nephrectomy,  215  ;  nephrorraphy  necrotic,  centres  after,  222 
Bartlett,  secondary  haemorrhage  from  common  femoral  artery,  3 
Bartlett,  use  of  filigree  in  radical  cure  of  umbilical  hernias,  108 
Barwell,  ligature  of  the  abdominal  aorta,  30  ;  vesico- vaginal  fistula  after  extraction  of 

calculus,  652  ;  osteotomy,  1068 
BA8SINI,  radical  cure  of  inguinal  hernia,  75,  76  ;  radical  cure  of  femoral  hernia,  94 
Bastian,  nerve  stretching  in  locomotor  ataxy,  1084 

Battle,  operation  for  radical  cure  of  femoral  hernia,  98  ;  renal  calculus  with  growth  of 
renal  pelvis,  182  ;  diaphragmatic  hernia,  272  ;  incision  in  acute  appendicitis,  J03  :  early 
operation  in  abdominal  injuries,  441,  443  ;  tuberculosis  of  the  bladder,  611 
Baudet,  ligature  of  the  internal  iliac,  21 
IUumgarten,  tuberculosis  of  testicle,  749 
Beck,  operation  for  hypospadias,  720 
Beddard,  infusion  with  dextrose  solution,  306,  334,  524 
Belfield,  prostatectomy,  668,  669 
Bell  (J.),  ligature  of  the  gluteal  artery,  29 
l''i:i.i.  (Montreal),  treatment  of  tuberculosis  of  the  bladder.  611 
Bellamy,  multilocular  hernial  sac,  52 

Bennett  (Sir  W.  II.  >, strangulated  hernia,  40  ;  abdominal  section  for  hernia,  61  :  method 
of  radical  cure,  93  ;  method  of  appendicostomy,  140;  on  removal  of  appendix  after 
opening  of  abscess,  299  ;  perforated  gastric  ulcer,  323  ;  supra-pubic  aspiration,  658  ; 
operation  for  varicocele,  744;  recurrence  of  varicocele,  746;  causes  of  recurrent 
synovitis  of  knee  joint,  975;  operative  treatment  in  fractures  of  leg,  1016  ;  on 
operations  for  varicose  veins,  1023 
Berg,  stone  impacted  in  common  bile  duct,  557 

BEBG  (A.),  ureteral  calculus,  247  ;  capacity  of  kidneys,  158  ;  renal  decapsulation,  240 
Beboee,  relapses  after  radical  cure  of  umbilical  hernia,  101 
Beenat,  case  of  enteroplasty,  420 

bi.\  an,  incision  in  operations  on  bile  tracts,  546  ;  nephrotomy  for  polycystic  kidney,  203  ; 
orchidopezy,  756 

BETEA,  operation  for  gastroptosis,  525 

BiOKEBSTETH,  on  Luys'  Begregator,  154 


TNDKX    OF    NAMES.  1107 

Biokham,  Laminectomy,  1098 

Bicknell,  method  of  Mai  as  in  arterio-venous  aneurysms,  gig 

I'.i  ddell,  Laminectomy,  1094 

Bidwell,  Limitation  of  colotom;  for  growths,  139;  ileo-aigmoidostomy,  .105  ;  method  of 

sut  uic  after  perinaal  excision  of  the  rectum,  789 
Bibb,  Ligature  of  the  internal  iliac  for  enlarged  prostate,  20;  gastroptosis,  525;  osteo- 
plastic method  of  amputation,  1002 
Big  blow,  Lithotrite,  639  ;  Litholopaxy,  G43 

Billboth,  earlier  method  of  partial  gastrectomy,  485;  later,  486;  extirpation  of  pan- 
creatic cyst,  585  :  operation  on  malignant  prostate,  685 
I'.iNMi:,  difficulties  in  suture  of  bile  ducts,  554  ;  method  of  drainage  in  these  cases,  556 
Bibcheb,  gastro-plication,  524 
Bibkett,  strangulated  obturator  hernia,  60 
Bishop  (E.  Stanmobe),  on  the  Czerny-Lemberl  suture.  354  ;  intestinal  bobbin,  377  ; 

hernia  after  hysterectomy,  851 
BLAIK.  treatment  of  capsule  in  nephrorraphy,  227 
BLAKE,  radical  cure  of  umbilical  hernia,  105  ;  mode  of  cleansing  infected  peritoneal  sac, 

304;  experimental  nasi ro-jejunostomy,  503 
Blake  (Miss  A.),  abdomino-perinseal  excision  of  rectum,  807 
BLOODGOOD.  mollification  of  Halstead's  method  of  radical  cure  of  hernia,  91  ;  removal  of 

endosteal  sarcoma,  ion 
BLUYSEN,  removal  of  toothplate  from  oesophagus  by  gastrotomy,  460 
BOABI,  uretero-vesical  grafting,  258 
BoLOJUBOFF,  anastomosis  of  vas,  750 
Bond,  suture  of   the   bladder  after   supra -public   lithotomy,  G27  ;    supra -pubic   cys- 

totomy,  652 
Borchardt,  Mikulicz's  tarsectomy,  1044 
Bottini,  method  of  prostatectomy,  680 
Bouisson,  treatment  of  hypospadias,  717 
Bovee,  ureteral  calculus,  243  ;  suture  of  ureter,  256 
Bowen  and  Annaud,  pneumococcal  peritonitis,  343 
Bowlby,  granular  kidney,  169  ;  enterorraphy,  375  ;  injury  to  intestine  in  warfare,  429, 

430  ;  nerve  suture,  1078,  1082 
Box,  peritonasal  watersheds,  327 

Box  and  Eccles,  ulceration  of  ileum  in  typhoid  fever,  144 
Boyd  (S.),  enterorraphy,  363,  365 
Bramer,  pylorectomy  for  carcinoma,  476 
Bramwell  (J.  P.),  nerve  stretching  for  sciatica,  1084 
Brashear  (W.),  amputation  at  the  hip-joint,  882 
BRAUN,  gastrojejunostomy  in  gastric  ulcer,  318,  with  entero-anastomosis,  517  ;  wound  of 

the  femoral  vein,  913 
Brewer,  diagnosis  and  treatment  of  abdominal  injuries,  439,  441,  442  ;  suture  of  large 

vessels,  918 
Briddon  (C),  injuries  of  the  kidney,  201  ;  case  of  gunshot  wound  of  the  abdomen,  439  ; 

cholecystenterostomy,  562 
Briggs    (W.    T.),    advantages   of   median    lithotomy,    630  ;     modification    of    median 

lithotomy,  632 
Brinton,  obstruction  of  the  large  intestine,  118 
Brinton  (Philadelphia),  amputation  through  the  knee-joint,  947 
Brodie  (Sir  B.),  villous  tumour  of  the  bladder,  588  ;  hypertrophied  prostate,  669 
Brown,  operations  in  penetrating  abdominal  wounds,  426 
Brown  (Dr.),  repeated  aspiration  in  prostatic  retention,  658 
Brown  (Tilden),  nephrectomy,  201,  211  ;  distension  of  the  bladder,  624 
Brown  (W.  H.)  ligature  of  external  iliac  by  abdominal  section,  24  :  intussusception  due 

to  a  worm,  280 
Browne  (L.),  case  of  splenectomy,  531 
Bruns  (Yon),  drainage  in  pneumococcal  peritonitis,  343  ;  results  of  hip  excision,  S95  ; 

excision  of  the  knee,  953  ;  of  ankle,  1040 
BRYANT,  colotomy,  122,  123,  127  ;  haemorrhage  in  splenectomy,  532  ;  injury  to  the  portal 

vein  in  tapping  a  hydatid  of  the  liver,  534  ;  removal  of  growth  of  the  bladder,  610  ; 

lateral  lithotomy  in  children,  647  ;    removal  of  vesical  calculi  in  the  female,  648  ; 

hypospadias,  717  ;  Stephen  Smith's  amputation,  946 
Bryant  (New  York),  importance  of  position  of  appendix,  294 
Bryant  (J.  H.),  aneurysm  of  abdominal  aorta,  33 

Buchanan,  ligature  of  external  ilial  for  elephantiasis,  3  ;  operation  for  talipes,  1048 
Buck  (G.),  appendicitis,  307 
Bull,  radical  cure  of  hernia,  62,  65,  67,  70,  79  ;  case  of  gunshot  wound  of  the  abdomen, 

439  :  antiseptic  incision  for  hydrocele,  740 
Bullard,  laminectomy,  1094 

70—2 


uo8  INDEX    OF   NAMES. 

Bulbteode,  gastric  ulcer,  460 
Bubgess,  injection  of  paraffin  for  prolapsus,  7.1 

Bubghabjd,  operative  treatment  of  congenital  dislocation  of  hip-joint,  90G 
Bi  kbell,  laminectomy,  1094 

I'.isAciii.  implantation  of  the  ureter  into  the  bladder,  258 

BtrscH,  appendix  in  a  hornial  Bac,  73  :  intussusception  due  to  Meckel's  diverticulum,  280 
Bubse,  relapses  alter  radical  cure  of  umbilical  hernia.  101 
Butcher,  ligature  of  the  common  femoral  artery,  915 
I'.i  11. 1:1;.  suppression  of  urine.  194 

Pi  11. in.  renal  calculus,  1G3:  renal  sarcoma  in  children,  198:  resection  of  intestinal 
carcinoma.  3S5  ;  pain  after  gastrostomy,  457  ;  malignant  disease  of  the  testis,  748 

Cabot,  abdominal  Bection  in  calculous  anuria.  193  ;  sacral  route  for  reaching  ureter,  249 
Cadge,  lateral  lithotomy,  618,  619,  621  ;  median  lithotomy,  630  ;  lithotrity.  C34,  635,  636, 

637  ;  comparison  of  old  and  new  operations  of  lithotrity,  643 
Caird,  inversion  in  limited  gangrene  of  intestine,  394  ;  resection  of  intestine,  397  ;  case 

of  pancreatic  cyst,  584 
Callisen,  colotomy,  no 
(  amkhox,  intestinal  absorption,  474 

<  am. midge,  chronic  pancreatitis, 570,  579 
Campbell,  method  of  enterectomy,  3G7 

Campbell  (Liverpool),  peritonitis  after  supra-pubic  aspiration  of  the  bladder,  658 

<  A.Mi'KNOX,  vaginal  excision  of  the  rectum,  801 

Cannon,  reversed  peristalsis,  409  ;  absorption  in  large  intestine,  no 

CANNON  and  P.lakj:.  experimental  L'astro-jejunostoruy,  503 

Cakdex,  amputation  above  the  knee-joint,  937 

CABLE,  gastrojejunostomy,  479,  520 

Carter,  diagnosis  of  perforated  gastric  and  duodenal  ulcer,  327 

Carwardine,  value  of  early  operation  in  strangulated  hernia,  40:  incision  in  iliac 
colotomy,  129  ;  enterostomy  tube,  132,  336,  346  ;  contracted  meso-sigmoid  in  colotomy, 
136  ;  colotomy  in  malignant  obstruction,  138  ;  nephrorraphy,  225  ;  intestinal  clamps, 
388  ;  clamps  for  gastrojejunostomy,  501 

Cathcart,  Murphy's  button,  369 ;  pancreatic  cysts.  563,  582,  583.  584  ;  method  of 
draining  the  bladder,  603 

Cavafy,  nerve  stretching  in  locomotor  ataxy,  1084 

Cayley,  perforation  of  typhoid  ulcer,  332 

Cazin,  gastrotomy  for  haemorrhage,  463 

Ceci,  ureteral  calculus  removed  per  rectum,  248 

Champneys,  indications  for  the  removal  of  the  uterine  appendages,  831 

Cheatle,  bullet  wound  of  abdomen,  429 

Chetwood,  perinatal  prostatectomy  in  two  stages,  679 

Chevalier,  resection  of  the  bladder,  607 

<hi;vne  (Watsox  C.  B.),  radical  cure  of  hernia,  84,  101  ;  movable  kidney,  168  ;  intus- 
susception by  Meckel's  diverticulum,  280;  tubercular  peritonitis.  340.  342  ;  epispadias. 
124;  gunshot  injury  of  intestine,  424;  osteotomy  for  coxa  vara,  911  ;  shortening 
after  erasion  of  knee-joint,  949  ;  bone-grafting,  1008 

Cheyne  and  Burgiiard,  ivory  pegs  in  ununited  fractures.  1021  ;  aluminium  plates  in 
ununited  fractures,  102 1  ;  excision  of  spina  bifida,  1089 

Chipault,  laminectomy,  1094,  I095t  i°99,  noi 

<  11 1  1  .m>ky,  size  of  knots  in  intestinal  suture,  359  ;  lateral  anastomosis,  403 
Civiale,  internal  urethrotomy.  701,  702 

Clado,  complete  extirpation  of  the  bladder,  C07 

Clairemont.  micro-organisms  in  gangrenous  intestine,  397 

CLARKE  (Bruce),  Luys'  segregator,  158,  191;  hydronephrosis,  168,  222:   nephro-litho- 

tomy,  177  :  speculum  for  the  bladder,  597  ;  encysted  vesical  calculus,  622  ;  obstruction 

after  pylorectomy  and  direct  suture.  486 
Clarke  (Jackson),  treatment  of  congenital  dislocation  of  the  hip-joint,  905,  908 
Claude,  renal  decapsulation.  239 
CLINTON,  inflammation  of  Meckel's  diverticulum,  313 
Clubbe,  operation  in  intussusception,  279 
1  11  tton,  femoral  aneurysm,  2  ;  Meckel's  diverticulum,  268  ;  intestinal  obstruction  by 

gall-stones,  284  ;   imperforate  anus,  813  ;   erasion  of  the  ankle  by  lateral  incisions, 

1040  ;  cases  of  spina  bifida  treated  by  injection,  1089 
Cock,  anuria  from  a  ruptured  single  kidney,  194  ;  external  urethrotomy,  G90,  G94  ;  ease  of 

carcinoma  testis,  748 
I  "iri;v,  'jastroptosis,  526 

COLE,  recurrence  of  intussusception  after  operation,  280 
Colkv.  radical  cure  of  hernia,  62,  97;  results  in  childhood,  G5.  67;  value  of  kangaroo 

tendon.  OS  :  prevention  of  infection,  70 


INDEX    OK    NAMKS. 


1 109 


Collieb,  trephining  for  sacro-iliac  disease,  874 

Collins  (J.),  growths  of  spinal  cord,  1096 

Colt,  method  of  supra-pubic  drainage,  602,  674,  675 

Cornell  (F.  <;.  and  ll.  E.)  intestinal  suture,  355,  359,  360;  gastrojejunostomy  in  gastric 

haemorrhage,  465 
Connob,  case  of  total  gastrectomy,  492 
Coopeb,  sigmoid  in  righl  iliac  fossa,  130 
1  nni'i.i;  (Sir  Astlet),  incision  for  Ligature  of  external  iliac,  5 ;  secondary  haemorrhage 

after  Ligature,  9  ;  Ligature  of  the  abdominal  aorta,  30,  32  ;  strangulated  hernia,  44 
Coopeb  (  Bbansby),  ligature  of  the  femoral  artery,  921 
Cobneb,  varieties  of  intussusceptions,  276  ;  Leakage  after  operations  for  acute  appendicitis, 

300;  plication  of  caecum  after   operation  for  volvulus,  281,   283;    retained   testis, 

757 

Coupek,  vomiting  after  lumbar  colotomy,  126 

Coi  PLAND,  distension-ulcers  of  the  caecum,  126 

CotJBVOISIEB,  operations  for  obstruction  by  gall-stones,  286;  incision  for  operations  on 
bile-tracts,  547 

I  !fi  wipton,  P.,  incision  for  ligature  of  common  iliac,  16,  18 

CbaWFOBD,  ureteral  calculus  removed  by  supra-pubic  cystotomy,  248 

( 'BILE,  shock  in  abdominal  injuries,  306,  423  ;  in  amputation  at  hip-joint,  884  ;  haemorrhage- 
forceps,  917  :  injection  of  eueaine  into  nerves  to  diminish  shock,  934,  1103 

Cripps,  inguinal  colotomy,  128,  130,  133,  136,  349  ;  intestinal  obstruction,  263  ;  Murphy's 
button,  371,  373  ;  fistula  in  ano,  758  ;  haemorrhoids,  760  ;  carcinoma  of  rectum  and 
excision,  777,  779,  780,  788,  809  ;  the  cautery  in  excision  of  the  rectum,  504  ;  ulcera- 
tion of  the  femoral  vessels,  915  ;  treatment  of  stab  wound  in  mid-thigh,  927  ;  injuries 
to  arteries  of  leg,  992 

Croft,  hydronephrosis,  197  ;  rupture  of  the  ureter,  255  ;  rupture  of  the  intestine,  441  ; 
two  cases  of  ruptured  intestine  without  external  wound,  443 ;  plaster  of  Paris 
splint,  1013 

Cullingworth,  indications  for  removal  of  uterine  appendages,  832  ;  removal  of  uterine 
appendages,  837  ;  hernia  after  hysterectomy,  851 

Cumston,  clamp  for  renal  vessels  in  exploration  of  kidney,  174,  177  ;  operation  for 
prolapse  of  the  rectum,  773 

(  'ixeo,  lymphatics  of  stomach,  479,  480,  487 

CURL,  caecostomy  in  dysentery,  116  ;  irrigation  through  caecum  in  colitis,  139  ;  appendi- 
costomy,  141  ;  appendicostomy  and  cascostomy  in  dysentery,  143 

CURLING,  colotomy  in  malformation  of  rectum,  114  ;  occasional  emptiness  of  colon  in 
colotomy,  123  ;  carcinoma  testis,  748  ;  treatment  of  fistula  in  ano,  760  ;  treatment  of 
anal  fissure,  771 

Curtis,  B.  P.,  ruptured  intestine,  439;  method  of  dilating  oesophageal  stricture,  457; 
comparison  of  gastroplication  with  gastrojejunostomy,  525 

Curtis  (Farquhar),  gastroplication,  525 

Currie,  intra-peritonaeal  ligature  of  external  iliac,  26 

Gushing,  suture  of  intestine,  354  ;  primary  amputation,  934  ;  laminectomy  for  growth  of 
spinal  membranes,  1096,  1100 

Gushing  and  Curtis,  method  of  radical  cure  of  femoral  hernia,  97 

<  IZEENY,  two  cases  of  ligature  of  abdominal  aorta,  31,  210  ;  ureteral  calculus,  247  ;  gastro- 
jejunostomy, 505,  518  ;  results  of  excision  of  the  rectum,  779;  sutures  after  excision 
of  rectum,  788 

Czerny-Lembert,  suture,  354 

DALTON,  case  of  gunshot  wound  of  the  stomach  and  liver,  432 

Dalziel,  removal  of  pancreatic  calculus,  580 

Davies,  gastropexy,  525 

Davies-Colley,  colotomy  in  two  stages,  123  ;  extra-peritonaea]  rupture  of  bladder  with 

fractured  pelvis,  654  ;  circumcision,  724  ;  case  of  wired  fractured  patella,  971  ;  excision 

of  varicose  veins,  1022,  1024 
Davis  (G.  E.),  operation  for  intra-capsular  fracture  of  femur,  942 
Davy,  splint  for  use  after  tarsectomy,  1051 
DAWBARN,  irrigation  in  dysentery,  123  ;  Murphy's  button,  370 
Day  (D.),  large  renal  calculus,  179 

Day  (M.),  case  of  vesical  calculus  in  a  pregnant  woman,  649 
Deaver,  sites  of  impacted  ureteral  calculus,  243  ;  suture  of  ureter,  244  ;  extra-peritoneal 

uretero-lithotomy,  249  ;    ureteral  calculus   and  carcinoma,  254 ;    early  operation  in 

acute  appendicitis,  291 ;  laminectomy,  1101 
De  Gahmo,  radical  cure  of  femoral  hernia,  96 
Delegarde,  Chopart's  amputation,  1053 
Depage,  gastrostomy,  455 
De  Pezzkr,  tractor  for  prostatectomy,  676 


I  no  INDEX    OF    XAMES. 

[man,  Bpinal  analgesia  with  stovaine,  1103 

Dennis,  ligature  of  iliac  arteries  by  an  abdominal  incision,  22  :  early  operation  in  acute 
appendicitis,  291 ;  ■  trostomy,  450 

l  'i.N  1  (( '.),  infant  ile  Btenosis  "f  pj  lorns,  499 

Imi.i  >  an  indication  for  nephrorraphy,  223 

DnrEUB,  in  Ha  in  illation  of  Meckel's  diverticulum,  313 

Dittkl,  Bnpra-pnbic  route  for  removal  of  bladder  growths,  595 

lu\  be,  ligature  of  external  iliac,  2 

I  '"i  be  \r.  perinseal  lithotrity,  I  15 

Donald,  case  of  bone  transference,  1009 

Doran.  incision  for  ovariotomy,  821  :    pedicle  in  ovariotomy,  52.)  ;    oophorecl y  for 

uterine  fibro-myomata,  ^33  ;  treatment  of  uterine  fibro-myomata,  846  :  Bupra-vaginal 

hysterectomy,  851 
DOWD,  Buccessful  resection  of  intussusception,  280  ;  intestinal  suture.  357.  3G6  ;  dilatation  of 

I  bageal  stricture  by  gastrostomy,  457 
Dowden,  orchidopexy,  756 
DOYEN,  removal  of  appendix,  311  ;  treatment  of  divided  bowel,  408  ;  clamp-forceps,  388, 

501;  gastro-jejnnostomy,  518 
DBUMMOND,  movable  kidney,  220,  226;  surgical  interference  in  cirrhosis  and  ascites,  541 
Di  dobok,  nature  of  infection  in  appendix  peritonitis,  302;  delay  in  removal  of  injured 

"•  529 
DUKE,  examination  of  kidneys  by  abdominal  section  in  calculous  anuria,  193 
Dtjjarier,  case  of  complete  extirpation  of  the  bladder.  607 
DUMBEICHEE,  relation  of  pleura  to  last  rib.  172 
DUM8TBEY,  nerve-implantation,  1081 

l'i  NCA.N  (.1.),  incision  for  exploration  of  the  bile  ducts,  547  ;  laminectomy.  1094 
DUNCAN  (M.),  pyelitis,  168;  aching  kidney,  169 
DUNHAM,  dilatation  of  'esophageal  strictures  by  gastrostomy,  457 
DUNN,  case  of  perforating  gastric  ulcer,  316  :  duodenal  ulcer.  329 
Duplay,  operation  for  hypospadias,  717  ;  epispadias,  723 
DUPUYTBEN,  >trangulated  hernia.  49;  wound  of  the  obturator  artery.  51;    injuries  of 

arteries  of  leg,  992 
I  lUBET,  gastropexy,  525 
Durham  (A.  E.),  gastrostomy,  465 
DUBHAH  (II.  B.),  amputation  for  chronic  gangrene,  936 

EASTMAN,   cautery  in  removal  of  appendix,  311;    nephrorraphy,  227,  234.  235:    renal 

decapsulation.  237 
EDEBOHLS,  exploration  of  the  •■other"  kidney.  196  ;  renal  decapsulation,  236,  239 
Edmunds,  comparison  of  methods  of  enterorraphy,  382,  383 
EiSENDBATH,  gastroto  ny  for  haemorrhage,  463 
Eldbb,  perforated  duodenal  ulcer.  329 
BLLIOT,  thrombosis,   2S7  ;    resection  of  intestine  for  carcinoma,  386,  387; 

cholecystenterostomy,  561 
Elsbebo,  typhoid  perforation  in  children,  330  :  opening  of  subdiaphragmatic  abscess,  539 
Emmett,  nreteral  calculus  removed  by  vagina,  248 

English  (C.)i  perforated  gastric  ulcer,  318.  319,  323  ;  perforated  duodenal  ulcer.  323.  329 
E  RDM  ANN,  intussusception,  273.280 
Bbiohsen  (Sir  J.  B.),  wound  of  external  iliac,  3  ;  strangulated  hernia,  49  ;  strangulated 

obturator  hernia,  60  j    difficulties  in  lateral  Lithotomy,  616,  621  :  median  lithotomy, 

632;  treatment  of  vesical  calculus  in  the  female,  648 ;  treatment  of  femoral  aneurysm, 

915  ;  ligature  of  the  femoral  artery.  928 
ESMABCB  and  KOWALZIG,  resection  of  pancreas  in  removal  of  Bpleen,  531 
E8  1  1.-.  Suture  of  spinal  cord,  1099 
EU8TI8,  volvulus  complicating  typhoid  fever,  282 

Evans  I  W.  a.  i.  Btricture  after  enterorraphy,  381 ;  circular  enterorraphy,  382 
Eve  intussusception,  274  :  intestinal  obstruction  by  gall-stone,  284.  286 
Eve,  (of  Tennesa  e  i.  amputation  at  the  hip-joint,  882 

Ewabt,  irrigation  in  dysentery,  143.  144  ;  abscess  due  to  perforated  gastric  ulcer,  323 
BwENS,  cuneiform  tarsectomy,  1050 

Fagoe,  obstruction  of  the  large  intestine,  ti8,  119;  solvent  treatment  of  renal  calculi, 
166  :  renal  tuberculosis,  795  ;  volvulus  of  caecum,  2S2  :  peritonitis,  ^^^ 
1.  1  < '.  II.),  results  of  operation  in  intussusception,  279 

Fatbbank,  sarcoma  of  colon,  384 

Fababeuf, ligature  of  the  external  iliac, i     -  Iritti's  amputation,  940 ;  one  cause 

of  conical  stump,  933  ;  ligature  of  the  anterior  tibial,  998 ;    Chopart's  amputation, 
1054  ;  Bubastragaloid  amputation,  1035  ;  excision  of  the  os  calcis,  1043 

FAWCETT,*choloemia  after  operation  for  cirrhosis  and  ascites,  542 


INDEX    OF   NAMES.  mi 

Fbhling,  removal  of  the  ovaries  for  osteomalacia,  543 

riM.i.K,  7alvalar  and  traumatic  Btricture  of  ureter,  250,  253,  254 

l''i.\  n  be,  penel  rating  wounds  of  abdomen,  425 

Fbnwiok,  Rontgen  rays  in  diagnosis  of  urinary  diseases,  153,  242;  fallacies  in  the  u  e 
of  Luys'  segregator,  154  ;  nephrotomy  for  unilateral  renal  hematuria,  161  ;  removal 
of  ureteral  calculus  by  perineal  route,  249;  Bymptoms  of  vesical  growths,  588  ;  use  of 
cystoscope,  589,  591  ;  bladder  caisson,  596  ;  treatment  of  growths  of  the  bladder,  598, 
599,601  ;  case  of  partial  resection  of  the  bladder,  604;  rupture  of  the  bladder  by 
injection  of  fluid,  610 ;  encysted  vesical  calculus,  626;  castration  for  enlarged  pro- 
state,  683 

Ferguson,  radical  curt'  of  umbilical  hernia,  107  ;   intestinal  anastomosis,  361,  383 

FERGl rssON  (Sir  W.),  rupture  of  aneurysm  by  manipulation^;  lateral  lithotomy,  615, 
618  ;  lithotrity,  633 

I'inm'.v,  volvulus,  282;  perforated  gastric  ulcer,  323  ;  typhoid  ulcer,  331  ;  septic  peri- 
tonitis, 338  ;  method  of  pyloroplasty,  469,  473 

Fitz,  acute  pancreatitis,  574 

Flint,  hypertrophied  fringes  in  knee-joint,  974 

Fontino.  gastrojejunostomy,  520 

FoOTE,  hour-glass  contraction  of  stomach,  500 

FOOTNER.  renal  calculus.  179 

FOWLER,  extra-peritoneal  incision  for  removal  of  ureteral  calculus,  247,  249  ;  abnormally 
situated  appendix  simulating  inflamed  gall-bladder,  295;  importance  of  position  of 
appendix,  294  ;  insidious  ulceration  of  appendix,  302  ;  value  of  serai-sitting  position 
after  abdominal  operations,  306,  329,  492  ;  empyema  and  purulent  pericarditis  as  com- 
plications of  appendicitis,  312  ;  silver  wire  ligature  in  gastrojejunostomy,  518  ;  case 
of  wiring  fractured  patella,  972 

Fowler  (G.  R.),  suture  of  spinal  cord,  1099 

Frank,  method  of  performing  gastrostomy,  451,  452 

Frank  (Dr.),  union  of  intestine,  382  ;  operation  for  ectopia  vesica?,  710 

1'i;.\nke,  pylorectomy  in  two  stages,  476 

Franks  (K.),  nephro-lithotomy,  175;  resection  of  intestine,  396  ;  case  of  obstruction  of 
lower  end  of  oesophagus  treated  by  gastrotomy,  456 

Franzozini,  case  of  removal  of  spleen,  530 

Fraser,  calculous  anuria,  194 

Frazier,  suture  of  nerve  roots,  1099 

Frederik,  castration  for  enlarged  prostrate,  682 

Freeman,  duodenal  hernia,  269  ;  operation  for  intracapsular  fracture,  942 

French,  leucocytosis  in  acute  appendicitis,  297  ;  results  of  operation  for  perforated  gastric 
ulcer,  318 

Freudenberg,  on  Bottini's  method  of  prostatectomy,  681 

Freyer,  ureteral  calculus,  248  ;  prostatectomy,  661,  663,  667,  669,670,672  ;  results,  674  ; 
castration  for  enlarged  prostate,  683  ;  vasectomy,  684  ;  lithotrity  for  large  stones,  633  ; 
lithotrity,  641 

Friedrich,  bone-grafting,  ico8 

Fuller,  prostatectomy,  670,  680 

FULLERTON,  removal  of  halfpenny  from  oesophagus  by  cesophagotomy,  459 

Fullerton  (Major)  eversion  method  in  radical  cure  of  hydrocele,  738 

Furbinger,  tuberculous  meningitis,  1101 

GrAGE  (H.),  colectomy  for  carcinoma,  393 

Galabin,  vesical  calculus  in  the  female,  649  ;  ruptured  perinaeum,  814  ;  suture  and 
drainage  of  ovariotomy  wound,  826,  827  ;  Koeberle's  serre-nceud,  845  ;  supra-vaginal 
hysterectomy,  847,  849  ;  abdominal  pan-hysterectomy,  852  ;  vaginal  hysterec- 
tomy, 859,  863 

Gallant,  support  for  movable  kidney,  223 

Gant,  osteotomy  of  femur,  1064 

Garceau,  removal  of  ureteral  calculi  by  vaginal  route,  193,  248 

Gardner,  modification  of  Phelp's  operation,  1048 

Garson,  suprapubic  cystotomy,  624 

Gask,  gastrojejunostomy  for  gastric  ulcer  and  hypertrophic  stenosis  of  pylorus,  498 

Gerhardt,  thrombosis  of  mesenteric  vessels,  286 

Gerster,  excision  of  the  rectum,  800,  801,  810 

Gersuny,  operation  for  ectopia  vesica?,  711  ;  torsion  of  the  rectum  after  excision,  780, 
800 

GESSNEB,  case  of  suture  of  popliteal  aneurysm,  985 

Gibbon,  ureteral  calculus,  246;  inflammation  of  Meckel's  diverticulum,  313;  perforated 
duodenal  ulcer,  329  ;  operation  for  fractured  patella,  968  ;  intra-spinal  injection  of 
cocaine,  1103 

Gibney.  treatment  of  hip  disease,  891 


II 12  INDEX   OF   NAMES. 

GIBSON,  valvular  csecostomy  for  irrigation  in  colitis,  139, 142  ;  acute  intestinal  obstruction 
261,  267:  diaphragmatic  hernia,  271,  272;  intussusception,  274,  279;  resection  of 
gangrenous  intestine,  280;   leucocytosis  in  acute  appendicitis,  297;    gangrenous 

hernia,  383,  399  I  enterectomy,  393,  399  ;  jejunostomy,  527 

Gibson-Kadeb,  method  of  gastrostomy,  527 
Giffobd,  experimental  renal  decapsulation,  239 

Gill  (L.  A.),  abdominal  injuries  in  warfare,  430 

G-ILL,  radical  cure  of  femoral  hernia,  98 

i;  KiKDAM).  splenopexy,  533 

G  [RALDES,  position  of  the  sigmoid  in  imperforate  anus,  114 

( I  u:\  ai;i>'s  disease,  525,  532 

(ii.ifcK.  bone  tubes  fur  use  in  nerve  suture,  1080  ;  nerve-grafting,  1081 

GODDARD,  absorption  in  large  intestine,  142,  410 

Godlee,  strangulated  obturator  hernia,  60  ;  diagnosis  of  renal  calculus,  170  ;  opening  of 

hepatic  abscess  through  chest,  539 
Goelet,  nephrorraphy,  232,  235 
GOLDINGRIRD,  colotomy  and  cajcostomy  for  colitis,  115,  117  ;    case  of  jejunostomy,   527  ; 

sacro-iliac  disease,  874  ;  excision  of  knee-joint,  955;  removal  of  pancreatic  calculus, 

580 
GOODALL,  perforated  typhoid  ulcer,  329,  331,  332 
Goodfellow,  results  of  median  perineal  prostatectomy,  G79 
Goodhart,  surgery  in  chronic  constipation,  411 
GOPEL,  silver  filigree  in  radical  cure  of  umbilical  hernia,  107 
Gordon,  radical  cure  of  femoral  hernia,  98  ;  diagnosis  of  movable  kidney,  221 
Gould  (A.  Peaeoe),  abscess  of  appendix,  298;  perforated  gastric  ulcer,  323;  pyloro- 
plasty,  467,  469;  removal  of  pancreatic  calculus,   5S0  :  pancreatic  cyst,  583,  584; 

amputation  of  the  penis,  730  ;  wound  of  the  common  femoral  vein,  914 
GoULEY,  medio-bilatcral  lithotomy,  632 
Graefe,  treatment  of  strangulated  intestine,  402 
( ;  kaiiam,  diagnosis  of  perforated  duodenal  ulcer,  327 
G  rattan,  osteoclasis,  1071 
Gray,  appendicostomy,  142 

Ukav  (II.)-  relation  of  obturator  vessels  to  femoral  hernia,  51 
Green  (II.).  malignant  disease  of  prostate,  685,  686 
GEEEN  (King),  gastrostomy  in  a  case  of  carcinoma  of  the  pharynx,  445 
Geeene  (('.),  use  of  cystoscope,  191,  192  ;  urinary  fistula  after  nephrorraphy,  224,  235 
Greiffenhagen,  splenopexy,  533 
GREENOTJGH,  epiplopexy  for  cirrhosis  and  ascites,  543  ;  drainage  of  distended  intestine  by 

csecostomy,  305 
Griffiths,  dysmenorrhoea  and  oophorectomy,  834 
GRIFFITHS,  introduction  of  wire  into  abdominal  aneurysm,  36  ;  use  of  Lynn  Thomas's 

forceps-tourniquet,  878 
Geitti,  trans-condyloid  amputation  above  the  knee,  939 
(iuiNARD,  gastroenterostomy  for  haemorrhage,  463  ;  pylorectomy,  485 
Guitebas,  renal  decapsulation,  240 

GUMPBECHT,  risks  of  lumbal'  puncture,  1102 

Gunther,  mollification  of  PirogoflE's  amputation,  1035 

GU8SENBAri;i;.  frequency  of  adhesions  in  cancer  of  the  pylorus,  478 ;  complete  extirpa- 
tion of  the  bladder,  607  ;  bone-staple,  1021 

1.1   ten,  co-existence  of  appendicitis  and  duodenal  ulcer,  327 

( i  ii'i'KunocK,  cystoscope,  590 

Guthbie,  case  of  pulsating  tumour  of  the  buttock.  14;  amputation  al  hip-joint,  885, 
888 

t ; rvoN.  growths  of  the  bladder,  595;  cases  of  tuberculous  disease  of  the  bladder,  611  ; 
haemorrhage  in  supra-pubic  lithotomy,  625 

Magen,  route  for  reaching  pancreas,  573  ;  splenectomy  for  sarcoma,  530 

HAGENBACH,  case  of  stricture  of  the  lower  end  of  the  oesophagus  treated  by  gastrostomy, 

456 
IIagca  iii>,  case  ol  Loreta's  opera!  ion,  466 
II  \i;t'i:.  supra-pubic  aspiration,  658 
Hahn,  digital  dilatation  of  pylorus,  1466;    pylorectomy  in  two  stages.  .176:  eases  of 

jejunostomy.  526;  operation  for  Hat   font,  1052 

II  a  i.i.  (  K).  met  hud  1  if  gastrojejunostomy,  505  ;  splenopexy,  533 

II  A  l.l-  (VY.),  renal  decapsulation,  2  •;()  :    perioral  ing  gast  lie  ulcer,  315 

Hai.-i  ED,  method  of  radical  cure  of  hernia,  874  ;  tuberculous  peritonitis,  341  :  intestinal 
suture.  354:  typhoid  perforation  of  Meckel's  diverticulum,  313;  intestinal  anasto- 
mosis, 404,  405;  metal  hammer  for  use  in  suturing  the  common  bile  duct,  554; 
operation  for  ectopia  vesicas,  710;  suture  of  injured  axillary  vessels,  917 


[NDEX    OF    NAMES.  1 1 1 3 

il  wi  1  i.n>\.  case  of  gunshol  wound  of  the  abdomen,  439 

Ham  "ik.  duodeno-choledochotomy,  557,  ^,^) ;  amputation  at  hip-joint,  876 

Hablei  .  enterorraphy,  363 

Harris,  injury  to  abdominal  viscera,  422,  425,  437 ;  results  >>f  Burgical  interference  in 

ascites  and  cirrhosis,  543 
1 1  \  1:1; is  (  M.  L.),  resection  of  bladder,  605.  609  ;  opera)  ion  for  traumatic  dislocation  of  the 

hip,  404 
Harbison  (Dameb),  cases  of  nerve-graft  ing,  1081 
Habbisok  (R.),  surgical  treatmenl  of  nephritis,  236  ;  villous  tumour  of  the  bladder,  588 ; 

forceps  for  bladder  growths,  598  ;  shock  after  removal  of  growths  of  the  bladder,  609  ; 

lithotrity  in  trabeculated  bladder,  640  ;  recurrence  after  lithrotrity,  637  j  time  taken 

in  lithotrity,  643  ;  repeated  washings  after  lithotrity,  644  ;  perinaeal  lithotrity,  645  ; 

treatment  after  internal  urethrotomy,  702 
II  ai;t.  foreign  body  in  the  female  bladder,  649 
Harte,  perforated  typhoid  nicer,  329.331:    Laminectomy  for  intra-spinal  growths,  1097, 

1098,  1100  ;  suture  of  spinal  COrd,  1099 
HARTLEY,   MayiU's  operation  for  ectopia  vesicas,  704  ;   total   resection  of  bladder,  607  ; 

excision  of  rectum,  S04 
II Ain.MANN,  method  of  gastrojejunostomy,  482  ;  lymphatics  of  stomach,  480 
Hartwell,  method  of  colotomy,  134  :  mortality  after  excision  of  rectum,  778 
Hakyii:  (of  New  York),  case  of  complete  gastrectomy,  493 
BASLAM,  question  of  colotomv  before  excision  of  rectum,  781  ;  erasion  of  the  knee-joint, 

94  S 
Hatcu.  haemorrhage  after  splenectomy,  532 
Haubold,  removal  of  new  growths  of  liver,  540 
Haussoxs.  aneurysm  of  hepatic  artery.  3S 
Haward,  renal  calculus,  183 
Hawkins  and  NlTCH,  intestinal  obstruction  after  gastro-jejunostomy.  529;  gastric  ulcer 

and  its  sequels.  461,  496 
Hawkins  1 1  .i>ar).  carcinoma  testis,  748 
Hawkins(H.  P.),  volvulus,  following  injury,  282  ;  death-rate  of  acute  appendicitis,  2S7  ; 

treatment  of  tuberculous  peritonitis,  340 
HAWIiEY,  malignant  disease  of  prostate,  685,  686 

Hayes,  bone  bobbin  for  enterorraphy,  377  ;  case  of  Tripier's  amputation,  1055 
Hayes  (It.  T.),  excision  of  spina  bifida,  10S9 
Hayxe,  anastomosis  of  vas,  750 
Hayxes,  nephrectomy  for  polycystic  kidney,  203 
Hays,  local  analgesia  in  operation  for  perforated  typhoid  ulcer,  332 
Heath,    inguinal   colotomy.    131,    137  :  median   lithotomy,    631  ;    lithotrity,    638  :  high 

amputation  for  gangrene.  435  ;  ligature  of  the  anterior  tibial,  998  ;  nerve-grafting, 

1081 
Heidexhai.v.  amputation  for  chronic  gangrene,  936 

Heixecke.  pyloroplasty,  467  ;  sacral  resection  in  excision  of  the  rectum,  794 
Helferich,  resection  of  the  bladder,  606  ;  results  of  carbolic  acid  injection  for  hydrocele, 

740 
Ilr.NCK.  on  Czerny's  experience  of  excision  of  rectum,  779 
Hex  i.e.  excision  of  spina  bifida.  10S9 
Hekezel.  ectopia  vesicae,  704 
Herman,  treatment  of  the  omentum  in  ovariotomy,  823  ;  haemorrhage  and  the  cautery,  823  ; 

drainage  after  ovariotomy,  827 ;  removal  of  the  uterine  appendages,  833  ;  operation 

in  myomata  uteri,  843  :    supra-vaginal  hysterectomy,  851  :    vaginal  hysterectomy, 

S57  :  Caesarian  section.  867  :  Porro's  operation,  S69,  870 
HERRICK,  mortality  of  gastric  ulcer,  461 
Herrixg.  silver  nitrate  for  bladder  growths,  604 
HeRXHEIMER,  experimental  renal  decapsulation,  239 
HEWSON,  ail  vantages  of  PirogofFs  amputation,  1032 
Hey.  wound   of   the   obturator   artery,  51  ;    amputation   through   the   tarso-metatarsal 

joints,  1056 
HlCKS,  rupture  of  the  ureter,  255 
Hildebraxd,  modification  of  Murphy's  button.  519 
Hill  (P>ERKELEY).  internal  urethrotomy,  699.  700.  701,  702;  injection  of  carbolic  acid 

for  hydrocele,  741 
HlLTOK,  case  of  double  aneurysm,  2  ;  strangulated  obturator  hernia.  60:  phimosis.  724; 

••  white  line"  at  the  anus.  769  ;  treatment  of  anal  fissure,  771  :  pelvic  belt  for  sacro- 
iliac disease,  S74  :  necrosis  in  hip  disease,  893 
Hixgstox.  lithotrity.  634 

Hirschkopf,  Kocher*s  method  of  radical  cure  of  hernia,  82 
Hlava.  exudations  in  acute  pancreatitis,  577 
Hochexegg,  colectomy,  38S  ;  intestinal  exclusion,  414  ;  excision  of  rectum.  799 


ni4  [NDEX    OF    NAMES. 

Hoffa,  operation  for  congenital  dislocation  of  the  hip,  907  ;  treatment  of  coxa  vara.  909; 

-.1.11  of  the  knee.  958 
BoLDBN,  ilio-femoral  aneurysm  cured  by  pressure,  2  ;  surface-marking  of  the  metatarso- 
phalangeal joints,  1059 
EolJj,  relation  of  the  last  rib  to  the  pleura.  172 
Eolmes,  ilio-femoral  aneurysm,  1,  n  ;  ligature  of  common  iliac,  n  ;  pnlss 

simulating  aneurysm,    14:    gluteal   aneurysm,   26:    multilobular    hernial    sac,  52; 

colotomy  for  recto-vesical  fistula,  114:  Loreta's  operation  for  pyloric  stenosis,  465; 

case  of  lateral  lithotomy,  614 ;  deficient  rectum,  811:  excision  of  the  ankle,  1037; 

excision  of  the  os  calcis,  1043  ;  excision  of  tarsal  bones,  1044 
BOLZKNECHT,  X-rays  in  treatment  of  bone  cavities.  1010 
Bobslky  (Dr.  J.  8.),  on  intestinal  suture,  361,  362,  363 
BOE8LEY  (Sir  V.),  nerve  stretching  for  reflex  epilepsy,  and  for  infantile  paralysis,  1084; 

laminectomy.  1096,  1098 
Eotchkiss,  cleansing  infected  peritoneal  sac,  304,  307 
EOWELL,  results  of  nerve  suture.  1078 

BOWSE   (Six   If.),  colotomy  in   two   stages,   133;    nephrolithotomy.   173;    operation  of 
trostomy,  449:    feeding  after  gastrostomy,  455  :    case  of  traumatic  stricture  of  the 

urethra,  652  ;  circumcision,  724  ;  excision  of  varicocele,  742  ;  method  of  amputation  at 

the  hip-joint,  884  ;  excision  of  the  knee-joint,  952,  955,  958,  959  ;  sequestrotomy,  1006 
BUBBABD,  renal  decapsulation,  240 
BtTBEB,  results  of  nerve  Buture,  1078 
BUGUIEB,  colotomy  for  imperforate  anus,  114 
Hii.Ki;.  wound  of  the  obturator  artery.  51 
Hume,  nephrectomy,  212 
lliMrniiV  (Sir  G.  Si.),  ease  of  encysted  vesical  calculus,  614  ;  injury  as  a  cause  of  loose 

cartilage  in  knee-joint,  973 
HUNNBB,  aneurysms  treated  by  introduction  of  wire  and  galvanism.  34,  36 
HUNTINGDON,  bone-transference.  1009 
BUTCHTNSON,  impairment  of  kidneys  in  lithotomy,  632 
Hutchinson  (J.,  jr.).  results  of  operations  for  radical  cure  of  inguinal  hernia,  64:  of 

femoral,  94  ;  subastragaloid  amputation,  1035 
BiJTEE,  excision  of  the  hip,  896 

[HBEBT,  ureteral  papillomata,  197 

ISRAEL,  ureteritis  simulating  renal  calculus,   169  ;  successful  nephrectomy  for  sarcoma, 

198;  vaginal  route  for  removal  of  ureteral  calculus.  249:  stricture  of  ureter,   254  : 

operation  in  irreducible  intussusception.  279 

JABOUXAY,    experimental    renal    decapsulation,    239 ;    gastrojejunostomy    with    entero- 

anastomosis,  474.  517  ;  eversion  of  tunica  vaginalis,  738 
JACKSON,  mesenteric  embolism  and  thrombosis,  286 
jAIiAOUIEB,  infective  peritonitis,  339 
JAMES,  ligature  of  the  abdominal  aorta,  32 

li.i  FRIES,  results  of  Bkin-cultures  in  operations  for  radical  cure  of  hernia.  70 
JELLETT,  drainage  af'  <:iiy.  826.  827  ;   ectopic   gestation,  873 

Jepson,  malignant  disease  of  spleen,  530 

JEBOSCH,  hydatid  disease  of  the  kidney.  202 

Jessett,  operation  for  irreducible  intussusception,  278  ;  omental  grafting,  401  ;  two  1 
of  jejunostomy  for  oesophageal  cancer,  526 

Jessop,  Lumbar  colotomy,  124  ;  forceps  for  bladder  growths,  599 

Johnson  |  II.  B.  i,  gunshot  wounds 

JohnboN  ( It.  W.  i.  operations  for  wounds  of  abdomen,  426 
for  talipes,  1047 

Jones,  intra-peritoneal  rupture  of  bladder,  653 

JONES  (K.). acute  intestinal  obstruction,  262  :  operation  for  haemorrhoids,  763,  764  ;  trans- 
trochanteric osteotomy,  898  :  arthrodesis  for  infantile  paralysis.  964  ;  loose  bodies  in 
knee-joint,  973;  operation  for  internal  derangements  of  knee-joint.  974.  975.  977; 
treatment  of  talipes.  1048 

•'"N;-  phro-lithotomy,  174 ;  wounds  of  femoral  vessels,  913 

JONNBSOO,  method  of  nephrorraphy,  229 

Jordan  (Fubneaux),  amputation  at  the  hip-joint,  881,  884 

KAISER,  infective  peritonitis.  337 

KAmmbrbr,  radical  cure  of  femoral  hernia,  96;  Murphy's  button.  372:  hour-glass  con- 
traction of  stomach,  500  :  gastrojejunostomy,  520  ;  suture  of  femoral  vein.  913 
Kaim.wnky.  pancreatic 

CAST,  collateral  circulation  after  ligature  of  abdominal  aorta,  31 
K.wi  mann.  malignant  disease  of  prostate,  CS5  ;  ruptured  urethra.  688 


INDEX   OF   NAMES.  1115 

Kui.w.  perinseal  lithotrity,  645;  giant-lithotrite,  646;  Litholapaxy  in  male  children, 
646,  "17  ;  litholapaxy  in  the  female,  652 

Been,  Ligature  of  the  abdominal  aorta,  37;  aneurysm  of  the  renal  artery,  203; 
nephrorraphy,  236  ;  perforation  of  typhoid  ulcers,  330  ;  Murphy's  button,  370;  case 
of  gunshol  wound  of  the  abdomen,  432  ;  removal  of  portions  of  the  liver  for  growths, 
540 ;  air-distension  in  diagnosis  of  ruptured  bladder,  655;  results  of  excision  of  the 
rectum,  779;  colotomy  before  excision  of  the  rectum,  781,  801;  excision  of  the 
rectum,  801  ;  resection  of  bone  in  nerve  suture,  1082 

Keetley,  abdominal  section  for  strangulated  hernia,  62  ;  appendicostomy,  140,  142,  144, 
146,  336,  410  ;  successful  removal  of  multiple  rena  Icalculi,  183  ;  partial  nephrectomy 
for  injury,  216  ;  operative  treatment  of  congenital  dislocation  of  bip-joint,  907; 
operations  in  coxa  vara,  908,  909;  osteotomies  in  out-patient  practice,  1072; 
Macewen's  osteotomy,  1067;  laminectomy,   1094 

Kkhk.  duodeno-choledochotomy,  558 

K  1:1  rii.  colotomy  in  colitis,  116 

KELLOCK,  intussusception,  274  ;  traumatic  pancreatic  pseudo-cysts,  581  ;  modification  of 
Phelps'  operatic  hi.  1048 

KELLY,  tuberculous  ureter  in  nephrectomy,  211  ;  anastomosis  of  ureter,  257  ;  removal  of 
appendix  by  crashing  and  cautery,  311  ;  urethral  dilators,  593,  603  ;  cholorectostomy, 
804  ;  encapsuled  ovarian  cysts,  828  ;  oophoritis,  834  ;  removal  of  the  uterine  appen- 
dages, 835,  836  ;  conservative  surgery  of  the  uterine  appendages,  839,  841  ;  pain 
associated  with  uterine  myomata,  843  ;  supra-vaginal  hysterectomy,  851  ;  partial 
hysterectomy,  853  ;  indications  for  vaginal  hysterectomy,  856  ;  Caesarian  section,  867  ; 
Porro's  operation,  870  ;  ectopic  gestation,  872 

Kelly  (H.  A.),  incomplete  ovariotomy,  818  ;  haemorrhage  in  ovariotomy,  830 

Kelsey,  excision  of  the  rectum,  791 

Kkxdiedjy,  ligature  of  internal  iliac,  21 

Key,  strangulated  hernia,  49  ;  lateral  lithotomy,  616,  619 

Keyes,  lithotrity,  641,  643  ;  treatment  of  vesical  calculus  in  the  female,  648 

Kirk,  perforated  gastric  ulcer,  324 

Kikkham,  ureteral  calculus  causing  anuria,  244 

Kik.misson,  wounds  of  the  femoral  vessels,  913 

KNAGGS  (L.),  hernia  of  stomach  through  diaphragm,  272 

Knott,  amputation  in  spreading  gangrene,  935 

Kocher,  method  of  radical  cure  of  inguinal  hernia,  79,  82  ;  radical  cure  of  femoral  hernia, 
93,  96  ;  formation  of  faecal  fistula,  347  ;  artificial  anus,  349  ;  enterectomy,  396  ;  gastros- 
tomyr,  453  ;  gastro-duodenostomy,  474  ;  partial  resection  of  stomach,  477  ;  combined 
pylorectomy  and  gastro-duodenostomy,  481,  484  ;  modification  of  gastrojejunostomy, 
515  ;  incision  in  operations  on  bile-tracts,  546  ;  stone  impacted  in  common  bile-duct, 
557  ;  access  to  pancreas,  572  ;  castration,  757  ;  coxa  vara,  909 

Koerte,  operation  in  acute  appendicitis,  292  ;  gastrotomy  for  haemorrhage,  463 

Kohladds,  Mikulicz's  tarsectomy,  1044 

Koxig,  nephrectomy,  205  ;  use  of  Murphy's  button,  372  ;  excision  of  urethral  stricture, 
694  ;  ectopia  vesicae,  710 

KnKAXvi,  cryoscopy,  158 

Koslowski,  results  of  surgical  treatment  of  ascites  and  cirrhosis,  543 

Kough,  case  of  strangulated  hernia  causing  haemorrhage,  47 

Kouwer,  splenopexy,  533 

Kramer,  peritonaeum  in  supra-pubic  lithotomy,  629 

Kraske,  excision  of  the  rectum,  779  ;  colotomy  before,  781  ;  operation,  790,  798  ; 
laminectomy,  1094 

Krause,  growth  of  spinal  cord,  1096 

Kroxlein,  gangrene  of  colon  after  pylorectomy,  489 

Kummell,  cryoscopy,  158  ;  evisceration  method  in  acute  intestinal  obstruction.  263,  264  : 
early  operation  in  acute  appendicitis,  292 

Kussmaul,  thrombosis  of  mesenteric  vessels,  286 

Muster,  stricture  of  ureter,  250,  252  ;  gastroenterostomy  for  haemorrhage,  463  ;  wound 
of  femoral  vein,  913 

Labbe,  gastrotomy  for  a  foreign  body,  458 

La  Garde,  operations  for  abdominal  wounds,  428 

Lance,  bilateral  intestinal  exclusion,  414 

Landon,  inguinal  colotomy,  133 

Laxdzeut.  paraduodenal  fossa,  269 

Lane  (W.  A.),  method  of  nephrorraphy,  227  ;  case  of  ureteral  calculus,  245  ;  intestinal 
obstruction  by  gall-stones,  284  ;  resection  of  gangrenous  volvulus  of  sigmoid,  264  ; 
enterectomy,  388.  393,  395  ;  intestinal  clamp,  389,  391  ;  ileo-sigmoidostomy,  408  ;  in 
chronic  constipation,  409  ;  needles  for  suture  of  bile-ducts,  554  ;  stone  impacted  in  com- 
mon bile-duets,  557  ;  operation  for  congenital  dislocation  of  hip-joint,  907  ;  treatment  of 


1 1  if,  IN  MA    OF    NAMES. 

ununited  Fracture,  1015  ;  u<e  of  screw*  for  fractures.  1017  ;  operative  treatm 

simple  fractures,  1015  ;  erasion  of  the  ankle,  1040;  modification  of  Phclp's  operation, 
operation  for  talipes,  104N:  laminectomy,  1094 
I .  \\i;:-:.  nephrectomy,  172,  207,  20S  :  explanation  of  inflammation  "f  kidney  reaching 

pleura,  215  ;  suture  of  the  femoral  vein.  913 
I.  \M, iM.i:'  k.   gunshot   injuries  of  the  hip-joint,  896;    case  of  wound  of  the  femoral 

vein.  914 
Langenbuch,  incision  for  nephrectomy,  209 
I. am;i;i;.  Bupra-pubic  cystotomy,  623 
I. a  1: 1: a  1:1:1:.  movable  kidney,  221 
LABBT,  amputation  at  hip-joint,  884 

Lauenbtein,  pylorectomy,  485  ;  case  of  gastro-jejunostomy,  515 
Lawrence  (Sir  W.),  strangulated  hernia,  49  ;  wound  of  the  obturator  artery.  51 
Lawbie,  colitis,  colotomy  in,  116 

LEBENSOHN,  results  of  Kocher's  earlier  operation  for  radical  cure  of  hernia,  82 
Le  CONTE,  resection  of  gangrenous   intestine.    2S6  ;    operation  for  gastric  ulcer,   ^^  ; 

typhoid  ulcer.  331.  ^^^  ;  peritonitis,  339  :  abdominal  injuries,  435.  440 
Le  Denttj,  case  of  papillomata  of  the  ureter,  202 
LEDIABD,  diagnosis  of  gastric  and  duodenal  ulcer-.  3^7 
I.i:k.  intestinal  suture.  365 
Lees  (1).  B.),  appendicitis,  301 

Le  FOBT,  modification  of  Pirogoff's  amputation,  1034 
I.i.'.'..  gastrostomy,  453 

it",  results  of  operative  treatment  of  calculous  anuria,  190 
Lejabe,  laminectomy,  1094 
LehbEBT,  suture.  353 

LeKHABTZ,  after  treatment  of  gastro-jejunostomy.  523 
Leohabd,  ligature  of  external  iliac  for  elephantiaf 
Leonabd    Philadelphia),  Kontgen-rays  in  the  d  urinary  diseases,  152  ;  in  renal 

and  ureteral  calculus.  242  ;  proportion  of  spontaneously  passed  ureteral  calculi,  243 
LEOPOLD,  nephrectomy.  207 

LETIEVANT,  autoplastic  Maps  in  nerve  suture.  1080 
LEVIS,  injection  of  carbolic  acid  for  hydrocele,  739.  741 
Levison,  removal  of  spleen  for  splenic  anaemia,  530 
LEWIS  (P>.).  on  Maydl's  operation  for  ectopia  vesica;,  704 
LlDDELL,  ligature  of  common  iliac,  17  ;  wounds  of  internal  iliac,  19 
LlCKENSTEIN,  traumatic  diaphragmatic  hernia.  272 
LlETHEBIN,  fallacy  of  mobility  in  carcinoma  pylori,  478 
I.iLiENTHAi.i..  visceral  evacuator.  132,  346 

Lindner,  partial  resection  of  the  intestine.  394  ;  lymphatics  of  stomach,  479 
I.inhakt.  case  of  wound  of  the  femoral  vein,  914 
LIKING  rON,  case  of  gangrene  from  mesenteric  embolism,  286 
LlSFBANC,  amputat  ion  at  hip-joint.  884  ;  through  the  tarso-metatarsal  joints.  1056 
LlSTEB  (  L  ird  ).  <  larden's  amputation,  937  :  operation  for  ununited  fracture  of  femur*,  942  ; 

treatment  of  fractured  patella  by  wiring,  966,  968.  969  ;  removal  of  loose  bodies  from 

the  knee-joint.  972  ;  excision  of  varicose  veins.  1022 
LlSTON,  ligature  of  the  common  iliac.   13  ;  amputation  at  hip-joint.  SS5  :  case  of  p  - 

shot  wound  of  the  groin,  912 
Little,  non-union  aft  may,  1070 

Littlewood,  -i'' — ful  cases  of  resection  of  intestinal  growths,  388,  392  ;  clam]  - 

gastro-jejunostomy,  501 
Littbe,  colotomy,  no 
Llobet,  diaphragmatic  hernia,  273 
LLOYD,  laminectomy,  1094 
Lloyd  (Jobdan),  tenderness  due  to  renal  calculus.  164  ;  pancreat  ;  method 

of  controlling  haemorrhage  in  amputation  at  the  hip-joint,  S75.  883 
LOB8INGIEB,  tuberculous  peritonitis,  341 
LOCKWOOD,  question  of   need  of  truss  after  radical  cure  of  hernia,  68  :  radical  cure  of 

femoral  hernia,  94  ;  inguinal  canal.  73.  75  ;  removal  of  appendix  in  case  of  al  -      - 

299:  diagnosis  in  perforated  duodenal  ulcer.  328  ;  operation  in  infective  peritonitis. 

335  ;  drainage  of  intestine.  33G  :  successful  cases  of  enterorraphy,  3S1  :  resection  of 
J  removal   of  BiedeTs  lobe,  540:    enterorraphy,  253 ; 

enterectomy,  393;  operation  for  hydrocele.  736,  737  ;  case  of  removal  of  semi-lunar 
977 
-  t   T.).    gunshot    wound-  of   the    hip-joint.    S96  :  gunshot    injuries  of   the 

knee-joint,  952 
Longuet,  eversion  method  in  radical  cure  of  hydrocele,  738 
LOBETA,  introduction  of  wire  into  an  aneurysmal  sac.  33  :  gastrotomy  for  dilatation  of 

a  stricture  of  the  oesophagus,  455  ;  dilatation  of  theorinci  -  imacb,  465.  467 


ENDEX    OF    NAMES.  mi; 

Lotheibben,  radical  cure  of  Femoral  hernia,  97 

Low,  diagnosis  of  gastric  and  duodenal  ulcers,  327 

Lowson,  resection  of  the  caecum,  591 

1.1  1  U3  (R.  C),  strangulated  ambilical  hernia,  59 ;  capacity  of  kidneys,  159;  diagnosis  of 

renal  >-:ilculus,   164,  171  ;  calculous  anuria,  193  ;  nephrectomy,  208  ;  hydronephrosis 

due  in  movable  kidney,  223  ;  nephrectomy,  442 
Lucas-Champonni  &bb,  radical  cure  of  ambilical  hernia,  107 
1.1  (  kb,  typhoid  ulceration,  333  ;  case  of  fal  embolism  after  hip  resection,  962 
Lund,  inflator  for  the  colon,  122  ;  fistula  in  ano,  758  :  astragalectomy,  [049 
Li  \n  ( II.).  total  removal  of  bladder,  608 
Lusb  ,  prostal  ic  abscess,  68G 
1.1  is.  segregator,  153,  154 
I, yds  ion,  suture  of  vas  deferens,  747 

\l  \c  OORMAG  (Sir  W.),  ligature  »l  the  gluteal  artery,  27  ;  of  sciatic  artery.  28  ;  intestinal 
suture,  355  ;  gunshol  wounds  of  the  abdomen,  439  ;  rases  of  ruptured  bladder,  G53  ; 
-mure  of  the  bladder  after  rupture,  656  ;  ligature  of  the  popliteal  artery, 980  ;  caseof 
Mikulicz's  operation,  1044 

MacDougall,  acute  appendicitis,  287 

Macdonald,  results  of  pylorectomy  compared  with  gastrojejunostomy,  477 

MA.OEWBN  (Sir  W.)  acupuncture  in  the  treatment  of  aneurysm,  33  ;  method  of  radical 
cure  of  hernia,  82,  85,  94  ;  value  of  catgut  in  radical  cure  of  hernia,  69  ;  resection  of 
gangrenous  pericecal  hernia,  271  ;  method  of  compression  of  the  aorta,  880  ;  sup- 
puration after  wiring  a  fractured  patella,  971  ;  cases  of  fractured  patella,  971  ;  bone- 
grafting,  1008,  1021  ;  osteotomy  of  the  femur,  1066  ;  multiple  osteotomies,  1068  ; 
laminectomy,  1094 

Mackenzie,  traumatic  diaphragmatic  hernia,  272 

Mackenzie  (D.),  caution  as  to  spinal  analgesia  with  stovaine.  1104 

MACLAEEN,  septic  peritonitis,  320,  338 

Macleod,  Syme's  amputation,  1029  ;  objections  to  PirogofFs  amputation,  1031 

Macnamaea,  ligature  of  the  common  femoral  artery,  915 

Macnevin,  mortality  of  gastric  ulcer,  461 

Maceeady,  radical  cure  of  hernia,  62,  72 

Madelung,  modification  of  inguinal  colotomy,  33  ;  intestinal  obstruction,  263 

Maisonneuve,  internal  urethrotomy,  701 

Makins,  ligature  of  iliac  arteries  by  abdominal  section,  23  ;  volvulus  of  cascum,  281,  283  ; 
closure  of  an  artificial  anus,  419  ;  gunshot  injuries  of  viscera  of  abdomen,  424,  428  ; 
430,  432  ;  inversion  in  limited  gangrene  of  intestine,  394  ;  ectopia  vesicas,  708  ; 
operation  for  hypospadias,  718  ;  trephining  for  sacro-iliac  disease,  874  ;  gunshot 
wounds  of  hip-joint,  896  ;  of  knee-joint,  953  ;  of  ankle,  1038  ;  of  nerves,  1082  ; 
gunshot  injuries  of  spinal  column,  1093 

Malcolm,  renal  sarcoma,  199  ;  fibrosarcoma  of  pancreas,  585 

Mallins,  operations  in  abdominal  injuries,  427 

Mann,  resection  of  humerus  in  suture  of  musculospiral,  1082 

Manson  (Sir  P.)  exploratory  puncture  for  hepatic  abscess,  537 

Mapothee,  ilio-femoral  aneurysm  cured  by  pressure,  2 

Maeagliano,  splenectomy  for  splenic  anaemia,  530 

Maesh,  partial  nephrectomy,  204  ;  acute  intestinal  obstruction,  271  ;  indications  for 
excision  of  the  hip,  892  ;  necrosis  in  hip  disease,  893  ;  method  of  fixing  the  bones 
after  knee  excision,  960  ;  case  of  needle  point  in  the  knee-joint,  972 

Maeshall,  nerve  stretching,  1085 

Maetin,  anastomosis  of  vas,  750 

Maewedel,  method  of  performing  gastrostomy,  453,  454 

Mason,  cocaine  and  analgesia  for  strangulated  hernia,  42 

Matas,  treatment  of  aneurysms  by  suture,  981 — 991 

Maubeac,  suture  of  wound  of  the  femoral  vein,  913 

Maunsell,  treatment  of  abdominal  aneurysm  by  Moore's  method  ;  appendicostomy  in 
volvulus,  145,  283 

Maunsell  (H.  \V.),  method  of  performing  enterorraphy,  353,  363  ;  method  of  excision  of 
rectum,  855 

May  (B.),  lumbar  colotomy,  124  ;  nephrolithotomy,  179,  180 

Maydl,  mortality  after  pylorectomy,  477,  485  ;  method  of  jejunostomy,  527  ;  operation 
for  ectopia  vesicas,  704,  711  ;  resection  of  femur  for  coxa  vera,  909 

Max  Xitze,  cystoscope,  590 

Maynaed,  intraperitoneal  ligature  of  common  iliac,  25 

Mayo  (VV.  J.  and  C.  H.),  radical  cure  of  umbilical  hernia,  103  ;  mortality  of  Finney's 
operation,  473  ;  results  of  partial  resection  of  stomach,  477  ;  of  pylorectomy  and 
gastrojejunostomy,  481.487,491  ;  results  of  gastrojejunostomy  for  carcinoma,  495  ;  for 
gastric  ulcer,  498  ;    occurrence  of  vomiting  and  obstruction  after  gastrojejunostomy, 


inS  INDKX    OF    NAMES. 

504  ;    secondary    operations    after    gastrojejunostomy,   506  ;    method    ■  f 
jejanostomy,  508,  511,  512  ;  posterior  gastrojejunostomy  without  reversing  jejnnnm, 
513:  gastrojejunostomy  with  Murphy's  button,  519:  with  elastic  ligature,  522  ; 
cholecystenterostomy,  559;  cholecystectomy,  564;  mortality  of  operations  on  bile 
tracts,  568  :  operation  lor  hypospadias  and  epispadias,  721,  724 

McAbdle,  risk  of  puncture  of  the  kidney,  222  ;  statistics  of  carcinoma  of  tin-  -tomaeh,  478 

McBubney,  incision  to  reach  appendix.  297,  308  ;  incision  of  the  duodenum  in  cholie- 
dochotomy,  557  ;  method  of  compressing  the  common  iliac,  881 

McCarthy,  thrombosis  of  the  mesenteric  veins,  286 

Mi  I  Iosh,  treatment  of  Beptic  peritonitis,  33S,  340  :  enterorraphy,  381.  3S2  ;  enterectomy. 
393  ;  mortality  after  excision  of  the  rectum.  778 

Met  1  ill.  radical  cure  of  umbilical  hernia,  83  ;  Meckel's  diverticulum,  the  cause  of  acute 
i  notion.  208  :  prostatectomy,  6C9.  670 

McGBAW,    .Murphy's   button,  370;  elastic   ligature.   406.    521:  ganshol    wounds   of   the 

abdi !i.  435,  439:  removal  of  wandering  spleen.  529:  cholecystenterostomy,  561, 

562.  5C3 

McI'hedran,  pancreatic  cyst,  5S1 

McWiu.iams.  results  of  nephrorraphy,  236 

Mkadi:,  ease  of  carcinoma  of  the  testis.  748 

Mkakins.  perforated  typhoid  ulcer.  330 

M  BYBB  (W.)i  ligature  of  internal  iliac  for  enlarged  prostate.  20  ;  thrombosis  of  femoral 
vein  a  complication  of  appendicitis.  312  ;  intestinal    anastomosis   by    ligature.   407: 
etomy,  450.  452 

Mikulicz,  intussusception.  279;  chief  types  of  septic  peritonitis,  334.  339:  gauze- 
tampon.  339  :  enterectomy.  393.  399  :  gastrostomy,  450  ;  gastrotomy  for  haemorrhage, 
463  ;  pyloroplasty,  467  ;  gastrectomy,  478  :  gastroenterostomy.  419  ;  gauze  packing 
after  splenectomy,  532  ;  cholecysterostomy,  563  :  results  of  operations  for  acute 
pancreatitis,  577 ;  extirpation  of  pancreatic  cysts,  585  ;  injuries  of  pancreas,  574, 
576  ;  operation  for  prolapse  of  the  rectum,  773  ;  treatment  of  abscess  in  hip-joint 
disease,  891  ;  tarsectomy.  1044 

Milks  (A.  B.),  cases  of  gunshot  wound  of  the  abdomen,  439 

Miller,  gluteal  aneurysm,  29 

Millki:  (Prof.),  amputation  of  penis,  729 

MlLTON,  temporary  occlusion  of  abdominal  aorta.  37  ;  lithotrity  for  large  stone,  633  ; 
lithotrity,  634,  635,  643 

Milward.  obstruction  of  sigmoid  by  gall-stone,  286 

Mitchell  (A.  B.),  suture  of  haemorrhoids,  766 

Mitchell  (J.  F.),  perforated  typhoid  ulcer.  331 

M  licHELL  (Weir),  removal  of  uterine  appendages  for  epilepsy.  835 

Mitchell  and  COBSON,  suture  of  ureter  after  removal  of  calculus,  244 

Mohr.  gunshot  injuries  of  abdomen,  426 

Mollard,  case  of  enteroplasty,  420 

Monks,  localisation  of  small  intestine.  344 

Monprofit,  intestinal  exclusion.  413  ;  epiplopexy  for  asciter  cirrhosis,  543 

Moore  (X.)  and  White  (II.),  influence  of  age  on  gastric  ulcer,  499 

MOKEATJ,  semilunar  incision  for  excision  of  the  knee,  955 

MOBESTIN,  tracheotomy  and  gastrostomy  for  epithelioma  of  pharynx.  445  ;  excision  of 
rectum,  809 

Mobgan,  valvular  obstruction  of  ureter,  253 

Mobisaki,  enterectomy,  367 

MOBISOB  (R.),  perforated  gastric  ulcer,  319  ;  kidney-pouch,  326,  555  :  successful  case  of 
pyloroplasty,  469  :  surgical  treatment  of  cirrhosis.  541.  543  ;  incision  for  exploration 
of  the  bile  ducts,  547  ;  drainage'  after  choledochotomy,  555 

Morris  (FI.).  aneurysm  of  renal  artery,  38;  distension-ulcers  in  caecum,  126;  Rontgen 
rays   in  d  calculi,  153;  pain   in  renal  calculus.  163:  solvent   treatment  of 

renal  calculi.  166:  calculous  anuria,  166:  diagnosis  of  renal  calculus,  167,  170,  172; 
excision  of  tuberculous  renal  foci.  16S  :  palpation  of  renal  calculus,  173;  nephro- 
lithotomy, 173,  175.  179  :  calculous  anuria,  190  ;  nephrectomy,  199,  202,  204.  212,  216, 
220  ;  choice  of  operation  in  hydatid  disease  and  cystic  disease  of  kidney.  202  ;  value  of 
palpation  of  kidney  after  abdominal  section,  209  ;  nephrorraphy.  223.  231.  234  ; 
operations  in  nephritis,  237  ;  ureteral  calculi,  242,  244.  24S  :  sacral  route  for  reaching 
ureter,  249  ;  plastic  operations  on  ureter,  250,  253  :  ureteral  catheterisatiou,  254  : 
obstruction  of  ureter,  255  ;  rupture  of  ureter,  255  ;  radical  cure  of  hydrocele,  734 

MOBBIS  (B.  I.i.  temporary  ligature  of  abdominal  aorta.  30,  37 

MOBBISON  i.l.  R.),  perforated  gastric  ulcer,  319 

MoRRlss.  early  operation  in  acute  appendicitis,  289,  290,  291 

MOBTOK,  cases  of  colectomy,  393;  gunshot  wounds  of  the  rectum  and  diaphragm,  433  : 
adary   haemorrhage  after    removal   of   vesical    growths,  609  ;    air-distension  in 

ruptured  bladder,  655 


INDEX   OF    NAMES.  1119 

Morton  (Bristol),  resection  ol  knee-joinl  Eor  endosteal  sarcoma,  ion 

Morton    Dr.),  injection  of  iodine  Eor  Bpina  bifida,  ro86 

Morton  ('!'•  s-  K.),  table  of  cases  of  gunshot  wounds  of  the  abdomen,  439 

Mosoowitz,  Biei  i  osteoplastic  method  of  amputation,  1002 

Mott,  incision  for  tying  the  common  iliac,  r 

Mori, i.in.  granular  kidney  simulating  renal  calculus,  169  ;  case  of  calculous  anuria.  176  ; 
operations  for  gastric  haemorrhage,  463 ;  prostatectomy,  669  ;  castration  for  enlarged 
prostate,  683  ;  suture  of  displaced  meniscus,  97G 

.Mmi, unci  1. 1 ,  excision  of  the  rectum,  800 

MOYNIHAK,  radical  cure  of  umbilical  hernia,  103;  rctropcritonaeal  hernia,  269,  271: 
gastrojejunostomy  in  perforated  gastric  ulcer,  319  ;  results  of  operations  for  perforated 
gastric  and  duodenal  ulcers,  324,  j-;<j  ;  diagnosis  in  duodenal  ulcer,  32G  :  question  of 
excision  of  perforated  duodenal  ulcer,  328;  operation  for  haemorrhage  from  gastric 
and  duodenal  ulcers,  464.  465  ;  mortality  of  partial  resection  of  stomach,  477  ;  explora- 
tion in  carcinoma  of  pylorus,  479  ;  results  of  gastrojejunostomy  for  gastric  ulcer,  498  ; 
of  gastroenterostomy  for  gastric  tetany,  500  ;  size  of  opening  in  gastrojejunostomy, 
501  ;  mortality  of  gastrojejunostomy,  505  ;  intestinal  obstruction  after  gastrojejunos- 
tomy, 504  :  occurrence  of  jejunal  ulcer,  505  ;  results  of  posterior  gastrojejunostomy, 
512 ";  modified  Nitzel's  method  of  gastrostomy,  527  ;  removal  of  spleen,  532  ;  epiplopexy 
for  ascites  and  cirrhosis,  542  :  incision  in  operations  on  bile  tracts,  546  ;  probe  scoop, 
553  :  duodeno-choledochotomy,  558  ;  cholecystenterostomy,  563  ;  cholecystectomy,  565, 
566,  5C7  ;  operation  for  ectopia  vesicae,  712,  716 

Muller,  haemorrhage  in  Caesarian  section,  867  ;  resection  of  femur  for  coxa  vara,  909 

MUMMERY,  infusion  and  injections  in  shock,  305,  306;  sigmoidoscope,  777 

Muxford,  case  of  gastrojejunostomy,  503 

Munro,  thrombosis  of  the  mesenteric  vessels,  286 

Muxro  (J.  C),  laminectomy  for  injury,  1093 

MURCHISON,  gall-stones  and  renal  calculi,  70 

Murphy  (J.  B.),  renal  calculus.  179  ;  operation  in  acute  appendicitis,  291  :  cleansing 
peritoneal  sac,  304  :  value  of  incision  and  drainage,  339  ;  removal  of  appendix  in  quies- 
cent stage,  311  ;  drainage  of  infected  peritoneum,  339  ;  intestinal  anastomosis  by 
elastic  ligature,  407  ;  cholecystenterostomy  in  malignant  disease  of  pancreas,  586  ; 
excision  of  rectum  by  vagina,  801  ;  button  for  intestinal  operations,  368,  406  ;  indica- 
tions for  gastrojejunostomy,  327  ;  gastrojejunostomy,  518,  519;  button  for  cholecyst- 
enterostomy, 559,  561  ;  results  of  median  perinaeal  prostatectomy.  679  ;  poisoning 
after  injection  of  a  hydrocele  with  carbolic  acid,  741  ;  suture  of  wounds  of  large 
vessels,  917,  919 

MURRAY,  appendicostomy  in  chronic  constipation,  145  ;  fractures  of  leg,  1016 

Murray  (Newcastle),  successful  compression  of  abdominal  aneurysm,  33 

MusPRATT,  successful  operation  for  acute  pancreatitis,  576 

MYERS  (T.  H.),  operation  for  congenital  dislocation  of  the  hip,  605 

Mynter,  plastic  operation  on  the  ureter,  251  ;  early  operation  in  acute  appendicitisj 
290 

Naxcrede,  nephrectomy  for  gunshot  injuries,  201  ;  operation  in  gunshot  wounds  of  the 

abdomen,  426,  431 
Nasse,  Mikulicz"s  tarsectomy,  1044 
Nelaton,  enterostomy,  350 
Neuber,  method  of  clamping  intestine,  389 
NEWMAN,  nephrorraphy  in  hydronephrosis,  241 
Nicoll,  radical  cure  of    inguinal  hernia,   92  ;    of  femoral,   99  ;    method  of    performing 

prostatectomy,  677,  679 
Noble,  method  of  closing  abdominal  incision,  103.  107,  512 
Norton,  excision  of  rectum  by  vagina,  801 
Noye-Jasseraxd,  results  of  Maydl's  operation  for  ectopia  vesicae,  704 

Ochsner.     elastic     ligature    in     acute    appendicitis,    288  ;     gastrojejunostomy,    407  ; 

hypospadias,  721 
CTCONOR,  removal  of  appendix  in  cases  of  abscess,  299 
Ogston,  operation  for  flat-foot,  1051  ;  osteotomy  of  femur,  1068 
O'Hara's  forceps,  378 
Ollier,  amputation  at  the  hip-joint,  882  ;  mode  of  growth  of  the  femur,  895  ;  excision  of 

the  knee,  956,  960 
Olshausex,  vaginal  hysterectomy,  865 

opEXSHAW,  operation  for  flat-foot,  1052  ;  manual  osteoclasis,  1071 
Opie,  operation  on  pancreas,  570 
Oraisox,  prostatectomy  for  malignant  disease,  685 
Orloff,  Maydl's  operation  for  ectopia  vesicae,  704,  705 
OSLER,  aneurysm  of  abdominal  aorta,  ^,  34 


1120  INDEX    OF    NAMES. 

Otis,  ligature  of  external  iliac,  3  ;  ligat  are  of  com a  iliac,  [3  ;  ligature  of  internal 

d;    internal   urethrotomy,  700;    gunshot    wounds  of   the   hip-joint,  nnshot 

injuries  of  the  knee-joint,  952  ;  of  the  ankle,  1 
Owen  (E.),  case  of  hydatid  cyst  of  the  liver  opened  through  chest,  539  i  fatal  rupture  of 

the  bladder  during  Litholapaxy  in  a  child,  647;  erasion  of  the  knee,  948;  Phelps' 

opera!  ion  for  talipes,  1048 
Owen  (G.),  recurrence  of  inl  ussusception  after  operation,  280 

Packard,  Ligature  of  the  common  iliac,  11.  13 

Padi  i. a,  anatomy  of  common  bile-duct,  552 

Page    i.).  nephrectomy,  208,  214,  215;  rupture  of  the  ureter,  255  ;  successful  case  oi 

pyloroplasty,  469  ;  caBe  of  1  raumat  ic  aneurysm  of  the  leg,  997 
Page  ill.  \V.),  nephro-lithotomy  by  abdominal  route,  r86 ;  case  of  gastrojejunostomy, 

514 
Paget  (Sir  J.),  symptoms  ot  strangulated  hernia,  41,  57:  site  <.i   Btricture  in  femoral 

herniae,  43  ;  condition  of  the  bowel  in  strangulated  hernia,  47  ;  strangulated  umbitica] 

hernia,  57  :  shock  after  Lithotomy,  632 
I'm;  i;t  i  S.  i.  inject  ion  of  paratlin  for  prolapsus  recti,  774 

Paoli,  partial  nephrectomy,  216  ;  implantation  of  the  ureter  into  the  bladder,  258 
Pabdoe,  modification  of  Max  Nitze's  cystoscope,  590 
Parkeb  i  K. ),  enterectomy,  396  ;  deficient  rectum,  811 
Parker  (R.  W.),  suture  of  the  bladder  after  supra-pubic  lithotomy,  627  ;  excision  of  the 

liip,  896  ;  syndesniotoiny,  1074 

Parker- Si  ms,  results  of  median  perinseal  prostatectomy,  679 

PARKES,  bullet  wound  of  the  kidney,  201  ;  amount   of  damage  in  gunshot    wound  of  the 
abdomen,  422,  424  ;  hae rrhage  from  ruptured  intestine,  442 

PARKILL,  clamp  for  use  in  ununited  fractures,  914 

I'akkin,  ealeulmis  anuria,  194  ;  laminectomy  for  spinal  caries,  1095 

PATERS0N,  nephrectomy,  212  ;  gastro-jejunostomy  in  perforated  gastric  ulcer,  318,319; 
irrigation  <>f  infected  peritonaeal  sac,  320  ;  mortality  of  operations  on  perforated  a 
ulcer,  323;  gelatin  intestinal  button,  378  ;  mortality  of  operations  for  gastric  ulcer, 
461  ;  treatment  of  gastric  hemorrhage,  462,465;  digital  dilatation  in  hypertrophic 
stenosis  of  pylorus,  4665  relapse  after  pyloroplasty,  469  ;  pylorectomy  in  two  stages, 
476;  mortality  of  partial  resection  of  stomach,  477  ;  comparison  of  partial  and  total 
gastrectomy,  477  ;  leakage  after  direct  suture  and  lateral  anastomosis,  485:  technique 
in  combined  pylorectomy  and  gastro-jejunostomy,  491  ;  results  of  total  and  sub-total 
gastrectomy,  492  ;  gastro-jejunostomy  for  gastric  ulcer,  496,  498  ;  gastro-jejunostomy 
Eor  hypertrophic  stenosis  of  pylorus,  499;  comparison  of  gastro-jejunostomy  and 
pyloroplasty,  499;  relapses  after  gastro-plasty  and  gastro-gastrotomy  for  hour-glass 
contraction,  500;  jejunal  ulcer,  505  ;  Murphy's  button  in  gastro-jejunostomy,  519 

I'attkhson,  spinal  amesthesia,  1103 

I'.u  1,.  tubes  for  drainage  of  the  intestine,  123,  349  ;  removal  of  gall-stone  causing  obstruc- 
tion, 284  :  operations  in  appendicitis,  292 ;  decalcified  bone  tubes  for  enterorraphy, 
384  ;  colectomy  in  two  stages.  386  ;  mortality  of  excision  of  the  rectum,  77S  ;  excision 
Of  the  rectum,  799  ;  laparotomy  in  excision   of  the   rectum,  804  :  truss  for  use  after 
on  of  the  rectum,  800  ;  splint  Eor  excision  of  the  ankle,  698 

Pawlik,   ureteral  catheterisation,   254;    case  of  complete  extirpation  of  the  bladder. 
607 

PEAN,  case  Of  gastrotomy  for  a  foreign  body,  458  ;   laminectomy.  1094 

Peck,  resect  ion  of  intest  ine,  396 

PENROSE,  implantation  of  the  ureter  into  the  bladder,  258 

Pepper,  lumbar  colotomy,  125  ;  perforated  gastric  ulcer,  323 
Perkins,  spinal  anaesthesia,  1103 
Perrier,  cnolecystgastrostomy,  560 

PERRY  (Sir  E.  C),  case  of  septic  peritonitis,  336 
Peters,  modified  lion  forceps.  1017 
Peters  (Mi  ml  real ).  operal  ion  for  ectopia  vesica;,  712 
l't.  1  i.i:-<  in,  ie  1  \  e  graft  ing,  1081 

I'M  it  B,  Mice,-, fnl  late  operation  lor  abdominal  injury.  426 

Phelps,  tenotomy  for  contracted  knee-joint,  960  ;  operat  ion  for  talipes,  1048 
Piccolo,  radical  cure  of  umbilical  hernia,  103 
I'k  k.  Bear  tissue  used  to  unite  ends  of  a  divided  nerve,  1080 

Pilcher,  primary  suture  of  bladder  after  supra-pubic  lithotomy,  627;  prostatectomy, 
669.679:  Buture  after  excision  of  haemorrhoids,  766 ;  wounds  of  the  femoral  vessels, 

9U.  914 
l'i llorb,  colotomy,  no 

PlNNOI  k.  Ligature  of   the  femoral  for  elephantiasis,  4 

PlROGOFF,  collateral   circulation   after  ligature  of  the  abdominal  aorta.  31  ;    amputation 
of   the  foot.  1031 


INl>lv\    <»K    NAMKS.  II2I 

I'it  r  i  v ).  caseo  f  perforated  gastric  nicer,  321  ;  case  of  pancreatic  cyst,  575, 582, 584 

i'n  i>.  splenectomy  for  injury,  528 

Poooi,  ectopia  vesicae,  703 

I'm  wi>.  suppression  of  urine,  mi  :  amputation  through  the  thigh  by  transfixion,  9,u 

Pollard,  resection  of  carcinoma  of  colon,  389,  302  ;  suture  of  bladder  after  supra-pubic 
lithotomy,  627 

Pollock,  recurrence  of  hydrocele  after  operation,  734 ;  amputation  through  the  knee- 
joint,  947 

Pobteb  (G.  EL),  ligature  01  the  common  Eemoral,  915 

Porter,  mesenteric  embolism  and  thrombosis,  286;  indiscriminate  gastrojejunostomy, 
494 

Posadas,  enucleation  of  hydatids  of  the  liver,  536 

Potts'  fracture,  operation  for,  1018 

P01  9SON,  nephrotomy  in  nephritis,  162,  195,  196 

Powell  (W.),  urethroscope,  697 

POWER  (D.),  introduction  of  wire  into  abdominal  aneurysms,  33  :  perforated  duodenal 
ulcer,  329 

POWERS,  nerve  suture,  1080,  1081 

Prinole,  -ui -sful  suture  of  wound  of  external  iliac,  3  ;    Bier's  osteoplastic  method  of 

amputation,  1002 

Putnam,  laminectomy  for  spinal  growths,  1096 

Pie  smith  (B.  J.),  obstruction  by  Meckel's  diverticulum,  268 

PtB  Smith  (Dr.),  perforating  duodenal  ulcer,  328 

QUENU,   case   of    gastroenterostomy,   519;     excision   of     the    rectum,   7S1,   784,   785  ; 

abdomino-perinsea]  excision  of  the  rectum,  805 
Ql  icK.  rupture  of  bladder,  653,  654 
QUIMBY,  mesenteric  embolism  and  thrombosis,  286 
QUINCKE,  tapping  spinal  theca,  1101 

RADZIEWSKI,  eholecysenterostomy  in  chronic  pancreatitis,  579 

BAKU,  nerve  stretching  for  perforating  ulcer  due  to  leprosy,  1084 

Kami:,   solvent   treatment   of    renal  calculus,    166;    duodenal   ulcer   simulating   renal 

calculus,  170 
Kamdohr,  enterectomy,  396 
IIamm,  castration  for  enlarged  prostate,  682 
RAMSAT  (Baltimore),  renal  tuberculosis,  161  ;  nephrectomy  for  tuberculous  kidney,  195, 

211  ;   partial  nephrectomy,  216;  case  of  pancreatic  cyst,  584 
RAMSAY,  case  of  acute  pancreatitis,  576 
BAND,  inUamed  appendix  in  a  femoral  hernia,  312 
Randall,  successful  operation  for  injured  pancreas,  574 
Uansohoff,  enterorraphy,  382  ;    enterectomy,  393  ;    condition  of  strangulated  intestine. 

402  ;  removal  of  tuberculous  mass  from  liver,  540 
Ranzi,  micro-organisms  in  gangrenous  intestine,  397 
RAWDON,  ruptured  kidney,  200 
Bees,  diagnosis  of  renal  calculus,  163 

Reeve,  risk  of  introduction  of  wire  into  abdominal  aneurysms.  37 
BEEVES,  excision  of  fistula  in  ano,  760 
BEGNIER,  tuberculosis  of  the  ureter,  211 
BEHN,    sacral    resection    in    excision    of    the    rectum,    794;    vaginal    excision    of    the 

rectum,  801 
Rbichel,  infective  peritonitis,  338;  enterectomy,  393 
It  1:1  del.  method  of  removing  appendix,  311  ;  enterectomy,  392,  400  ;  chronic  pancreatitis 

and  cholelithiasis,  578 
REYNOLDS,   papilloma  of   renal   pelvis  causing  hydronephrosis.    197;    treatment  of   hip 

disease.  891 
RICHARDS  (D.).  results  of  operation  in  malignant  growths  of  kidney  in  children,  199 
RICHARDSON  (M.  II.).  gastrotomy  for  foreign  body  in  the  oesophagus,  459  ;   recurrence  of 

pancreatic  cyst  after  drainage,  584 
RICHMOND,  ureteral  calculus,  247 
BlCHTEB,  partial  enterocele,  41 

RlCKARD.  cholangitis  after  cholecystenterostomy,  562 
Bickettis,  enterorraphy,  366  ;  enterectomy  for  carcinoma,  385 

Ridlon,  treatment  of  congenital  dislocation  of  hip-joint,  906.  90S  ;  of  talipes,  1046 
Bies,  method  of  removal  of  appendix,  311 
Bigby,  results  of  operation  in  intussusception,  279 
ItiXDFLEisCH,  malignant  disease  of  the  testis  following  injury,  750 
RrviNOTON,  gangrene  after  ligature  of  external  iliac,  9  ;  rupture  of  the  bladder,  653 
RIZZOLI.  operation  for  imperforate  anus.  812 

S. — VOL.  II.  71 


[122  INDEX    OF    NAMES. 

Roberts,  acute  obstruction  by  Meckel's  diverticulum,  268  ;  volvulus  complicating  typhoid 
_■  :   inflammation  <>f   Meckel's  diverticulum,  313  ;    operation  f" 

patella,  968 
Roberts  i  B  periments  on  the  Bolubility  of  calculi,  166 

Robinson  (A.  B.),  enterorraphy,  381,  382 
1 ; ■  1 1  ■. j n - .  1  n  (B.).  removal  <>f   ureteral  calculus,  246  :   case  of   rupture  of    bladder  in  a 

child,  657 
Robson,  colotomy  for  colitis,  115;  a  possible  difficulty  with  Murphy's  button,  373  ;  bone 

bobbin,  373.  3*4  :  enterectomy  fur  growths,  392  :    enterect«nny  and  -hurt  circ  1 

403  :  operation  in  abdominal  injuries,  441  ;  digital  dilatation  of  Btomach  orifices,  466  ; 

pyloroplasty,  469;  partial  gastrectomy  in  two  Btages,  476  ;  mortality,  477  ;  bobbin  in 

pylorectomy,  4*6:  case  ol  t;    gastro-plication,  525;   removal 

of  growth   from   liver,  541  ;  calculi   in   biliary  tracts,  544.  545:   calcium  chloride 
erations  here,  545  ;  operation,  545.  546.  548  ;  Bcoop,  549  ;  cholelithotrity,  552, 

554;   ch  ay    in    chronic    pancreatitis,   560;    cholecystectomy,  563; 

operations  <>n  pancreas.  570.  575  ;  biliary  calcul  ug  with  pancreatic  disease, 

576;  acute  pancreatitis.  577  :    chronic.  578.  579;    pancreatic  calculi,  580  ;    pan 
its  and  growths,  585  ;  ectopia  vesicae,  706;  operation  Eor  prolapsus  recti,  774 

of  wired  fractured  patella,  971 ;  nerve-grafting,  1081  :  excision  of  spinal  bifida.  1089 
Robsok  and  MOYNIHAN,  result  of  operation  for  perforated  gastric  ulcer.  31  ■.  omy, 

44>s  :  haemorrhage  from  gastric  ulcer,  460  ;   pyloroplasty,  469  ;   gastro-jejuncc 

507,  509.  520 
Rodman  (  Dr.),  tabage  for  oesophageal  stricture.  447 
Rodman,  operation  for  fractured  patella,  968 
ROEBSCH,  tubercular  peritonitis.  340 
ROGEBf  treatment  of  tetanns,  1 102 

Rosi  1  urn  in  exc  '11111.  794 

ase  of  choledochotomy,  553 
ROSVTNO,  cystoscope,  158;  ureteral  catheterisation,  160;  gastropexy,  525 
Roughton,  case  of  intestinal  anastomosis,  420 
ltoux,  radical  cure  of  femoral  hernia,    100;  ev  -•(•Hon  of  intestine,  396:  • 

of  gastrotomy  for  haemorrhage,  463;    method  of  gastrojejunostomy,  516:   ca 

wound  of  the  femoral  vein.  914  ;  modification  of  Byrne's  amputation,  1030 
Rowlands  (i:.   P.),   reduction  en   masse,  44;   intestinal  tube,  132.  133.  336;  modern 

methods   in    diagnosis    of    urinary   diseases,    160;    operations    fur   acute    int.  - 
traction,  267,  269:  technique  of  op  ration  on  ulcer  on  posterior  wall  of  stomach, 

319  ;  cases  of  gastric  ulcer  operated  upon,  322,  323 
Rugoles,  prostatectomy,  668 
Russell,  peritonaea!  watersheds,  327 

RUSSELL  t  EL),  nature  of  sac  in  inguinal  hernia.  66  ;  operation  for  hypospadias,  718 
RUTHEBFOBD,  ruptured  urethra.  688 
RUTKOW8KI,  o[ieration  for  ectopia  vesicae,  703 
Kvdygier,  enterectomy,  396:  pylorectomy,  4S4.  4S5  :  splenopexy,  533  ;  sacral  resection 

in  excision  of  the  rectum,  794  :  excision  of  the  rectum,  800 

SACHS,  partial  resection  of  intestine,  394 
SAMPSON,  ureteral  calculus,  247 

BE,  ureteral  calculus.  247 
5APEJKO,  radical  cure  of  umbilical  hernia,  103 

Sabobd  1.  volvulus  of  caecum,  2S1.  2S3  ;  nature  of  infection  in  appendix  peritonitis,  302  ; 
msing  of  peritonaeum,  304  ;  operations  on  perforated  gastric  ulcer.  323  ;  stricture 

after  strangulated    hernia.   420.   421  :    result   of  delay  in   removal  of   injured  spleen, 

5-9 
Saybe,  paralysis  due  to  phimosis,  724 

Sohaceneb,  gunshot  wonnds  of  the  mesentery,  432  ;  intestinal  clamps,  434 
SCHEDE,  :un  of  the  ureter,  603  ;  suture  of  the  femoral  vein. 913  ;  laminectomy, 

:og4 

ScHEUEB,  bone-grafting,  1022 
Bob  lange,  operation  for  ectopia  vesicae,  710 
Schlatter,  case  of  total  gastrectomy,  492 
Schleich,  production  of  Local  anaesthesia,  262 
Schmidt,  renal  sarcoma  in  an  infant,  19S 

'iun  i,f  femur  for  coxa  vara,  909 
Schnelleb,  intestinal  obstruction  by  gall-stones,  286 
v>  ii"t  1 ,  cholecystectomy,  564 

r-MATTOLi,  suture  in  gastrojejunostomy,  518 
Set  DDES,  radical  cure  of  inguinal  hernia.  79  :  Fii  473 

Sedillot,  modification  ffs  amputation,  103*5 

Second,  operation  for  ecto]  710 


INDEX    OF    NAMES.  1123 

Sengeb,  nerve-implantation,  1081 

Senn,  acute  intestinal  obstruction,  264 ;  tnl  tion,  279;  volvulus,  283  ;  inflation  of 

the  intestine  with  hydrogen,   \<,'>;   Murphy's  button,  372;  omental  grafting,  400; 

intestinal  anasto Bis,  403  ;  multiple  internal  injuries  from  bullet,  .) yj ;  rupture  "f 

intestine,  440;   treatment  of  pancreatic  cysts,  5^2;  excision  of  the  rectum,  794; 

bone  cylinders  tor  ununited  fractures,  944,  1021 
>n  m'kni'.i;.  suture  "I"  intestine,  432,  434 
Shaw  (L.  E.),  case  of  perforated  gastric  nicer,  319 
Sheaf,  ileo-sigmoidostomy  in  chronic  constipation,  410 
Sheen,  ligature  of  external  iliac,  5,  9 
Shenton,  Etontgen  rays  in  diagnosis  of  urinary  disease,  150 
Shepherd,  nephro-lithotomy,  134;  haemorrhage  after  cholecystenterostomy,  560.  562; 

ligature  of  anterior  tibial.  997 
Shebeen,  successfn]  resection  of  gangrenous  volvulus  of  sigmoid,  284 
Sherrill,  malignanl  disease  of  gall-bladder,  564 

Shield,  i  on  of  the  femoral  vessels  by  a  bubo,  915;  erasion  of  the  knee- 

joint.  948 
mii  tee,  case  <>f  amputation  at  the  hip-joint,  881 
sick,  nerve  implantation,  1081 
SlLBEBMACH,  tilling  bone  cavities,  ioio 

SlLCOOK,  volvulus,  2S2  ;  drainage  in  perforated  gastric  ulcer,  321 
Simon,  valvular  obstruction  of  the  ureter.  250 
Sinclair,  vaginal  hysterectomy,  858,  865 
sii'i'v,  splenectomy  for  splenic  anaemia,  530 
Skevington,  enterectomy  for  gangrenous  invagination,  280 
Skkv.  ligature  of  the  common  iliac,  18;  Chopart"s  amputation,  1054  ;  amputation  through 

t he  tarso-metatarsal  joints.  1056 
smith  (B.),  amputation  for  chronic  gangrene,  939 
Smith  (E.),  congenital  diaphragmatic  hernia,  272 
SMITH   (XxREIG),  radical  cure  of  umbilical  hernia,  102:   adhesions  between  kidney  and 

vena  cava,  204  ;  vessels  in  renal  pedicle,  206  ;  one  advantage  of  lumbar  nephrectomy. 

213  ;  acute  intestinal  obstruction,  262,264  !  intussusception,  275,  278  ;  volvulus,  282  ; 

sub-diaphragmatic  abscess,  325;   emptying  distended   intestine,  336;   enterostomy, 

345,  346,  348  :  enterectomy,  352,  357  ;    artificial  anus  and  faecal  fistula,  415,  416  ; 

operation  in  abdominal  injuries,  426.  431  ;  opening  of  liver  abscess,  537;  removal  of 
'">  53°.  532  ;  preparatory  treatment  of  ectopia  vesicae.  706;  opium  after  ovario- 
tomy, 831  ;  conservative  surgery  of  the  uterine  appendages,  840,  841 
Smith  (H.).  clamp  and  cautery  operation  for  haemorrhoids,  762 
Smith  (JOHNSON  i.  cases  of  Syme's  amputation.  1029 
Smith  (M.),  duodenal  ulcer,  326.  328.  329 
Smith  (O.).  inflammation  of  Meckel's  diverticulum.  313 
Smith  (It.  R.),  suture  of  injured  axillary  vessels,  917 
Smith  (S.  M.).  obstruction  of  sigmoid  by  gall-stone,  285 

smith  1  STEPHEN),  ligature  of  common  iliac,  n,  12  ;  amputation  through  the  knee-joint.  946 
smith    (Sir  '1'.).   nephro-lithotomy,    186;     intestinal   obstruction    by   gall-stones,   284; 

supra-pubic  puncture.  658,  659  ;  ligature  of  femoral  artery,  928 
Smyly,  Ligature  of  the  common  femoral,  915 
SMViHK.  case  of  ulceration  of  calculus  into  renal  artery,  181 
SONNENBERG,  the   peritonaeum   in   supra-pubic  lithotomy,   629;    operation   for   ectopia 

vesicae,  710 
South,  huge  scrotal  hernia.  54 
Southam.  ruptured  femoral  aneurysm,  2  ;  a  case  of  short  circuiting,  312  ;  carcinoma  and 

pylorectomy,  478  ;  recurrence  of  hydrocele  after  carbolic  injection.  740 
SPENCER,  appendicostomy  and  caecostomy,  141  ;  operation  for  traumatic  dislocation  of  the 

hip,  904 
SPENCER  (Dr.  EL),  sterilisation  after  Cavsarian  section,  868 
Si'iLLEH,  suture  of  nerve-roots.  1099 
SPRENGER,  resection  of  hip-joint  for  coxa  vara,  909 
SPBIGG8,  treatment  of  gastric  ulcer,  497 
Ssabanijewb,  gastrotomy,  452 

STANLEY,  in^i-ion  for  ligature  of  the  common  iliac,  16  ;  rupture  of  the  ureter,  355 
STABB,  growth  of  spinal  column,  1094 
Stavely,  injury  as  a  cause  of  volvulus,  282 
Stevens,  ligature  of  internal  iliac,  21 

Stevenson,  case  of  ulceration  of  calculus  into  renal  artery,  181 
STEWABD   ([•'•  .1.),  hydronephrosis  from    kinking  of  ureter.  224:    successful  removal  of 

ureteral  calculus,  247 ;  case  of  operation  for  injured  meniscus,  975 
Stewart,  treatment  of  abdominal  aneurysm  by  introduction  of  wire  and  galvanism,  36  ; 

suture  of  spinal  cord,  1099 

71—2 


1124 


INDEX    OF    NAMES. 


Btbwaet  (F.  1.  .  volvulus  of  great  omentum,  2S3  :  operations  for  perforated  typhoid 
ulcer.  330  ;  one  objection  to  O'Hare's  intestinal  forceps,  380 

Stiles,  radical  enre  of  hernia  in  early  childhood,  66 

Sttmson,  Bupra-vaginal  hysterectomy,  E ;;  ;  subastragaloid  amputation,  1035 

Stokes,  amputation  above  the  knee,  939  i  operation  for  flat-foot,  105 

Stonham,  cases  of  gastrostomy  for  cancer  of  the  pharynx,  445 

Stbatton,  experimental  gradual  closure  of  I 

Stbetton,  appendicostomy,  142 

Summebs,  Qeo-symoidostomy,  409  ;  drainage  of  fixation  of  gall-bladder,  550 

Bottom  il'..).  perforated  typhoid  ulcer.  332:  sarcomatous  ovarian  growtl  ge  in 

ovariotomy.  819  :  encapsnled  ovarian  cysts.  828  ;  removal  of  the  uterine  append 
834.  S35  :  case  of  Mikulicz's  tarsectomy,  1044 

Swain,  question  of  excision  of  gastric  ulcer.  317 

Swain  (K.).  two  cases  of  digital  dilatations  of  the  pylorus,  467 

Syme,  old  operation  on  gluteal  aneurysm,  29  ;  external  urethrotomy, 690, 698  ;  amputation, 
1027 

BTMONDS,  needles  for  radical  cure  of  femoral  hernia.  98  :  nephrolithotomy,  175;  treat- 
ment of  oesophageal  stricture  by  tubes,  445,  448 

Syms  i  1'. ).  nephrectomy  in  polycystic  disease  of  kidney,  203 

Tait.  abdominal  section  for  hernia.  61  ;  gall-stones   forceps,  551  :  cholelithotrity,  552  ; 

removal  of  the  uterine  appendages,  S36  ;  Porro's  operation 
Tait  (Dudley),  elastic  ligature  in  gastro-jejunostomy,  523 ;  intestinal  an  407; 

eversion  method  in  radical  cure  of  hydrocele,  738 
TALMA,  surgical  treatment  of  cirrhosis,  541 
Taylor  (IV).  intussusception,  275 
TAYXiOB  (E.  E.),  unsuspected  conditions  with  movable  kidney,  221  ;  excision  of  the  rectum. 

781.  791,  792,  793,  800  ;  forcipressure  of  subclavian  artery.  913 
TEALE,  probe-gorget.  692  ;  amputation  through  the  thigh.  933  ;  case  of  fractured  patella, 

970  ;  amputation  through  the  leg,  1003 
Tebille,  splenectomy  for  splenic  anaemia,  530 
Tebbibb,  ureteral  calculi,  242.  243.  249;  condition  of  gall-bladder  in  obstruction  of  the 

common  duct.  544 
Thayer,  swelling  in  acute  pancreatitis.  375 
Tbtebsch,  hypospadias,  flaps  in,  708;  in  epispadias.  723.  724 

THOMAS  (LYME),  operations  on  appendicitis.  312  :    suture  of  vas  deferens,  747;  forceps- 
tourniquet.  878,  1028 
THOMAS  (TheLWELL),  operation  for  haemorrhoids,  763.  764 
THOMAS,  Villiet's  method  of  nephropexy,  234 
Thomas  fW.  T.),  case  of  ruptured  intestine,  444 
THOMPSON  <<;.  P.),  successful  operation  for  ruptured  bladder,  654 
Thompson  (Sir  EL),  growths  of  bladder,  587;  hematuria  from  growth  of  the  bladder, 

588;  supra-pubic  method  of  removal.  595  ;  forceps  for  growths  of  the  bladder,  598  ; 

abscess  after  removal  of  growths  of  the  bladder.  610:  supra-pubic  lithotomy, 622, 

lithotrity.  035.639;    recurrence  after  lithotrity,  636,  637;   form   of    lit  h<  it  rite.  639; 
nation   in   lithotrity,  642:   treatment   of  Lculus   in    the   female,  648; 

anatomy  of  prostate,  662  ;   internal  urethrotomy,  699  ;  urethrotome,  701 

Thomson,  perforated  typhoid  ulcer,  333 

Thomson  (A.),  cases  of  stricture  of  small  intestine.  420 

Thobbtjbn,  laminectomy  for  injury,  1091 ;  laminectomy  for  perforating  wounds.  1093; 
laminectomy  for  tuberculous  disease,  1095 

THORNTON,  nephro-lithotomy,  184,  189;  abdominal  nephrectomy,  209.  211.  212,  215; 
ureteral  calculus,  247:   gastrotomy  for  foreign   body,  458;  BUCC  of  splenec- 

tomy. 530.  532  ;  danger  in  puncturing  hepatic  \~  ;  enucleation  of  hydatids 

of  liver.  536;  liver  abscess  opened  through  chest  wall,  539:  cavity  in  the  liver  con- 
taining  biliary  calculi.  549:  ovariotomy,  821 ;  encapsnled  ovarian  cysts.  828 ;  treat- 
ment of  papillary  ovarian  cysts,  S29  ;  supra-vaginal  hysterectomy.  844,  846  :  mortality 
after  hysterectomy,  852 

Ticehtjbst  iii.).  gastro-jejunostomy  in  gastric  hemorrhage,  465;  results  of  delay  on 
prog  ;   vomiting  after  gastro-jejunostomy,  504  :  mortality  of  the  operation. 

505  :   Murphy's  button  in,  518 

TlCEHURSl  (N.),  case  of  gangrene  in  amputation  of  leg,  935 

TlBABD,  ad  'e.-n  colon  and  kidney.  170 

Tizzoni,  sicae,  703 

Tobbancb,  -uture  of  arteries 

Tbavebs,  strangulated  hernia,  191  :  operation  in  infective  peritonitis,  115 

TbendeLENBEBO,  feeding  after  gastro-tomy.  451  ;  position  in  supra-pubic  cystotomy.  596, 
612  ;  operation  for  ectopia  vesicae,  703,  707  ;  operation  for  varicose  veins.  1025  ; 
operation  for  flat-foot,  1052 


INDKX    OF    NAMES.  1125 

li;i:\i:-  <sir  l<\  T. ).  Ligature  of  internal  iliac  by  abdominal  section,  25  ;  causes  of  death 
after  Btrangulated  hernia,  52  ;  artificial  anus  in  the  caecum,  [38;  kidney  Bupport,  223  , 
acute  intestinal  obstruction,  261,  264  ;  Btrangulation  through  the  foramen  of  Winslow, 
:  volvulus.  282;  intestinal  obstruction  by  gall-stones,  284;  appendicitis  with 
abscess,  298;  relapsing  appendicitis,  307,  309.  313:  appendix  in  hernial  Bac,  312; 
septic  peritonitis,  337,  338;  intestinal  union,  384  ;  Mauser  bullel  wounds  of  the 
abdomen,  429;    treatmenl    of    ununited    fracture    of    the    femur,  943;    Chopart's 

amputation.    1054 

Tbipieb,  modification  of  Chopart's  amputation,  1055 

TUBBT,  excisit C  knee-joint,  959  ;  arthrodesis  for  infantile  paralysis,  965  ;  treatment  of 

talipes,  1046  :  laminectomy,  1098 
I  tin  Ki;.  partial  nephrectomy,  215  ;  nephrectomy,  220  ;  nephrorraphy,  229.  234  :  ureteral 

calculus, 244,  24S  ;  splenopexy,  533  ;  case  of  complete  extirpation  of  the  bladder, 607; 

spinal  anaesthesia,  1103 
TUPOLSKE,  pylorectomy  in  two  stages,  476 
TUBNEB,   volvulus.    282;    early  operation    in   appendicitis,    292;    relapsing  appendicitis, 

311  ;  perforated  gastric  ulcer.  324  ;  cases  of  fractured  patella  treated  by  wiring,  971 
TUTTLB,  mortality  after  excision  of  rectum,  778;  choice   of   operation,  782;   perinatal 

extirpation,  7S6— 789 ;  bone-flap  operation,  794 — 799  ;  excision  of  rectum  by  vagina, 

802:  abdominal  anal  extirpation,  806 
Tyrrell,  accident  in  lateral  lithotomy,  619 
Tyson,  resection  of  gangrenous  intestine  from  mesenteric  embolism,  286  ;  diagnosi 

acute  appendicitis,  294 

Ullmann,  former  results  of  rupture  of  the  bladder,  653 

VAN  Arspali:.  drainage  after  septic  peritonitis,  339 

Van  Hook,  uretero-ureterostomy,  256  ;  operation  for  hypospadias,  721,  724 

Van  lair,  bone  tubes  for  use  in  nerve  suture,  1080 

Vaughan,  volvulus  of  small  intestine,  282 

VELPEATT,  wound  of  external  iliac,  3  ;  galvano-puncture  of  abdominal  aneurysm,  33 

Villard.  gastro-duodenostomy,  475 

\"<k;t.  case  of  fat  embolism  after  excision  of  knee-joint,  963 

VOLKM ANN,  supra-pubic  route  for  removal  of  growth  of  the  bladder,  595;  results  of 
excision  of  the  rectum,  779  ;  sutures  after  excision  of  the  rectum.  788  :  arthrectomy, 
948  •  trans-patellar  excision  of  the  knee,  955  ;  shock  after  incision  of  the  knee,  963 

Vi>n  ANTAL,  supra-pubic  route  for  removal  of  growth  of  the  bladder,  595 

VON  Bbuns,  results  of  castration  for  tuberculous  testis,  749 

Von  Hacker,  method  of  gastrojejunostomy,  502,  505 

Von  Mosetig,  method  of  filling  bone  cavities,  1009 

VULLIET,  method  of  nephrorraphy,  233 

WAGSTAFFE,  advantages  of  Tripier's  amputation.  1055 

Walker  (B.),  enterectomy  for  growth,  386 

Walker  (<*.),  renal  sarcoma  in  children,  198,  199 

Walker  (J.  W.),  resection  of  ileum  for  gunshot  wound,  438 

Walker  (T.),  anatomy  of  prostate,  662 

Wall,  frequency  of  haemorrhage  from  gastric  ulcer,  461 

Wallace  (C),  growths  of  bladder,   595  ;  prostatectomy,  669  ;   castration  for  enlarged 

prostate,  683,  684  ;  vasectomy,  684 
Wallis  (F.    C),  early  operation  in  intussusception,  279  ;  resection  of  chronic  enteric 

intussusception,  280  ;  retention  of  Murphy's  button,  372 
Walsh  am,  omental  grafting,  402  ;  vesical  calculus  in  female  children,   651  ;  cases  of 

ruptured  bladder,  653,  655,  657  ;  ligature  of  femoral  artery,  928  ;  astragalectorny, 

1049  ;  age  for  cuneiform  tarsectomy,  1050 
Walter,  perforated  gastric  ulcer,  315  ;  enterectorny,  396 
Walters,  lumbar  colotomy,  121 
Walton,  laminectomy  for  injury,  1093 
Warbasse,  ectopia  vesicae,  Rutkowski's  operation  for,  703 
Ward,  case  of  fractured  patella,  970 
Warren   (C),   splenectomy,   530,  531  ;    laminectomy  for   growths  of  the   spinal  cord, 

1094.  1096 
Washbocrn,  detection  of  tubercle  bacilli  in  the  urine,  167 
Waterman,  treatment  of  hip  disease,  891 
WATSON  (Boston),  speculum  for  the  bladder,  597  ;  removal  of  bladder  growths,  599,  601  ; 

partial  and  total  resection  of  bladder,  604,  607  ;  prostatectomy,  661,  668,  669,  675, 

677  ;  castration  for  enlarged  prostate,  683;  Maydl's  operation  for  ectopia  vesica;,  704 
Watson  (E.).  modification  of  Pirogoffs  amputation,  1033 
Watson  (P.  H.),  tarsectomy,  1044.  1045 


1 126  INDEX    OF    NAMES. 

Wki.ks.  laminectomy  for  injury,  1092 

Weigall.  gangrene  of  kidney  from  twisted  pe  tide,  cured  by  nephrectomy,  223 

Weir,  nephrectomy,  208;  enterectomy,  385  ;  appendicostomy,  [40;  resection  of  intestinal 
carcinoma,  385:  hour-glass  contraction  of  stomach,  500:  gastrojejunostomy  with, 
cntero-anastomosis,  517 :  modification  of  Murphy's  button,  519 ;  results  of  treatment 
of  hydrocele  by  carbolic  injection,  740  ;  excision  of  rectum,  805 

Wells  (Sir  SPENCER),  abdominal  nephrectomy,  213  ;  pedicle  in  splenectomy,  532  ;  lateral 
lithotomy,  619 

WEST,  granular  kidney,  169  ;  peritonitis,  333 

WHEELER,  resection  of  humerus  in  suture  of  museum-spiral,  1082 

WhEEIiHOUSE,  iliac  aneurysm,  1  ;  external  urethrotomy.  690,  691,  694,698:  castration 
after  amputation  of  the  penis,  731  ;  case  of  fractured  patella,  970 

Wherry,  ligature  of  internal  iliac  by  abdominal  section,  25 

WHIPHAM,  renal  calculus,  183 

Whitacre,  case  of  renal  decapsulation,  240 

White,  prostatectomy,  669  ;  castration  for  enlarged  prostate.  682  ;  laminectomy  for 
fractured  spine,  1092 

AVhite  (Hale),  colitis  and  dysentery,  115,  117  ;  gastrostaxis,  463  ;  after  treatment  of 
operations  on  stomach,  492 

White  (S.),  surgical  treatment  of  cirrhosis  and  ascites.  543 

White  (St.  ('.),  cases  of  excision  of  perforated  gastric  ulcer,  317 

White  (W.),  spinal  anaesthesia.  1103 

Whitehead,  case  of  gastrostomy  for  cancer  of  the  pharynx,  445;  operation  for 
haemorrhoids,  767 

WHITING,  volvulus  of  small  intestine,  282 

Whitman",  osteotomy  for  coxa  vara,  910,  911 

Wiener,  prostatectomy,  668,  669 

WIGGINS,  treatment  of  intussusception  by  distension,  274  ;  enterorraphy.  363.  365  :  case 
of  ruptured  intestine,  443 

Wilks  (Sir  S.).  symptoms  of  strangulation  of  stomach,  272 

Willard.  treatment  of  tuberculous  conditions  of  the  spine,  1094 

WlLLEMS,  treatment  of  bowel  after  excision  of  rectum.  800 

WlLLEMS,  excision  of  the  rectum,  800 

Willett,  sudden  death  from  puncture  of  a  growth  of  liver,  534  :  cholecystenterostomy, 
560  ;  case  of  ruptured  bladder,  655 

Williams  (Sir  J.),  indications  for  removal  of  the  uterine  appendages,  831 

Willis,  case  of  appendicostomy  for  colitis,  142 

Wilson  (< ;.  F.),  case  of  multiple  gunshot  wounds  of  the  ileum,  438 

WINIWARTER,  frequency  of  adhesions  in  cancer  of  the  pylorus.  478 

WiNSLOW.  radical  cure  of  umbilical  hernia,  101  ;  method  of  closing  abdominal  incision, 
103,  512 

Withersi'OON,  removal  of  ureteral  calculus,  245 

Witzel,  radical  cure  of  umbilical  hernia  with  silver  filigree,  107  ;  uretero-vesical  grafting, 
258  ;  method  of  gastrostomy,  450  ;  excision  of  the  rectum,  800 

Wolff,  a  possible  risk  of  nephrorraphy,  225 

WOLPLER,  method  of  gastrojejunostomy,  502,  514,  515 

WOOD,  strangulated  umbilical  hernia,  57,  58  ;  operation  for  ectopia  vesicae,  705 

Wood  (A.  ('.),  results  of  vasectomy  and  castration  for  enlarged  prostate,  684 

W00L8EY,  perforated  typhoid  ulcer,  330,  332  :  prostatectomy,  669 

Wright  ((J.  A.),  diagnosis  of  renal  calculus,  162  ;  gall-stones  complicating  renal  calculus, 
170  ;  diagnosis  betwet  -n  spinal  caries  and  renal  calculus,  171  ;  haemorrhage  after  splenec- 
tomy, 532  :  indications  for  hip  incision,  892  ;  condition  of  the  limb  after  hip  excision, 
895  ;  excision  of  the  hip,  895  ;  erasion  of  the  knee,  948,  950  ;  splint  after  excision  of 
the  knee,  960  ;  erasion  of  the  ankle,  1040  ;  excision  of  the  astragalus,  1049  ; 
laminectomy,  1094 

Wyeth,  bloodless  method  of  amputation  at  the  hip-joint.  876  ;  laminectomy,  1094 

Yelloly,  removal  of  vesical  calculus  in  the  female.  648 

Young,  surgery  of  lower  ureter,  249;  stricture  of  ureter,  254  ;  pros  y,  668,676, 

677,  678,  679 

Zeidler,  enterectomy,  393 

ZSLLER,  method  of  removing  appendix.  311 


INDEX    OF    SUBJECTS, 


VOLUME     II. 

Abbe's  modification  of  Kader's  method  of  gastrostomy,  454 

Abdomen,  gunshot  injuries  of,  422  ;  see  Gunshot  injuries  of  abdomen 

Abdominal  aneurysm,  operative  interference  in,  33  ;  acupuncture,  ^3  >  introduction  of 
wire,  33  ;  introduction  of  wire  and  galvanism,  34,  36  ;  ligature  of  aorta,  31  ;  tem- 
porary ligature  and  compression  of  aorta,  37 

Abdominal  aorta,  ligature  of,  30,  37  ;  temporary  ligature  and  compression,  37 

Abdominal  nephrectomy,  203,  209;  by  incision  along  rectus,  209;  through  linea  alba, 
24  ;  without  opening  peritonaeum,  212  ;  combined  with  the  lumbar  route,  212 

Abdominal  nephro-lithotomy,  184 

Abdominal  section  for  ligature  of  iliac  arteries,  22  ;  in  obturator  hernia,  Go  ;  in  strangu- 
lated hernia,  60  ;  in  nephrolithotomy,  184 ;  in  peritonitis,  333 

Abdomino-anal  removal  of  rectum,  805 

Abdomino-perinaeal  method  of  excision  of  the  rectum.  805 

Abdominal  removal  of  rectum,  803  ;  of  uterus,  myomatous,  847  ;  carcinomatous,  865 

Abernethy's  incision  for  ligature  of  external  iliac,  7 

Abnormalities  of  colon,  114,  124 

Abscess,  of  kidney,  161 ;  in  appendicitis,  291,  296  ;  of  liver,  537  ;  opening  of  through 
chest,  538  ;  of  prostate,  686  ;  sub-phrenic,  324  ;  tuberculous,  161,  195 

Acid,  use  of  in  haemorrhoids,  763 

Acupuncture  for  abdominal  aneurysm,  ^2  >  f°r  gluteal  aneurysms,  29 

Acute  intestinal  obstruction,  question  of  operation,  260  ;  extent  of  interference,  261  ;  see 
Intestinal  obstruction,  acute 

Acute  osteo-periostitis  and  necrosis,  1007,  1009  ;  early  sub-periosteal  resection  in,  1008  ; 
question  of  amputation  in,  1008 

Acute  pancreatitis,  574 

Adam's  osteotomy,  722 

Age,  earliest  for  radical  cure  of  hernia,  66 

Albert's  method  of  gastrostomy,  452 

Allingham's  bobbin,  376 

Aluminium  plates  in  osteotomy,  911  ;  in  ununited  fractures,  1021 

Amputation  at  the  hip-joint  (see  also  Hip-joint),  875  ;  Carden*s  937  ;  Chopart's,  1052  : 
Gritti's,  939  ;  Hey's,  1056  ;  Lisfranc's,  1056  ;  of  the  penis,  727  ;  of  the  toes,  1059  ;  at 
the  metatarso-phalangeal  joints,  1059  ;  through  the  phalanges  or  interphalangeal 
joints,  1059  ;  of  the  great  toe,  1059 ;  Pirogofi's,  1031  ;  question  of,  in  acute  necrosis, 
1008  ;  in  shock,  934  ;  in  gangrene,  935  ;  Roux's  modification  of  Syme's,  1030  ;  Skey's, 
1056 ;  Stokes'  supra-condyloid,  939  :  sub-astragaloid,  1035  ;  Syme"s,  1027  ;  Tripier's, 
1055  ;  through  the  knee  ;  see  Knee-joint,  946  ;  through  the  leg  (see  Leg),  1000  ; 
through  the  tarso-metatarsal  joints,  1056  ;  through  the  thigh,  see  Thigh,  928 

Amputations,  multiple,  934  ;  during  shock,  934  ;  for  gangrene,  935  ;  with  spinal  analgesia, 
1 103 

Anaesthesia,  spinal,  1102 

Anastomosis  of  intestine,  lateral,  403  ;  by  suture  alone,  403  ;  by  Murphy's  button,  406  ;  by 
McGraw's  elastic  ligature,  406  ;  of  vas  deferens,  746 

Aneurysm,  ilio-femoral  or  inguinal,  1,  10  ;  ruptured  femoral,  2  ;  of  superficial  femoral, 
915  ;  gluteal,  26,  29  ;  abdominal,  33  ;  acupuncture,  33  ;  introduction  of  wire,  33  ; 
wire  and  galvanism,  34  ;  ligature  of  abdominal  aorta,  30,  37  ;  of  iliac  arteries,  10,  38 ; 
hepatic,  38  ;  renal  artery,  38,  203  ;  iliac,  n,  38  ;  ilio-femoral,  2,  n  ;  renal,  38,  203  ; 
sciatic,  19,  27  ;  suture  of,  919,  981 


1 1 28  INDKX    OF    SUBJECTS. 

Ankle,  excision  and  erasion  of,  indtcati  ins.  1037  ;  operations  by  transverse  incision,  1040  ; 

by  lateral  incisions,  1038 
Ankylosis  of  the  hip,  operations  for.  894,  898,  1063 

Allks  lo>is  of  the  knee.  963 

Anterior  tibial  artery,  ligature  of,  997;  indications,  997  ;  operations,  998 

Anuria,  calculous,  166,  190  :  nature  of  operation,  192 

Anus,  fissure  of,  771  ;  fistula  of,  758  ;  imperforate,  810 

Anus,  imperforate,  810 

An  is,  artificial,  see  Artificial  anus 

Aorta,  abdominal,  ligature  of,  30,31,  32  ;  aneurysm  of,  33 

Apertures,  acute  intestinal  obstruction  by,  269,  271 

Appendicostomy,  140;  in  colitis  and  dysentery,  141  ;  in  typhoid  fever,  144;  in  chronic 
constipation,  145  ;  in  ileo-cascal  intussusception,  145  ;  in  volvulus  of  crecum.  145  ;  in 
intestinal  obstruction,  146;  operation,  140 

Appendicitis,  varieties,  287;  early  operative  interference  in  acute,  287;  mortality  of 
cases  treated  medically,  289;  results  of  early  operation,  290  ;  chief  symptoms  indica- 
tive, early  operation,  294  ;  acute  with  abscess,  296,  297  ;  with  suppurating  peritonitis, 
301.  333  ;  relapsing,  307,  308  ;  complications  of.  312  ;  simulating  renal  calculus.  171 

Appendages,  uterine,  removal  of,  831,  835.     See  Uterine  appendages. 

Arteries,  ligature  of  (see  the  separate  Arteries) 

Arteries,  aneurysms  of,  see  Aneurysm 

Arteries,  ligature  of,  external  iliac,  1.5.  22;  common  iliac,  11,  16,  22;  internal,  19.  20, 
22  ;  gluteal,  26.  29  ;  sciatic,  30  ;  abdominal  aorta,  30,  32,  37  ;  common  femoral,  912  ; 
superficial  femoral,  in  Scarpa's  triangle,  921  ;  in  Hunter's  canal,  926  :  popliteal,  978  ; 
tibials,  992,  997  ;  dorsalis  pedis,  1026 

Arteries,  wounds  of,  external  iliac,  3  ;  common,  12  ;  branches  of  internal,  19  ;  gluteal,  26  ; 
sciatic,  30  ;  obturator,  51  ;  femoral,  912,  916,  926  :  popliteal,  978  ;    tibials,  992,  997 

Arthrectomy  of  ankle,  1037  ;  of  knee.  948  ;  of  sacro-iliac  joint,  874 

Arthrodesis,  963  ;  of  knee-joint,  965  ;  ankle-joint,  965 

Artificial  anus,  closure  of,  414,  416,  418,  419 

Artificial  anus,  formation  of,  344.  347 

Artificial  anus,  in  crecum,  138;  in  transverse  colon,  139;  formation  of.  344:  in  small 
intestine  and  acute  obstruction,  344,  346  ;  in  middle  line.  347  ;  opening  the  bowel.  348  ; 
right  iliac  enterostomy,  350  ;  in  large  intestine  and  chronic  obstruction,  350  :  tee 
also  Colotomy,  120,  146  ;  closure  of.  414.  416  ;  when  peritonaea!  sac  is  not  opened,  416  : 
when  it  is  opened,  418  ;  with  partial  and  complete  resection  of  bowel.  418 

Ascites  and  cirrhosis,  operative  interference  in,  541 

Astragalectomy,  for  disease,  1042;  for  injury,  1042  ;  for  talipes,  1049 

Atresia  ani,  810 

Bailey's  intestinal  bobbin,  377 

Bands,  strangulation  by,  266 

Bassini's  method  of  radical  cure  of  hernia,  inguinal,  75  :  femoral,  94 

Bigelow,  lithotrite,  639 

Biliary  calculi,  chief  sites  in  bile  tracts.  544  ;  intestinal  obstruction  by,  284 

Biliary  fistula,  568 

Biliary  tracts,  chief  sites  of  calculi  in,  544  ;  operations  on.  544,  545  ;  indications,  544  ; 
cholecystectomy,  563  ;  cholecystenterostomy,  559  ;  rholecystostomy.  548  ;  choh 
tomy,  552  ;  choledoch-enterostomy,  563  ;  choledochotomy,  552  ;  cholelithotrity,  552  ; 
duodeno-choledochotomy,  557 

Bishop's  bobbin,  377 

Bladder,  urinary,  aspiration  of,  657;  question  of  repetition,  658;  ectopia  of,  702; 
cystotomy,  G52  ;  drainage  of,  627,  628  ;  growths  of,  587  :  lithotomy  (tee  Lithotomy), 
391  ;  lithotrity (see Lithotrity),  409;  perinaeallithotrity,  421  ;  pouched,  626.635 
puncture  of,  657  ;  aspiration,  657  ;  supra-pubic,  658,659  :  removal  of  growths  of.  587, 
596;  causes  of  death  after,  609  ;  choice  of  operation.  595:  complete  extirpat 
607;  partial  resection  for,  604,  606:  rupture!.  653:  intra-peritonseal,  653;  extra- 
peritoneal, 654  ;  operation.  655  ;  stone,  treatment  of,  in  male  children,  630,  646  :  in 
female.  651  ;  in  the'  female,  648  :  supra-pubic  puncture  of.  658  ;  tuberculous  disease, 
operation  for,  610,  613  ;  trabeculated,  640 

Bladder  gall,  see  Biliary  tracts 

Bobbins,  decalcified  bone,  Mayo  Bobson's,  373,  384  ;  Allingham's,  376  ;  Bishop's,  377  ; 
Hayes',  377  ;  Paterson's  soluble,  378  ;  in  intestinal-union.  373  :  in  gastrojejunostomy, 
500 ;  in  cholecystenterostomy,  560 

Bone-grafting,  1008,  1021 

Bone  transference,  1009  * 

Bone  cavities,  filling  of,  1009,  1010 

Bones  and  joints  of  the  tarsus,  excision  of,  702 
Bottini's  galvano-cautery  operation,  680 


INDEX    OF   SUBJECTS.  1129 

Blight's  disease,  suiuieul  int<  rference  in,  236 

Button,  Murphy's,  368  ;  advantages  and  disadvantages,  370  ;  in  gastrojejunostomy,  518  ; 
in  cholecj  Btenterostomy,  560 

C  E(  dm,  artificial  anus  in,  ijS;  valvular  opening  in  colitis,  138,  141;  excision  of.  391 
Caesarian  section,  abdominal  incision,  867;  extraction  of  child,  868;  incision  of  uterus, 

867  ;  indications,  866  ;  operation,  867  :  sterilisation  of  patient,  868  ;  time  of  operating, 

866  ;  uterine  Butures,  868 
Carcinoma  of  large  intestine  and  colotorny,  no,  131  ;  of  kidney,  198;  of  intestine  and 

colectomy,  384  ;  of  u-sophajjus,  445  :  of  stomach.  479  ;  of  head  of  pancreas,  560  ;  of 

bladder,  5S7  ;  of  prostate,  685  ;  of  anus  and  rectum,  777  ;  of  uterus,  operations  for,  855 
Calcium  chloride  before  operations  on  bile-ducts,  545 
Calculous  anuria,  166,  190;  operation,  192 
Calculus,  biliary,  544,  568  ;  pancreatic,  580  ;  renal,  163,  172  ;  ureteral,  241  ;  vesical  (fee 

Bladder). 
Carden's  amputation  above  the  knee-joint,  937 
( 'a-t  ration,  747,  751  ;  for  enlarged  prostate,  682  ;  in  amputation  of  penis,  731  ;  indications 

of,  747 

Cavities  in  bone,  filling  of,  1008 

Cavum  Retzii,  626,  672,  673 

Children,  male,  lithotomy  in,  617,  621,630  ;  litholapaxy  in,  646  ;  female,  removal  of  vesical 
calculus  in,  648,  651 

Cholecystectomy,  563 

Cholecystenterostomy,  559 

Cholecystostomy,  548 

Cholecystotomy,  552 

Choledochotomy.  552 

Choledoch-enterostomy,  563 

Cholelithotrity,  552 

Chopart's  amputation,  1052 

Chronic  constipation,  intestinal,  exclusion  in,  409;  question  of  operation  in.  410 

Circumcision,  724 

<  'irrhosis  of  liver  and  ascites,  surgical  treatment  of.  541 

Clamp  and  cautery  operation  for  haemorrhoids,  762 

Clamps,  intestinal,  388 

•  'oek's  external  urethrotomy,  694 

Colectomy,  384,  391,  392 

Colitis,  colotomy  in,  115  ;  caecostomy  in,  138,  141  ;  appendicostomy  and  irrigation,  141 

Colon,  operations  on,  see  Colotomy  and  Colectomy  ;  abnormalities  of,  114,  124 

Collateral  circulation  after  ligature  of  external  iliac,  4  ;  common  iliac,  16  ;  internal  iliac, 
21 ;  of  iliacs  and  femorals,  923  ;  of  tibials,  993 

Colotomy,  no  ;  indications,  no  ;  for  malignant  disease,  no  ;  for  non-malignant  stricture 
of  rectum,  113  ;  for  pelvic  growths.  113  ;  for  pelvic  cellulitis,  113  ;  for  vesicointestinal 
fistula,  113  ;  for  mal-formation  of  rectum,  114  ;  for  ulceration  of  rectum,  113.  115  ;  for 
stricture  of  large  intestine,  115  ;  for  colitis,  115  ;  site  of  colotomy  in  malignant  disease 
and  obstruction,  117  ;  lumbar  colotomy,  120;  iliac,  126  ;  colotomy  belt,  135  ;  colotomy 
in  caecum,  138  ;  in  transverse  colon,  139  ;  Madelung's  modification  of  colotomy,  133 

Common  femoral  artery,  ligature  of,  indications,  912  ;  operation,  916  ;  wounds  of.  912 

Common  iliac  artery,  ligature  of,  io,  16,  22  ;  wounds  of,  10 

( 'oinparison  of  different  methods  of  enterorraphy  with  other  devices,  380 

Compound  fractures,  treatment  of,  1012 

Congenital  dislocation  of  the  hip,  operative  interference  in,  905,  906 

Conical  stump,  one  cause  of,  933 

Constipation,  chronic,  appendicostomy  in.  145  ;  intestinal  exclusion  in,  409 

I  V>xa  vara,  indication  for  operation,  908  ;  operation  on  the  neck,  909  ;  sub-trochanteric.  910 

Crushing  operation  for  haemorrhoids,  763 

Cryoscopy,  158 

Cuneiform  osteotomy  of  femur,  1069  ;  of  tibia,  1070 

Cuneiform  tarsectomy  for  talipes,  1049 

Cysto-colostomy,  711 

Cystic  disease  of  kidney,  202 

Cystoscope,  149,  590 
Cystotomy,  652 

Cysts  of  pancreas,  581  ;  of  ovary,  818 

Cysts  of  the  broad  ligaments,  828  ;  ovarian,  818 

Decalcified  bone  bobbins,  Allingham's,  376;  Bailey's,  377  ;  Bishop's,  377  ;  Hayes,  377  ; 

Mayo  Robson's,  373 
Decapsulation  of  kidney,  237 


H30  INDKX    OF    SUBJECTS. 

Derangements,  internal,  "f  knee-joint.  973,  976 

Digital  dilatation  of  stomach  orifices,  465 

Dilatation  of  oesophageal  strictures  through  opening  in  stomach,  455 

Dilated  stomach,  gastrojejunostomy  for,  500  ;  gastro-plication  for,  524 

Dislocation  of  the  hip,  op  rative  interference  in  traumatic,  904  ;  from  disease,  894  ;  con- 
genital, 905 
rticulum,  Meckel's,  inflammation  of,  313  ;  acute  obstruction  by,  268 

Dorsalis  pedis,  ligature  of,  indications,  1026  ;  operation,  1027 

Drainage  after  operation  for  perforated  gastric  ulcer,  320  ;  for  duodenal  ulcer,  329  :  in 
infective  peritonitis.  339  ;  after  operation  on  biliary  tracts.  555  ;  of  bladder,  602.  657. 
668,  673 
nal  ulcer,  simulating  renal  calculus.  170  ;  perforating.  326,  328 

Duodenostomy,  526 

eno-choledochotoniy,  557 

Duodenum,  rareness  of  gunshot  wound  of,  431  ;  rupture  of,  440  ;  impacted  calculus  in 
Vater's  ampulla.  557 

Duplay's  operation  for  hypospadias,  717  ;  for  epispadias,  723 

Dysmenorrhoea,  removal  of  uterine  appendages  for,  834 

Ectopia  vesica;.  702  ;  Wood's  operation,  705  ;  Trendelenberg's,  707 ;  Sonnenberg's,  710  ; 

anastomosis  of  bladder  and  rectum,  710:  Maydl's  operation.  711  ;  Moynihan's,  712, 

716 
Ectopic  gestation, operations  for,  870,  871  ;  when  the  tube  is  unruptured.  870  ;  at  the  time 

of  rupture,  870 

■  ligature  in  gastrojejunostomy,  521 
Elephantiasis,  ligature  of  external  iliac  for,  3 

lism  of  mesenteric  vessels,  286 
Emptying  distended  intestine  during  abdominal  section.  335 
Encapsnled  ovarian  cysts.  828 

sted  calculus,  626.  635,  664 
Enlarged  prostate.  661  ;  see  Prostate  and  Prostatectomy 
En  masse,  reduction  of  intestine  in,  56 
Enterectomy,  384,  388,  393:  for  new  growths,  384;  during   obstruction,  3S5  :  in    two 

!'s,  386,  38S  :   for  gangrene.  393,  395  :  for  injury.  43.8 
Entero-anastomosis  in  gastrojejunostomy,  517 
Enteroplasty.  420 
Enterorraphy,  essentials  of,   351  :  compared  with  other  devices.  3S0  ;  gee  also  Suture  of 

intestine 
Enterostomy,  tubes  for.  Paul's.  132  ;  Carwardine's,  132  ;   Rowlands'.  133  ;  in  small  intes- 
tine and  acute  obstruction,  344  ;  in  large  intestine  and  chronic  obstruction,  350  :  see 

also  Colotomy,  120, 126 
Enucleation  of  hydatids  of  liver.  536 
Epiplopexy  for  cirrhosis  of  liver.  541 
Epispadias,  723 
Epithelioma  of  penis,  727 

Erasion,  of  sacro-iliac  joint,  S74  ;  of  knee-joint,  948  ;  of  ankle-joint.  1037 
Estimation  of  urea,  159 
Excision  of  ankle,   1037;  astragalus,    1042,   1049;  hip-joint,  889,  896,  900,  see  Hip-joint ; 

knee-joint.  951.  953,*"'  Knee-joint  ;  os  calcis,  1042  ;  rectum.  770  :  spina  bifida.  1087  : 

tarsal  bones,  1040  :  varicose  veins.  1022 
Exclusion  of  intestine,  407  :  tee  Intestinal  exclusion 

:  adductor  tubercle,  removal  of,  941 
External  iliac  artery,  ligature  of,  1.  5  :  Sir  A.  Cooper's  method,  5  ;  Abernethy's,  7  ;  intra- 
thod,  22  :  w.nind  of,  3  ;  case  treated  by  Buture,  3  :  causes  of  failure  and 

death,  9  ;  collateral  circulation,  4  ;  difficulties  and  possible  mistakes,  8  :  indie 

1  :  surgical  anatomy.  4 
External  urethrotomy.  690 
Extirpation  of  bladder,  607 
Extra-uterine  gestation,  treatment  of.  S70  :  when  the  tube  is  unruptured,  870  :  at  the  time 

of  rupture,  870 

I'.r.c  U.  fistula,  formation  of.  347  :  closure  of,  414 

Fallopian  tube,  rupture  of,  870 

Femoral  aneurysm,  1,  915 

Femoral  arterv,  abnormalities  of.  925  ;  ligature  of.  common,  912,  916  :  in  Hunter's  canal, 

926,92751      -  -  ifter,  928;  indications.  926 ;  operation,  927  ;  in  Scarpa's 

triangle.  921.922  :  difficulties  and  mistakes.  924:  indical  :  operati  11.922; 

suture  of.  916  ;   ulceration  of  growths  into,  914  ;  of  bubo  into.  915  :   wounds  of.  913. 

916.  926 


INDEX    OF   SUBJECTS.  1131 

Femoral  hernia,  operation  for  strangulated,  42  ;  radical  cure  of,  92,  878,  1010  ;  methods  of 
treating  the  Bac,  93;  of  closing  the  canal.  94;  Bassini's  method,  94;  l's, 

94;  De  Garmo's,  96  ;  Kammerer's,  96 ;  Cushing's  and  Curtis's,  97  ;  Lotheissen's,  97  ; 

Bal  1  :  Roux's,  100 

Femur,  -aroma  of,  S78,  1010;  osteotomy  of,  for  coxa  vara.  908  ;  for  genu  valgum,  1065  ; 

for  varum.  1069 
Femur,  ununited  fractures  of,  942;  of  neck,  942  ;  of  shaft.  942  ;  ahoul  lower  ends,  944 
Fihro-cartUages  of  knee,  treatment  of,  in  S.  Smith's  amputation,  949  ;  removal  of,  973. 

976 
Fibro-myoma  of  uterus,  removal  of  uterine  appendages  for,  833  ;  removal  of  uterus  fur, 

842 
Filigree  or  wire  netting,  use  of,  in  operations,  107 
Finney's  operation,  469 
Fissure  of  the  anus.  771 
Fistula,  biliary.  568 

Fistula,  faecal,  formation  of,  347  ;  closure  of,  414 
Fistula  in  ano,  758 

Fistula,  vesicointestinal,  colotomy  for,  113 
Flat  foot,  operations  for,  105 1 
Flushing  gouge  of  Barker,  899 
Foot,  amputation  of,  PirogofFs,  1031  ;  modifications  of,  1033  ;  operation.  1032  ;  question 

of   value  of,   1031  ;  Roux*s  modification  of  Syme's  method,  1030;  Syme  s   method, 

1027  ;  cause's  of  failure  after,  1030  ;  Chopart's  amputation,  1052  ;  subastragaloid.  1035  ; 

Tripier's.  1055  ;  through  tarso-metatarsal  joints,  1057  ;  of  toes,  1059  ;  flat,  1051  ;  excision 

and  erasion  of  ankle.  1037  ;  excision  of  bones  and  joints  of  tarsus,  1041,  1042,  1043  ; 

inveterate  talipes,  1045  ;  hammer  toe,  1060  ;  hallux  flexus,  1061  :  ingrowing  toe-nail, 

1062  . 

Fractures,  of  femur,   942  ;    of   patella,   966 ;    compound,   treatment   of,    1012 ;    simple, 

operative  treatment  of,  1015  ;  Pott's,  1018  ;  ununited,  1019 
Frank's  method  of  gastrostomy,  452 
Functional  capacity  of  kidneys,  determination  of,  158 

Gall-bladder  and  bile  ducts,  operations  on,  544  :  see  Biliary  tracts 

Gall-stones,  intestinal  obstruction  by,  284  ;  chief  sites  in  biliary  tracts.  544:  removal  of, 

552  :  from  duodenum,  557 
Gangrene,  amputations  for.  acute.  935  :  chronic,  935 

Gangrenous  hernia,  resection  of  intestine  for,  393,  397  I  limited  gangrene,  394:  extensive. 
^95  ;  amount  of  bowel  resected,  396  ;  clamps,  389,  398  ;  chief  courses  open.  47.  49, 
399  ;  question  of  radical  cure,  399  ;  treatment  of  intestine  not  actually  gangrenous,  401 
Gant's  osteotomy,  894,  1064 
Gastrectomy,  476,  492 

Gastric  ulcer,  simulating  renal  calculus,  170;  perforation  of,  314.  315.  324;  question  ot 
primary  gastrojejunostomy.  318,  496  ;  cleansing  of  peritonseal  sac,  319  :  drainage, 
320  :  causes  of  failure.  321  ;  mortality  of  perforated  gastric  ulcer,  314,  323  ;  chronic 
perforation.  324  ;  subphrenic  abscess,  324  ;  treatment  of  haemorrhage  by  gastro- 
tomy,  460,  463  ;  by  gastrojejunostomy,  462,  464;  sequelae  of,  gastrojejunostomy 
for,  496 
Gastro-duodenostomy,  473 
Ga<tro-eastrostomy,  500 

Gastrojejunostomy,  primary  in  gastric  ulcer,  318,  496  ;  in  malignant  disease.  477,  494  ; 
for  non-malignant  disease,  496  ;  for  gastric  ulcer  and  sequela?,  496  :  for  infantile 
hypertropic  stenosis  of  pylorus.  499  ;  for  dilated  stomach,  500  :  for  hour-glass 
contraction,  500  ;  conditions  essential  to,  500  ;  methods,  502  :  comparison  of  anterior 
and  posterior  methods,  503  :  posterior,  512—514  ;  anterior.  514  :  Wblfler's  method, 
515  •  posterior  method  with  a  loop.  516  ;  Y-method,  516  ;  together  with  entero- 
ana-tomosis.  517  ;  with  Murphy's  button,  518  ;  with  bobbins.  520  ;  with  elastic 
ligature,  521 
lia-tropexy,  525 
Gast replication,  524 

Gastro-ptosis,  question  of  operation  in.  525 

(ia-trostomy,  445,  448;  for  malignant  disease  of  oesophagus,  445:  question  ot  use  ot 
tubes,  445  ;  causes  of  death  after.  457  ;  difficulties  in,  457  :  for  dilatation  <.f  strictures 
of  the  oesophagus,  456  ;  operation,  448  :  Abbe's  modification  of  Kader  s  method,  454  ; 
Albert's  method,  452  ;  Marwedel's  method,  454  ;  Witzel's  method,  450  ;  Depages 
method,  455  ;  Frank's  method,  452 
Gastrotomy.  458.  463  :  for  dilatation  of  strictures  of  oesophagus,  455  ;  for  haemorrhage 
from  gastric  ulcer,  460  ;  for  removal  of  foreign  bodies  in  the  oesophagus.  459  ;  for 
removal  of  foreign  bodies  from  the  stomach,  458 
Genu  valgum,  osteotomy  for,  1065  ;  varum,  1069 


1 1 32  INDEX   OF   SUBJECTS. 

Gestal  ion,  ectopic,  870 

(Hands  infiltrated,  removal  of,  in  carcinoma  pylori.  479  ;  in  epithelioma  of  [ •< -n i ~.  731  ;  in 
carcinoma  uteri,  865,  866 

Glenard's  disease,  221,  223,  525,  532 

Glutseal  aneurysm,  acupuncture  in,  29  ;  old  operation,  29 

GlutaeaJ  artery,  Ligature  of,  26,  27,  29 

Grafting  of  omentum,  400  ;  oretero  vesical,  25s  ;  aretero-sigmoid,  71  r  ;  of  nerves,  ro8i  ;  of 
periosteum  ami  bone,  1089 

Greal  toe,  amputation  of,  1059  ;  with  metatarsal  bone,  1060 

Gritti's  amputation,  939 

Growths  of  bladder,  585  ;  removal  of,  595,  596 

Growths  of  liver,  540  ;  of  spleen,  530  ;  pancreas,  585 

Gunshol  wounds  of  femoral  artery  ami  secondary  haemorrhage,  3 ;  of  common  iliac,  2: 
of  internal  iliac,  19  ;  of  abdomen,  422;  examination  of  wound.  422:  symptoms  of 
perforation,  422;  advisability  of  operative  interference,  in  civil  practice,  425;  in 
warfare,  427  ;  operation,  431,  435  ;  wounds  of  viscera,  432,  433 

Gunshol  wounds  of  hip-joint,  896  ;  of  knee-joint,  952  ;  of  ankle-joint,  1038 

Gunther's  modification  of  Pirogoff's  amputation,  694 

<  I  ussenbauer's  staple,  1021 

Guthrie's  method  of  amputation  at  hip-joint,  888 

II  r.M  \i  1  1:1  \  of  renal  calculus,  162;  of  bladder  growths,  587 

I  hemorrhage,  secondary,  in  gunshot  injuryiof  femoral  artery,  3  ;  from  gastric  ulcer,  469  ; 

Lrastrotomy  for,  463  ;  gastrojejunostomy  for,  462,  464 
I  hemorrhagic  pancreatitis,  574 
Haemorrhoids,  operations  for,  760;  acid,  763;  clamp  and  cautery,  702:  crushing,  763; 

indications  for.  760  ;  ligature,  761,  763;  R.  Jones's  and  Thelwell   Thomas'-  method, 

763  ;  Whitehead's  method,  767 
Hallux  valgus,  operation  for,  1061 

Halstead,  hammer  for  choledochotomy,  554  ;  operation  for  radical  cure  of  hernia,  87 
Hammer-toe,  operations  for,  1060 
Hamstring  tendons,  tenotomy  of,  1076 
Hayes'  bone  bobbin,  377 

Hepatic  abscess,  operation  for,  537 

Hepatic  artery,  aneurysm  of,  38 

Hernia,  femoral.  sttaiiLtulatcd.  42  ;  radical  cure  of,  92  ;  tee  Femoral  hernia 

Hernia,  gangrenous,  47,  49,  394,  397  ;  tee  Gangrenous  hernia 

Hernia,  inguinal,  strangulated,  52;  radical  cure  of,  72;  Bassini's  method.  76:  Kocher's, 

79  ;  Macewen's,  82  ;  Halstead's,  87  ;  Nicoll's,  92 
Hernia,  oht  orator,  59 

Hernia,  rel  roperitonaeal,  causing  acute  obstruction,  269 
Hernia,  radical  cure  of,  62  ;  value  of  term,  62  ;  mortality  of  operation,  62  ;  indications 

for,  71  ;  of  inguinal  hernia,  72  ;  femoral,  92  ;  umbilical.  101  ;  ventral,  109  ;  qm 

of  during  resection  of  gangrenous  intestine,  399 
Hernia,    strangulated,   operation    for,    40:    femoral,   42;    inguinal,    52:    umbilical,    57: 

obturator,  59  ;  gangrenous  intestine  in,  47,  49,  393,  395  ;  dangerous  but  not  gangrenous 

intestine  in,  401  ;  difficulties  of  reduction  of  intestine  in.  53  :  reduction  <  m  matte,  56 
Hernia,  umbilical,  strangulated,  57  ;  radical  cure  of,  101 
Hernia,  ventral,  109 

Hey's  amputation,  1056 

Hip-joint,  amputation  at.  S75  ;  antero-intcrnal  and  postero-external  (laps.  884  :  antero- 
post  -.3;     Km  ncaux-. Ionian's   method,   88l  ;    Sir    II.    Howse's   method,   884; 

Lateral  flaps.  884;   methods  of  controlling  haemorrhage   in,  875;    Lynn   Thomas's 
method,  878  ;  Wyeth'e  bloodless  method,  876 

Hip.  congenital  dislocation  of,  operation  for,  905,  906 
Hip.  disiocat  ion  of.  operative  interference  in,  904 

Hip-joint,  gunshot  wound-  of,  896 

Hip-joint,  infective  arthritis  and  epiphysitis  of,  operation  for,  902 

Hip-joint,  injection  of  abscesses  with  iodoform,  891  ;  question  of  conservative  treatment 
or  excision,  889;  anterior  method,  896;  causes  of  failure  after.  902  :  condition  of 
limb  after,  895;  conditions  of  success  in,  895;  indications,  888,  893;  in  gunshot 
injuries.  S96  ;  posterior  method  of,  900  ;  site  of  bone  section  in,  902 

Hip-joint,  osteoarthritis,  question  of  operation  in,  903 

Hour-glass  contraction  of  stomach,  500 

Howse  (Sir  II.).  method  of  amputation  at  hip-joint,  S84  :  excision  of  knee.  954,  960 

Hydatids  of  kidney,  202  ;  of  liver,  treatment  of,  534,  536,  538 

Hydrocele  of  tunica  vaginalis,  radical  cure  of,  733;  carbolic'  acid,  739.  741  ;  iodine 
injection,  738 ;  partial  excision  of  sac,  734,  735  :  eversion  of  tunica  vaginalis,  738: 
tendency,  to  recurrence,  734,  740 


INDKX    OF    SUBJECTS.  1133 

Hyd  pididymis,  cord,  canal  of  Muck,  737 

Hydronephrosis,  nephrotomy  Eor,  t6i  :  simulating  renal  calculus,  168;  in  obstruction  of 
ureter,  250 

Hypospadias,  716 ;    Duplay's  operation   for,   717:    Bussell'B  operation  for,  718;  I' 
operation,  720 ;  Van  Book's  and  Mayo's  operations,  721 

Eysterectomy,  Eor  uterine  cancer,  855;  for  aterine  myomata,  843;  extra  and  intra- 
abdominal methods,  844,  847,  851  ;  total,  853;  Kelly's  hysteromyomectomy,  853 

1 1  .  steromyomectomy,  853 

Ii.iac  arteries,  ligature  of  external,  15,  22;    common,  10,  16,22:    internal,  19,21,22; 

intra-peritonseal  methods,  22  ;  aneurysms  of,  1,  10,  38 
llio-femoral  aneurysm,  10,  38 

Ileo-ca?cal  coil,  resection  of,  391 

Imperfectly  developed  rectum,  114,  810,  813 

Imperforate  anus,  810;  imperforate  rectum,  813 

Infantile  paralysis,  excision  and  arthrodesis  for,  964 

Ingrowing  toe-nail,  operation  for,  1062 

Inguinal  aneurysm,  1,  10,  38 

Inguinal  enterostomy,  350  ;  see  also  Colotomy,  120,  126 

Inguinal  hernia,  operations  for  strangulated,  52;  radical  cure  of,  72;  see  Hernia 
inguinal 

Inguinal  or  iliac  colotomy,  126 

Internal  derangements  of  the  knee-joint,  973,  976 

Internal  iliac  artery,  ligature  of,  19,  21,  22 

Internal  urethrotomy,  698,  701 

Intestinal  anastomosis.  402  ;  by  sutures,  403  ;  Murphy's  button  for,  406  ;  by  elastic  liga- 
ture, 406 

Intestinal  exclusion,  407  ;  unilateral,  408  ;  in  chronic  constipation,  409  :  bilateral,  409 

Intestinal  obstruction,  chronic  and  colotomy,  117,  123,  131;  acute,  260,344:  chronic. 
350  :  see  also  Colotomy,  120,  126  ;  varieties,  266  ;  apertures  ani  slits,  269  ;  bands, 
266  ;  gall-stones,  284";  intussusception,  273 ;  Meckel's  diverticulum,  266,  268  ; 
mesenteric  embolism  and  thrombosis,  286  ;  volvulus,  280 

Intestinal  sutures,  353  ;  Cushing's,  354  ;  Czerney-Lembert,  354  ;  Halstead's,  354  ;  Lem- 
bert's,  353  ;  Maunsell's  and  ConnelTs.  355 

Intestine,  clamps  for,  388,  390 

Intestine,  resection  of,  384,  388,  394  ;  for  artificial  anus  or  fsecal  fistula,  418,  419  ;  for 
gangrene,  393,  401  :  not  actually  gangrenous,  treatment  of,  401  ;  for  growths,  384, 
386,  388  ;  omental  grafting  in,  400  ;  operation,  388,  394 

Intestine,  exclusion  of,  407  ;  see  Intestinal  exclusion  ;  anastomosis  of.  402  ;  see  Intestinal 
anastomosis  ;  Resection  of,  384,  388,  394  ;  see  Resection  of  intestine  ;  non-malignant 
stricture  of,  enteroplasty  for,  420  ;  rupture  of,  439,  441  ;  gangrenous,  47,  49.  393  ; 
dangerous,  but  not  gangrenous,  401  :  union,  351  ;  gunshot  wounds  of,  422 

Inte-tine,  rupture  of,  439  ;  treatment,  441 

Intestine,  union  of  divided,  351  ;  by  suture.  351  ;  essentials,  351  ;  chief  varieties,  333; 
operation.  357  :  modifications  of  circular  enterorraphy.  363  :  Murphy's  button,  368; 
bone  bobbins,  373  :  O'Hara's  forceps,  378  ;  comparison  of  enterorraphy  with  other 
means,  380 

Intestines,  operations  on,  260 

Intraligamentous  cysts,  828 

Intra-peritonseal  ligature  of  iliac  arteries.  22 

Intussusception,  273  ;  question  of  distension,  273  :  operation,  275  ;  irreducible  intus- 
susception, 277 

Iodine,  injection  of  hydrocele  with,  738 

Iodoform  emulsion,  injection  of  in  abscesses  of  hip-joint,  891 

Ivory  pegs,  102 1 

JEJUN OSTOMY.  526 

Jonas's  operation  for  talipes,  1047 

Jordan,  Furneaux.  method  of  amputation  at  hip-joint,  881 

Jones  (R.),  operation  for  haemorrhoids.  763 

Kidxey.  and  ureter,  operations  on,  149,  241 

Kidney,  determination  of  functional  capacity,  158  ;  cryoscopy,  15S  :  estimation  of  urea, 
159  ;  methylene  blue  test,  160  ;  phloridzin  test,  160  ;  stone  in,  symptoms.  163  :  condi- 
tions simulating,  166  ;  nephrolithotomy,  172  ;  tuberculous,  161,  167  ;  nephrotomy  for, 
161  ;  nephrectomy,  194  ;  partial,  216  ;  movable,  168,  220  ;  nephrectomy  for,  201  ; 
suture,  220,  224  :  aching.  168  :  pyonephrosis,  161,  168,  250  ;  nephritis,  160,  169  ; 
calculous  anuria,  166,  190  :  injury  of,  200  ;  hydatid  disease,  202  ;  cystic  disease, 
202  ;  removal,  194,  203  ;  see  Nephrectomy 


H34  l.\l»K.\    OF   SUBJECTS. 

Kidney-pouch,  547,  555 

Knee,  ankylosis  of,  963 

Knee-joint,  amputation  through,  lateral  flaps,  946;  Long  anterior  and  short  posterior  flaps, 
947;  amputations  immediately  above,  Carden's,  937;  Qritti's,  939;  Stokes's,  939 ; 
arthrodesis  of,  963,  965  ;  erasion  of,  948  ;  causes  of  failure  after,  951,  961  ;  operation, 
950;  value  of  as  compared  with  excision,  948;  excision  of,  951  ;  after-treatment, 
961  ;  causes  of  failure  and  death  after,g6i  ;  indications,  951  ;  operation,  953  ;  internal 
derangements  01,973,  97c  ;  removal  of  fibro-cartilages  of ,  973,  976  ;  removal  of  loose 
bodies  from,  972 

Kocher,  method  of  pylorectomy,  and  gastro-duodenostomy,  481 ;  operation  for  radical  cure 
of  hernia,  79 

Kraske's  method  of  excision  of  the  rectum,  790  ;  nee  alio  Rectum. 

LAMINECTOMY,  1090;  1097;  causes  of  failure  and  death  after,  1101  ;  for  new  growths, 
1096,   1100  :  for  penetrating  wounds,   1093;  in  gunshot  injuries,  1093;  m  c-1' 
injury,  1090;  in  inflammatory  disease,  1094,  1099  ;  operation,  1097 

Lane's  operation  for  talipes,  1048 

Langenbiich's  incision  for  nephrectomy,  209 

Larry,  method  of  amputation  at  hip-joint,  884 

Lateral  intestinal  anastomosis,  383,  402,  406 

Lateral  lithotomy,  614 

Le  Fort's  modification  of  PirogofPs  amputation,  1034 

Leg,  amputation  of,  1000:  lateral  skin  flaps  with  circular  division  of  the  muscles,  1000; 
Bier's  osteoplastic  method,  iooj.  ;  Teale's  method,  1003 

Lembert's  sul  are,  354 

Ligature  of  arteries;  see  the  separate  arteries 

Ligature  for  haemorrhoids,  761,  763 

Lilienthal's  enterostomy  tube,  132 

Lisfranc's  amputation,  1056;  at  hip-joint,  884 

Liston's  method  of  amputating  at  the  hip-joint,  885 

Litholapaxy,  633,  637,  643  ;  in  male  children,  646  ;  in  the  female,  648 

Lithotomy,  lateral,  614  ;  chief  difficulties.  618,620;  entering  the  bladder,  616  :  extract- 
ing the  stone,  619  ;  finding  the  stone,  614  ;  passing  the  staff,  614:  preparatory 
treatment,  614;  median,  630  ;  medio-bilateral,  632;  supra-pubic,  indications,  621  ; 
operation,  623  ;  vaginal,  649 

Lithotrity,  633 ;  after-treatment,  644;  choice  of  operation.  633  ;  complications,  644: 
detection  of  last  fragment,  643  ;  in  male  children.  646  ;  in  the  female,  648  ;  old  and 
new  operations  contrasted,  643  ;  operation,  637  ;  perinseal  method.  645 

Liver,  abscess  of,  operation  for,  536  ;  through  chest-wall.  538  :  see  i/lxii  Biliary  tracts 

Liver  and  biliary  tracts,  operations  on,  534 

Liver,  cirrhosis  of  and  ascites,  surgical  treatment,  541 

Liver,  hydatids  of,  electrolysis  for,  534;  enucleation  of,  536;  incision  of,  534  ;  in  two 
stages,  535  :  puncture  for,  534 

Liver,  removal  of  portions  of.  for  new  growths,  540  ;  of  Riedel's  lobe,  540 

Loose  bodies  in  knee-joint,  removal  of,  972 

Loreta's  method  of  dilating  the  orifices  of  the  stomach,  465 

Lumbar  nephrectomy,  204,  213 

Lumbar  or  posterior  colotomy,  120 

Lumbar  puncture,  1101,  1102 

M  u>eluko's  modification  of  coloi y,  133 

Macewen'a  operation  tor  radical  cure  of  hernia,  82 

Macewen'a  osteotomy,  1066 

Male  children,  radical  cure  of  hernia  in,  65,  66  :  treatment  of  vesical  calculus  in,  617,  621, 
647 

Malformation  of  rectum,  colotomy  in,  114  ;  of  bladder,  702  ;  of  urethra,  716.  723 

Malignant  disease  of  rectum,  colotomy  in,  no:  removal  of  rectum  (see  Rectum);  of 
kidney,  nephrectomy  for,  197;  of  ileo-ccecal  coil,  391  ;  of  stomach,  gastrojejunostomy 
lor,  494  ;  of  oesophagus,  use  of  tubes  in,  445  ;  gastrostomy .  448  ;  of  test  i>.  747 

Manual  rectification  of  curved  tibia,  1071 

Marwedel'a  method  of  gastrostomy,  453 

Matas's  operation  Eor  aneurysm,  981 

MaunseU's  method  of  enterorraphy,  363 

Maydl's  operation  for  ectopia  vesica',  71 1 

Mayo  Robson's  bone  bobbin,  373 

Meckel's  diverticulum,  intestinal  obstruction  by,  268  :  inflammation  of.  313 

Median  lithotomy.  630 

Medio-bilateral  lithotomy,  632 

Mesenteric  vessels,  embolism  and  thrombosis  of ,  286 


INDEX    OF   SUBJECTS.  1135 

Met h\  lene  blue  test,  160 

Mc<  Iraw's  elasl  ic  ligature,  406 

Mikulicz's  operation  of  t ill-sect oiny,   n>  |  | 

Military  surgery,  cases  of  ligature  of  common  iliac,  12,  13;  injury  to  pelvic  arteries  in,  12, 

13,  ig ;  injuries  of  abdomen  in,  422 
Morton's  fluid,  1087 
Movable  kidney,  simulating  renal  calculus,  t68 ;  nephrectomy  in,  201,  221 ;  unsuspected 

organic  disease  in,  221  ;  nephrorraphy  in,  220;  different  methods,  224 
Multiple  amputal ions,  934 
Murphy's  button  for  enterorraphy,  368  :  advantages,  369 ;  contraction  after  use  of.  370  ; 

for  cholecystenterostomy,  560  ;  for  gastrojejunostomy,  518  ;  Eor  lateral  anastomosis, 

406  ;  in  excision  of  the  rectum,  800;  kinking  and  strangulation  from  weigh!  of,  372  ; 

objections  to,  370,  373:  obstruction  due  to,  372  ;  peritonitis  due  to  sloughing  over, 

371  ;  sloughing  a1  line  of  junction,  371 
Myeloid  sarcoma,  operation  for,  ioio 
Myomatous  uterus,  removal  of,  842 

N  1:1, axon's  operation,  350 

Nephrectomy,  question  of  performance  during  nephrolithotomy,  180;  indications,  194; 
methods,  203;  lumbar,  204,  213;  abdominal,  209,  214;  combined  method,  184; 
partial,  215;  in  tuberculous  disease,  194;  calculous  pyelitis,  196;  pyo-  or  hydro- 
nephrosis, 196  :  malignant  disease,  197  ;  injury,  200,  433  ;  movable  kidney,  201,  221  ; 
hydatid  disease,  202  ;  cystic  disease,  202  ;  renal  aneurysm,  203 

Nephritis,  surgical  interference  in,  162  ;  chronic  simulating  renal  calculus,  169 

Nephrolithotomy,  162,  172;  difficulties  in,  178;  question  of  nephrectomy  during.  180; 
lumbar  or  abdominal  route,  184  ;  for  calculous  anuria,  190,  192,  194 

Nephropexy,  220  ;  indications,  223  ;  methods,  238 

Nephrorraphy,  220;  indications,  223;  methods,  224;  Edebohl's,  227;  Turner's  229; 
Jonnesco's,  229  ;  Fullerton's,  230  ;  Morris's,  231  ;  Godet's,  232  ;  Vulliet's,  233 

Nephrotomy,  161 

Nerves,  operations  on,  1078 

Nerve  grafting,  1081 

Nerve  stretching,  1083 

Nerve  suture,  1078  ;  aids  in  difficult  cases,  1080  ;  amount  of  nerve  tissue  which  may  be 
removed,  1079  ;  causes  of  failure,  1080  ;  period  required  for  repair,  1082  ;  primary, 
1078  ;  secondary,  1078 

Non-malignant  stricture  of  rectum,  113  ;  of  small  intestine,  420 

Obstruction,   of  intestine,    chronic   and    colotomy,    117,    123,    131  ;    acute,    260  :    see 

Intestinal  obstruction  ;  formation  of  artificial  anus  in  acute,  344 ;  in  chronic,  350  ; 

see  colotomy,    120,    126  ;  of  ureter  by  stone,  241,  244;   valvular,  250;  of  common 

bile-duct,  544,  552 
Obturator  artery,  wounds  of,  151 
Obturator  hernia,  operation  for  strangulated,  59 
Oesophagus,  malignant  strictures  of,  question  of  tubes  or  gastrostomy,  445  ;  gastrostomy, 

448  ;  non-malignant  strictures  of ,  dilatation  through  stomach,  455  ;  removal  of  foreign 

bodies  in  by  gastrotomy,  459 
Ogston's  osteotomy,  1068  ;  operation  for  flat-foot,  1051 
O'Hara's  forceps,  378 
Omental  grafting,  400 
Oophorectomy,  831,  835 
Oophoritis,  834 
Orchidopexy,  753 

Os  calcis,  excision  of,  operation,  1043  ;  practical  remarks,  1042 
Osteo-clasis,  1071 

Osteo-periostitis,  acute  infective,  1007 
Osteomalacia,  removal  of  uterine  appendages  for,  835 
Osteoplastic  method  of  amputation,  1007 
Osteotomy,  for  coxa  vara,  908  ;  causes  of  death  and  failure   after,    1071  ; "cuneiform,  of 

femur,   1069;  of  tibia,   1069,    1070;   for  ankylosis  of  hip,  Adams'  operation,  1063; 

Gant's  operation,  894,  1062  ;  for  genu  valgum,  of  shaft  of  femur,  1065  ;  Macewen's 

1066  ;  Ogston's,  1068  ;  for  genu  varum,  1069 
Ovaries,  diseases  of  and  removal  of  uterine  appendages,  832 
Ovariotomy,  819 ;  accidents  during,  829  ;  after-treatment,  830  ;  date  of  operation,  828  ; 

drainage,  826  :  emptying  the  cyst,  821  ;  encapsuled  ovarian  cysts,  828;  incision  for, 

intra-ligamentous  cysts,  828  ;  operation,  820  ;  incomplete,  828':  pedicle,  treatment  of, 

823  ;  preparation  of  patient,  819  ;  toilet  of  peritoneum,  824  ;  treatment  of  adhesions,  822 
Ovaritis,  834 
Ovary,  operations  on,  SiS 


1136 


ixdk.x   of  si  i:.ii;<ts. 


Pancreas,  operations  on,  571;  injuries  of,  573;  inflammation,  acute,  574;   sub-acute, 

577;  chronic,  578;  calculi,  580;  cysts,  581  ;   growths  of.  5S5 ;    pancreatitis,  acute, 

574  :  hemorrhagic,  574 
Paraffin,  injection  of  in  prolapsed  rectum,  774 
Parker's  Byndesmotomy,  731 
Partial  nephrectomy,  215 
Patella,  wiring  fractures  of,  966  :  in  recent  cases,  967  ;  in  long-standing  ones,  969  ;  causes 

of  failure,  971  ;  difficulties  in,  970 
Paterson's  soluble  bobbin,  379 
Paul's  enterostomy  tube,  132 
Paul's  method  of  colectomy,  387 
Paul's  truss-pad  for  excision  of  the  rectum,  800 
Pelvic  growths  simulating  aneurysm,  13 
Penetrating  wounds  of  abdomen,  symptoms  indicating,  422 
Penis,  amputation  of,  727  ;  circular  method,  728  ;  flap  method,  728  ;  galvanic  cautery  for, 

729  ;  total  removal,  730  ;  removal  of  glands,  731  :  question  of  castration,  731 
Perforated  duodenal  ulcer,  326,  328 
Perforated  gastric  ulcer,  314.  324  ;  see  Gastric  ulcer 
Perforated  typhoid  ulcer,  329 
Perinseal  excision  of  the  rectum,  783 
Perinseal  lithotrity,  645 
Perinseal  prostatectomy,  675 
Perinseal  section,  690  ;  see  Urethrotomy 

Perinseum,  treatment  of  ruptured,  814  :  partial,  814  ;  complete,  815 
Peritonaea!  sac,  method  of  cleansing  after  perforated  gastric  ulcer,  319  ;   after  duodenal 

nicer,  329  ;  in  infective  peritonitis,  339 
Peritonitis,  suppurative,  in  appendicitis,  301  ;  abdominal  section  in,  333  :   classification  of, 

333:  infective,  333 ;    emptying  of  intestine  in.  335  ;    cleansing  peritonaea!  sae.  336  : 

drainage,  339  ;  tuberculous,  340  ;  pneumococcal,  343 
Peroneal  artery,  ligature  of,  1000 
Peronei  tendons,  division  of,  1075 
Phelps'  operation  for  talipes,  1048 
Phloridzin  test,  160 
Piles,  760  ;  see  Haemorrhoids 

Pirogoff's  amputation  of  foot,  1031  ;  compared  with  Smye's,  1031  :  modification,  1033 
Plantar  fascia,  division  of,  1074 
Pleura,  lower  limit  in  operations  on  kidney,  172 
Pneumococcal  peritonitis,  343 
Popliteal  aneurysm,  Matas's  operation  for,  981 
Popliteal  artery,  ligature  of,  978 
Porro's  operation,  869 
Posterior  tibial  artery,  ligature  of,  992  :  indications,  992  ;  operation,  in  middle  of  leg, 

995  ;  in  lower  third  of  leg,  996  ;  at  the  inner  ankle.  996 
Pott's  fracture,  operative  interference  in,  1018 
Prolapse  of  intestine  after  iliac  colotomy,  127.  129  :  of  the  rectum.  772  ;  complete  removal, 

773  ;  injection  of  paraffin,  774 
Prostate,  operation  for  diseases  of,  660:  anatomical  and  pathological  conditions,  660  ; 

indication  for  removal  of  enlarged,  663  :  choice  of  operation.  666  ;    partial  removal. 

669  ;  complete  removal.  670.  675,  679  ;    ligature  of  internal  iliac  for,  20  ;   castration 

for,  682  :  malignant  .lismse  of,  685  :  abscess  of.  686 
Prostatectomy,    anatomical   and    pathological  conditions    affi   iting,    660;   indications  for. 

660;    choice  of  operation,  666;   partial,  669;    complete  by   suprapubic  route,  670 ; 

671  :  perineal,  675  ;  combined  perineal  and  suprapubic,  679;  for  malignant  disease,  685 
Puncture  of  the  bladder,  657  ;  by  aspirator.  657  ;  suprapubic,  658 

Pylorectomy,  476, 479 ;  with  direct  suture  of  divided  ends,  485 ;  combined  with   gastro- 
enterostomy. 181,  187  ;  with  union  of  divided  end-  by  bobbins,  486 
Pyloroplasty,  467 
Pylorus,  digital  dilatation  of,  465  ;  operations  on  for  carcinoma,  476  :  tee  Stomach  ;  pi 

operations  on,  467  ;  infantile  hypertrophic  stenosis,  gastrojejunostomy  for,  499 
Pyonephrosis,  161 

Radical  cure  of  hernia.  67  :  decision  between  operation  and  use  of  truss,  65;  best  form 
of  suture,  68  ;  choice  of  operation  in  inguinal  hernia.  72  :  in  femoral,  101  :  indict 
for,  71  :  permanence  of  cure.  62  :  methods  in  inguinal  hernia,  Xicoll's.  92  :  Bassini's, 
76;  Halstead's,  87  ;  Kocher,  79  ;  Macewen's,  82  ;  need  of  wearing  a  trass  after.  66: 
of  femoral  hernia.  92;  different  methods,  93:  Bassini's,  94:  Lockwood'a, 
Kocher's,  96  ;  De  Garmo's,  96;  Cushings's  and  Curtis's,  97  ;  Lotheissen's,  97  ;  Battle's. 
98  ;  Nicoll's,  99  ;  Roux's,  100  ;  of  umbilical  hernia.  101  :  methods,  103  ;  simple  suture. 
103  ;  Window's,  103  ;  Mayo's,  103  :  by  filigree.   107  ;  ventral  hernia,  109 


INDEX    OF   SUBJECTS.  1137 

Radical  cure  of  hydrocele,  733  ;  see  Hydrocele 

Rectum,  carcinoma  of ,  colotomy  in,  no 

Rectum,  excision  of,  770  ;  abdominal  method,  803 ;  abdomino-anal  method,  805;  abdomino- 
perineal method,  805:  after-treatment,  808  ;  amount  of  comfort  afforded  by,  779  ; 
catises  of  trouble  and  Eailure  after,  809 ;  choice  of  operation,  782;  comparison  with 
colotomy,  778  ;  duration  of  life  after,  779  ;  indications,  777  ;  Kraske's  operation  and 
its  modifications,  790;  laparotomy  for,  803  ;  management  of  defalcation  after,  801  ; 
mortality,  778;  Murphy's  button  for,  800 ;  Paul's  truss-pad  for,  800;  perineal 
method,  7S3  ;  preliminary  treatment,  780  ;  question  of  partial  removal,  790  ;  question 
of  preliminary  colotomy,  781  ;  treatment  of  the  ends  of  the  bowel,  798  ;  vaginal 
method,  801 

Rectum,  imperfectly  developed,  114,  Sio,  813  ;  colotomy  in,  114 

Rectum,  prolapse  of,  772  ;  acid  for,  772  ;  cautery  for,  772  ;  excision  of,  772  ;  complete,  773  ; 
injection  of  paraffin,  774 

Rectum,  ulceration  of,  colotomy  in,  113,  115 

Reduction  of  intestine  en  masse,  56 

Relapsing  appendicitis,  307 

Removal  of  uterine  appendages,  83 

Renal  artery,  aneurysm  of,  38,  203 

Renal  calculus,  symptoms,  163  ;  conditions  simulating,  166  ;  operations  for,  172 

Renal  decapsulation,  237 

Resection  of  intestine,  384,  388,  394  ;  clamps  for,  388,  390  ;  for  gangrene,  393,  401  ;  for 
growths,  384  :  during  obstruction,  385  ;  in  two  stages,  386,  388  ;  for  fascal  fistula,  or 
artificial  anus,  partial,  418  ;  complete,  419  ;  omental  grafting  in,  400  ;  operation,  388, 

394 
Retro-peritoneal  hernia  and  obstruction,  269 
Rib.  last,  importance  in  operations  on  kidney,  172 
Right  iliac  colotomy,  138 
Roux's  amputation,  1030 

Ruptured  bladder,  653  ;  intra-peritoneal,  653  ;  extra-peritoneal,  654  ;  operation,  655 
Ruptured  Fallopian  tube,  870 
Ruptured  intestine,  439,  441 

Ruptured  perinasum,  841  ;  partial,  814  ;  complete,  815 
Ruptured  urethra,  688 

Sacro-iliac  disease,  operation  for,  S74 

Sarcoma  of  femur  and  tibia,  operations  for,  1010 

Sciatic  artery,  ligature  of,  30 

Screws,  use  of  in  fractures,  1017 

Sedillot's  modification  of  Pirogoff's  amputation,  1035 

Segregator  or  separator  of  Luys,  153 

Semilunar  fibro-cartilage,  removal  of,  973,  976 

Senn's  bone  ferrules,  102 1 

Septic  peritonitis,  abdominal  section  for,  301,  333 

Sequestrotomy,  1005 

Shock,  question  of  amputation  during,  934 

Sigmoidoscope,  777 

Simple  fractures,  operative  treatment  of,  1015 

Skey's  amputation,  1056 

Skin,  cultures  of  before  operation  for  radical  cure  of  hernia,  70 

Small  intestine,  drainage  of,  335 

Smith  (Stephen),  amputation  through  knee-joint,  946 

Spina  bifida,  treatment  of,  1087  ;  causes  of  failure  of,  1089  ;  excision,  1087  ;  injection 
with  Morton's  fluid,  1086  ;  simple  tapping,  1086 

Spinal  anaesthesia,  1192 

Spinal  theca,  tapping,  1101 

Spine,  operations  on,  1086 ;  see  Laminectomy 

Spleen,  injuries  to,  528  ;  excision  of,  528  ;  causes  of  death,  532  ;  indications,  528  ;  opera- 
tion, 530  ;  fixation  of,  532 

Splenectomy,  528,  530 

Splenopexy,  532 

Stab  in  mid  thigh,  treatment  of,  926 

Sterilisation  of  hands,  etc.,  in  operation  for  radical  cure  of  hernia,  70 

Sterno-mastoid,  division  of,  734 

Stitching  movable  kidney,  220,  224 

Stokes's  amputation,  939 

Stomach,  operations  on,  445  ;  gastrostomy,  445,  448  ;  dilatation  of  oesophageal  strictures 
by  gastrostomy,  456  ;  by  gastrotomy,  455  ;  gastrotomy,  458  ;  for  foreign  bodies,  458  ; 
for  gastric  haamorrhage,  460,  463  ;  digital  dilatation  of  orifices,  465  ;  pyloroplasty,  467  ; 

S. — VOL.    II.  72 


1 138  INDEX    OF   SUBJECTS. 

Finney's  operation,  469  ;  pylorectomy  and  partial  gastrectomy,  476  ;  mortality  of, 
477  ;  compared  with  gastrojejunostomy,  477  ;  different  methods,  479  ;  pylorectomy 
and  gastro-duodenostomy.  4S1  ;  pylorectomy  with  end  to  end  union,  485;  resection 
and  gastrojejunostomy,  487;  partial  resection,  476;  complete,  492;  gastro-j* 
tomy  for  malignant  disease,  494  ;  for  ulcer,  500  ;  for  dilated  stomach,  500  ;  for  hour- 
glass contraction,  500;  gastro-plication,  524  ;  ptosis,  525;  wounds,  432 

Stone  in  kidney,  162,   190;  in  ureter,   176;  in  biliary  tracts,  544  ;  in  pancreas,  580  ;  in 
bladder,  C14,  621,  630,  633.  646,  648 

Stovaine.  for  spinal  analgesia,  1103 

Strangulated  hernia,  40  ;  operation  for,  40  ;  in  femoral  hernia,  42  ;  in  inguinal  hernia,  52  ; 
in  obturator  hernia,  59  ;  in  umbilical  hernia,  57 

Stricture  of  rectum,  malignant,  question  of  colotoniy  in,  no;  non-malignant,  113;  of 
small  intestine,  non-malignant,  enteroplasty  for,  420 

Strictures  of  oesophagus,  malignant,  treatment  by  tubes  or  gastrostomy,  445,  448  ;  non- 
malignant,  dilatation  through  stomach,  445  ;  string  method,  446 

Strictures  of  the  ureter,  253 

Stricture-retention,  choice  of  operation  for,  698 

String  method  in  dilatation  of  oesophageal  stricture,  456 

Sub-astragaloid  amputation,  1035 

Sub-phrenic  abscess,  324 

Superficial  femoral   artery,  ligature  of,  921  ;  in   Hunter's  canal,  926,  927  ;  in   Scarpa's 
triangle,  922  ;  stab  wound  of,  926 

Suppression  of  urine  from  calculus,  190,  192 

Suppurative  peritonitis  in  appendicitis,  301,  333 

Supra-condyloid  amputation  of  Stokes,  939 

Supra-pubic  lithotomy,  301 

Supra-vaginal  hysterectomy  with  extra-peritoneal  treatment  of  the  stump,  844  ;   intra- 
abdominal method,  847  ;  comparison  of  the  two  methods,  851 

Sutures,  best  for  operation  of  radical  cure  of  hernia,  68 

Suture  of  movable  kidney,  220,  224 

Suture  of  divided  or  injured  intestine,  351  ;  chief  methods.  353  ;  modifications  of  circular 
enterorraphy,  363  ;  suture  compared  with  other  methods,  380 

Suture  of  large  vessels,  916 

Suture  of  aneurysms,  919,  981 

Syme's  amputation,  1027  ;  compared  with  Pirogoff's,  1031 

Syme's  external  urethrotomy,  690 

Syndesmotomy,  1074 

Talipes,  astragalectomy  for,  1049  ;   cuneiform  tarsectomy  for,  1049  ;  Jonas's  operation, 

1047  ;    Lane's  operation  for,  1048  ;    Phelps'  operation  for,  1048  ;  removal  of  tarsal 

bones  for,  1045 
Tapping  the  spinal  theca,  1101 
Tarsal  bones,  removal  of  for  talipes,  1045 

Tarsectomy,  cuneiform,  1049  ;  Mikulicz's  operation,  1044  ;  Watson's  operation,  1045 
Tarso-metatarsal  joints,  amputations  through,  1056 
Tarsus,  excision  of  bones  and  joints  of,  1040 
Temporary  compression  of  the  aorta,  37,  880 
Tendo-Achillis,  tenotomy  of,  1075 
Tenotomy,  1073  ;  causes  of  failure  after,  1077  ;  of  hamstrings.  1076  :  of  the  peronei,  1075  ; 

of  plantar  fascia.  1074  ;  of  the  sterno-mastoid,  1076  ;  of  tendo-Achillis,  1075  ;  of  the 

tibialis  anticus,  1073  ;  of  the  tibialis  posticus,  1073 
Testis,  malignant  disease  of,  747 ;  tuberculous,  749  ;  removal  of,  751  ;  retained  in  hernia, 

56  ;  orchidopcxy  in,  753,  755 
Thelwell  Thomas's  operation  for  hemorrhoids,  763,  764 
Thigh,  amputation  through,  928  ;  circular  method,  932  ;  lateral  flaps,  933  :  mixed  anti 

posterior   flaps  and  circular   division  of   the    muscles,  929;    practical   points,  928; 

rectangular  flaps,  933;    transfixion  flaps,  931  ;    in   multiple  amputations,  935;    ia 

gangrene,  335 
Thomas's  wrench,  1045 
Thompson's  fluid,  175 

Thornton's  method  of  nephrectomy,  184,  211 
Thrombosis  of  mesenteric  vessels,  286 
Tibia,  osteotomy  of,  1069 
Tibia,  sarcoma  of,  1010 
Tibialis  anticus  tendon,  division  of,  1073 
Tibialis  posticus  tendon,  division  of,  1073 
Toe-nail,  ingrowing,  1062 
I  I  tea,  amputal  ion  of,  1060 
Transverse  colon,  artificial  anus  in,  139 


INDEX   OF   SUBJECTS.  1139 

Trendelen berg's  position,  612 ;  operation,  1025 

Tripier's  amputation,  1055 

Truss,  iu  case  "1"  hernia,  65  ;  occasional  use  of  after  operation,  67 

Tuberculous  disease  of  bladder,  operative  treatment  of,  610,  613 

Tuberculous  peritonitis,  abdominal  section  for,  340 

Tubes  for  enterostomy,  132 

Tubes,  question  of  use  in  malignant  stricture  of  oesophagus,  445 

Tunica  vaginalis,  hydrocele  of,  733  ;  eversion  of  in  radical  cure,  738 

Typhoid  ulcer,  perforation  of,  329  ;  operation  for,  330,  332 

ULCER,  gastric,  perforation  of,  314  ;  haemorrhage  from,  406,  463  ;  gastrojejunostomy  for, 

462,  464  ;  see  gastric  ulcer  ;  duodenal,  326  ;  typhoid,  329 
Ulceration  of  rectum  and  colotomy,  no,  113,  115  ;  of  the  femoral  vessels  by  growths,  610 
Umbilical  hernia,  operation  tor  strangulated,  57  ;  radical  cure  of,  101  ;  by  overlapping  of 

layers,  103  ;  Mayo's  operation,  103  ;  use  of  filigree,  107 
Union  of  divided  or  injured  intestine,  351  ;  see  also  suture  of  intestine 
Ununited  fracture  of  femur,  942  ;  of  bones  of  leg,  1019 
Urea,  estimation  of.  159 
Ureter,  calculus  in,  176,  241,  244  ;  injuries  of,  255  ;  stricture  of,  253  ;  valvular  obstruction 

of,  250 
Uretero-ureterostomy,  256 
Uretero-vesical  grafting,  258 

Urethra,  rupture  of,  688  ;  extraction  of  calculi  by,  in  the  female,  648 
Urethrotomy,  external,  690  ;  Cock's  operation,  694  ;  Syme's  method,  690  ;  Wheelhouse's 

method,  691  ;  internal,  698,  701 
Urine,  separator  of  Luys,  153 
Uterine  appendages,  removal  of,  831,  835  ;  conservative  surgery,  839  ;  drainage  after,  838  ; 

enucleation  of  appendages,  837  ;  haemorrhage,  838  ;  indications  for,  831  ;  operation, 

835  ;  removal  of  diseased  parts,  837  ;  treatment  of  tube  when  distended,  838 
Uterine  myomata,  843  ;  indications  for  operation,  843  ;  supra- vaginal  hysterectomy  with 

extra-abdominal  treatment  of  stump,  844  ;  intra-abdominal  method,  847  ;  comparison 

of    intra-    and    extra-abdominal    methods,  851  ;    total    hysterectomy,    853  ;    Kelly's 

hystero-myomectomy,  853 
Uterus,  carcinoma  of,  operations  for,  855  ;  vaginal  method,  855,  857  ;  abdominal  method, 

865 
Uterus,  operations  on,  842 

Vaginal   hysterectomy,  855  :   after-treatment,   865  ;   closure  of  vault  of  vagina,  864  ; 

management  of  the  broad  ligaments,  858  ;  opening  Douglas's  pouch,  858  ;  operation, 

857  ;  preliminary  treatment,  857  ;  separation  of  bladder,  857 
Vaginal  method  of  excision  of  the  rectum,  801 
Vaginal  lithotomy,  649 
Valvular  obstruction  of  the  ureter,  250 
Varicocele,  excision,  742  ;  indications,  742  ;  recurrence,  746  ;  risks  and  causes  of  failure, 

745 
\  aricose  veins,  indications  for  operation,  1022  ;  the  "dangerous  area"  of  Bennett,  1023  ; 

operation,  1024  ;  Trendelenberg's  method,  1025 
Vas  deferens,  anastomosis  of,  746 
Vasectomy,  684 

Vater,  biliary  calculi  in  ampulla  of,  557 
Ventral  hernia,  radical  cure  of,  109 
Vesical  calculus,  lateral  lithotomy  for,  614;  supra-pubic,  621  ;  median,  630;  lithotrity, 

6337  637  ;  litholopaxy  in  male  children,  646  ;  in  the  female,  648 
Vesical  growths,  587 

Vesicointestinal  fistula  and  colotomy,  113 
Volvulus,  280,  283 
Von  Hacker's  and  Courvoisier's  method  of  gastrojejunostomy,  505 

Watson  (E.),  modification  of  Pirogoff's  amputation,  1034 

Watson  (P.  H.),  operation  of  tarsectomy,  1045 

Wheelhouse's  external  urethrotomy,  691 

Whitehead's  operation  for  haemorrhoids,  767 

Wire  in  ununited  fractures,  1020 

Wiring  fractures  of  the  patella,  966  ;  in  recent  cases,  967  ;  in  long-standing  ones,  969 

Witeel's  method  of  gastrostomy,  450 

Weld's  operation  for  ectopia  vesicae,  706 

Wyeth's  bloodless  method  of  amputation  at  the  hip-joint,  876 

BRADBURY,   AGNEW,    &    CO.   LD.,    PEINTERS,   LONDON   AND    TONBRIDGE. 


DUE  DATE 

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in  USA 

